Bio

Bio

Eric was born and raised in New Jersey. He completed his undergraduate degree in Neurobiology at Duke University, and attended medical school at the Icahn School of Medicine at Mount Sinai School in New York. During this time he also spent a year as a Doris Duke Clinical Research Fellow at Columbia University, where he studied the clinical outcomes of hemorrhagic stroke patients. During residency, Eric has continued to focus on cerebrovascular disease, and has completed a 2-year comprehensive enfolded fellowship in Neurointerventional Radiology. In 2019-2020, Eric is serving as the CSNS Socioeconomic Fellow, focusing on coding and reimbursement for Endovascular neurosurgical procedures. Outside of neurosurgery, Eric enjoys skiing, tennis, hiking, watching sports, and spending time with his wife, Jessica.

Clinical Focus

  • Neurosurgery
  • Cerebrovascular Disease
  • Endovascular Neurosurgery
  • Interventional Neuroradiology
  • Intracranial Aneurysms
  • Subarachnoid Hemorrhage
  • Cerebral Vasospasm
  • Cerebral Arteriovenous Malformations
  • Dural Arteriovenous Fistulas
  • Stroke
  • Thrombectomy
  • Intracerebral Hemorrhage
  • Subdural Hematoma
  • Radiosurgery
  • Residency

Honors & Awards

  • Joe Niekro Research Grant, Society of Neurointerventional Surgeons (SNIS) (2019-2020)
  • Socioeconomic Fellow, Council of State Neurosurgical Societies (CSNS) (2019-2020)
  • AOA Medical Honor Society, Icahn School of Medicine at Mount Sinai (2014)
  • Gold Humanism Honor Society, Icahn School of Medicine at Mount Sinai (2014)
  • Doris Duke Clinical Research Fellowship, Columbia University Medical Center (2012-2013)
  • Summer Research Scholar Award, Icahn School of Medicine at Mount Sinai (2010)

Boards, Advisory Committees, Professional Organizations

  • Member, American Association of Neurological Surgeons (AANS) (2012 - Present)
  • Member, Congress of Neurological Surgeons (CNS) (2013 - Present)
  • Member, Society of Neurointerventional Surgeons (SNIS) (2018 - Present)
  • Member, California Association of Neurological Surgeons (CANS) (2014 - Present)
  • Member, American Society of Neuroradiology (2018 - Present)

Professional Education

  • M.D., Icahn School of Medicine at Mount Sinai, Medicine (2014)
  • B.S, Duke University, Neurobiology (2009)

Research & Scholarship

Current Research and Scholarly Interests

My primary academic interest is to expand the scope of precision medicine in cerebrovascular neurosurgery. Specifically, I utilize advanced neuroimaging, electrophysiology, and proteomics and metabolomics in order to optimize and personalize the clinical management of patients with hemorrhagic and ischemic stroke. In addition, I utilize large institutional and national databases to advance clinical outcomes following cerebrovascular insults, and to clarify how improvements in systems-based practices can improve the quality and value of care for cerebrovascular patients.

Current Clinical Interests

  • Cerebrovascular Neurosurgery
  • Endovascular Neurosurgery
  • Neurosurgery

Lab Affiliations

Publications

All Publications

  • Hypoperfusion Intensity Ratio Correlates With Angiographic Collaterals In Acute Ischemic Stroke With M1 Occlusion. European journal of neurology Guenego, A., Fahed, R., Albers, G. W., Kuraitis, G., Sussman, E. S., Martin, B. W., Marcellus, D. G., Olivot, J., Marks, M. P., Lansberg, M. G., Wintermark, M., Heit, J. J. 2020

    Abstract

    PURPOSE: Among patients with an acute ischemic stroke (AIS) secondary to large-vessel-occlusion, the hypoperfusion-intensity-ratio (HIR, TMax>10 volume / TMax>6 volume) is a strong predictor of infarct growth. We studied the correlation between HIR and collaterals assessed with digital-subtraction-angiography (DSA) before thrombectomy.METHODS: Between January 2014 and March 2018, consecutive patients with an AIS and a M1 middle-cerebral-artery occlusion who underwent perfusion imaging and endovascular treatment at our center were screened. Ischemic core (mL), HIR and perfusion mismatch (TMax>6sec minus core volume) were assessed through MRI or CT perfusion. Collaterals were assessed on pre-intervention DSA using the American-Society of Interventional and Therapeutic-Neuroradiology/Society of Interventional-Radiology (ASITN/SIR) scale. Baseline clinical and perfusion characteristics were compared between patients with good (ASITN/SIR 3-4) and those with poor (ASITN/SIR 0-2) DSA collaterals. Correlation between HIR and ASITN/SIR was evaluated using Pearson's correlation. ROC analysis was performed to determine the optimal HIR threshold for the prediction of good DSA collaterals.RESULTS: Ninety-eight patients were included. 49% (48/98) had good DSA collaterals, those patients had significantly smaller hypoperfusion volumes (TMax >6sec 89mL versus 125mL; p=0.007) and perfusion mismatch volumes (72mL versus 89mL; p=0.016). HIR was significantly correlated with DSA collaterals (-0.327 [IC 95%: -0.494 to -0.138; p=0.01]). A HIR cut-off of <0.4 best predicted good DSA collaterals with an odds ratio of 4.3 (1.8-10.1) (Sensitivity=0.792, Specificity=0.560, AUC=0.708).CONCLUSION: HIR is a robust indicator of angiographic collaterals and might be used as a surrogate of collateral assessment in patients undergoing MRI. HIR<0.4 best predicted good DSA collaterals.

    View details for DOI 10.1111/ene.14181

    View details for PubMedID 32068938

  • Conventional Versus Stereotactic Image Guided Pedicle Screw Placement During Spinal Deformity Correction: A Retrospective Propensity Score-Matched Study of a National Longitudinal Database. The International journal of neuroscience Rezaii, P. G., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2020: 1?13

    Abstract

    Purpose/aim: To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity.Methods: The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses.Results: A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures (p?=?0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions (p?=?0.0295), as well as 30- and 90-day postoperative revisions (30-day: p?=?0.0304, 90-day: p?=?0.0059). Hospital, physician, and total payments favored the conventional group for initial admission (p?=?0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups.Conclusions: Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.

    View details for DOI 10.1080/00207454.2020.1763343

    View details for PubMedID 32364414

  • Dual antiplatelet therapy after carotid artery stenting: trends and outcomes in a large national database. Journal of neurointerventional surgery Sussman, E. S., Jin, M., Pendharkar, A. V., Pulli, B., Feng, A., Heit, J. J., Telischak, N. A. 2020

    Abstract

    While dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established.We canvassed a large national database (IBM MarketScan) to identify patients receiving carotid endarterectomy (CEA) or CAS for treatment of ischemic stroke or carotid artery stenosis from 2007 to 2016. We performed univariable and multivariable regression methods to evaluate the impact of covariates on post-CAS stroke-free survival, including post-discharge antiplatelet therapy.A total of 79?084 patients diagnosed with ischemic stroke or carotid stenosis received CEA (71 178; 90.0%) or CAS (7906; 10.0%). After adjusting for covariates, <180 days prescribed post-CAS P2Y12-inhibition was associated with increased risk for stroke (<90 prescribed days HR=1.421, 95%?CI 1.038 to 1.946; 90-179 prescribed days HR=1.484, 95%?CI 1.045 to 2.106). The incidence of hemorrhagic complications was higher during the period of prescribed P2Y12-inhibition (1.16% per person-month vs 0.49% per person-month after discontinuation, P<0.001). The rate of extracranial hemorrhage was nearly six-fold higher while on dAPT (6.50% per patient-month vs 1.16% per patient-month, P<0.001), and there was a trend towards higher rate of intracranial hemorrhage that did not reach statistical significance (5.09% per patient-month vs 3.69% per patient-month, P=0.0556). Later hemorrhagic events beyond 30 days post-CAS were significantly more likely to be extracranial (P=0.028).Increased duration of post-CAS dAPT is associated with lower rates of readmissions for stroke, and with increased risk of hemorrhagic complications, particularly extracranial hemorrhage. The potential benefit of prolonging dAPT with regard to ischemic complications must be balanced with the corresponding increased risk of predominantly extracranial hemorrhagic complications.

    View details for DOI 10.1136/neurintsurg-2020-016008

    View details for PubMedID 32414894

  • Functional Mapping for Glioma Surgery: A Propensity-matched Analysis of Outcomes and Cost. World neurosurgery Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Li, G., Desai, A. M. 2020

    Abstract

    To compare clinical outcomes and payments between glioma resections with and without functional mapping.The Thomas Reuters MarketScan national longitudinal database was used to identify patients undergoing resection of supratentorial primary malignant glioma with or without functional mapping between 2007-2016. Patients were stratified into mapped and unmapped (conventional) groups, and subsequently propensity-matched based on demographics, clinical comorbidities, and surgical characteristics (i.e., use of stereotactic navigation, microscope, intratumoral chemotherapy). Outcomes and charges were compared between matched groups using bivariate analyses.A total of 14,037 patients were identified, of which 796 (6.0%) received functional mapping. Propensity-matching (1:1) resulted in 796 mapped patients and 796 propensity-matched controls. Thirty-day postoperative rates of new-onset seizures, cerebral edema, hemorrhage, and neurological deficits were significantly lower for the functional mapping group (all p < 0.05). Functional mapping was also associated with shorter hospital length of stay (p = .0144), lower 30-day rates of emergency department visits (p = .0001) and fewer reoperations (p = .0068). Total costs of initial admission were not significantly different between groups.Intraoperative functional mapping during glioma resection was associated with decreased complications, reoperations, emergency department visits, and shorter lengths of stay. Furthermore, total charges of mapped resections were not significantly different from those of conventional resections. These findings support the utility of functional mapping for resection of supratentorial primary malignant gliomas.

    View details for DOI 10.1016/j.wneu.2020.01.197

    View details for PubMedID 32028000

  • Postoperative outcomes following pediatric intracranial electrode monitoring: A case for stereoelectroencephalography (SEEG). Epilepsy & behavior : E&B Kim, L. H., Parker, J. J., Ho, A. L., Pendharkar, A. V., Sussman, E. S., Halpern, C. H., Porter, B., Grant, G. A. 2020; 104 (Pt A): 106905

    Abstract

    For patients with medically refractory epilepsy, intracranial electrode monitoring can help identify epileptogenic foci. Despite the increasing utilization of stereoelectroencephalography (SEEG), the relative risks or benefits associated with the technique when compared with the traditional subdural electrode monitoring (SDE) remain unclear, especially in the pediatric population. Our aim was to compare the outcomes of pediatric patients who received intracranial monitoring with SEEG or SDE (grids and strips).We retrospectively studied 38 consecutive pediatric intracranial electrode monitoring cases performed at our institution from 2014 to 2017. Medical/surgical history and operative/postoperative records were reviewed. We also compared direct inpatient hospital costs associated with the two procedures.Stereoelectroencephalography and SDE cohorts both showed high likelihood of identifying epileptogenic zones (SEEG: 90.9%, SDE: 87.5%). Compared with SDE, SEEG patients had a significantly shorter operative time (118.7 versus 233.4?min, P?

    View details for DOI 10.1016/j.yebeh.2020.106905

    View details for PubMedID 32028127

  • Utilization of Novel High-Resolution, MRI-Based Vascular Imaging Modality for Preoperative Stereoelectroencephalography Planning in Children: A Technical Note. Stereotactic and functional neurosurgery Feng, A. Y., Ho, A. L., Kim, L. H., Sussman, E. S., Pendharkar, A. V., Iv, M., Yeom, K. W., Halpern, C. H., Grant, G. A. 2020: 1?7

    Abstract

    Stereoelectroencephalography (SEEG) is a powerful intracranial diagnostic tool that requires accurate imaging for proper electrode trajectory planning to ensure efficacy and maximize patient safety. Computed tomography (CT) angiography and digital subtraction angiography are commonly used, but recent developments in magnetic resonance angiography allow for high-resolution vascular visualization without added risks of radiation. We report on the accuracy of electrode placement under robotic assistance planning utilizing a novel high-resolution magnetic resonance imaging (MRI)-based imaging modality.Sixteen pediatric patients between February 2014 and October 2017 underwent SEEG exploration for epileptogenic zone localization. A gadolinium-enhanced 3D T1-weighted spoiled gradient recalled echo sequence with minimum echo time and repetition time was applied for background parenchymal suppression and vascular enhancement. Electrode placement accuracy was determined by analyzing postoperative CT scans laid over preoperative virtual electrode trajectory paths. Entry point, target point, and closest vessel intersection were measured.For any intersection along the trajectory path, 57 intersected vessels were measured. The mean diameter of an intersected vessel was 1.0343 ± 0.1721 mm, and 21.05% of intersections involved superficial vessels. There were 157 overall intersection + near-miss events. The mean diameter for an involved vessel was 1.0236 ± 0.0928 mm, and superficial vessels were involved in 20.13%. Looking only at final electrode target, 3 intersection events were observed. The mean diameter of an intersected vessel was 1.0125 ± 0.2227 mm. For intersection + near-miss events, 24 were measured. An involved vessel's mean diameter was 1.1028 ± 0.2634 mm. For non-entry point intersections, 45 intersected vessels were measured. The mean diameter for intersected vessels was 0.9526 ± 0.0689 mm. For non-entry point intersections + near misses, 126 events were observed. The mean diameter for involved vessels was 0.9826 ± 0.1008 mm.We believe this novel sequence allows better identification of superficial and deeper subcortical vessels compared to conventional T1-weighted gadolinium-enhanced MRI.

    View details for DOI 10.1159/000503693

    View details for PubMedID 32062664

  • Contralateral acute vascular occlusion following revascularization surgery for moyamoya disease JOURNAL OF NEUROSURGERY Sussman, E. S., Madhugiri, V., Teo, M., Nielsen, T. H., Furtado, S., Pendharkar, A., Ho, A. L., Esparza, R., Azad, T. D., Zhang, M., Steinberg, G. K. 2019; 131 (6): 1702?8

    Abstract

    OBJECTIVERevascularization surgery is a safe and effective surgical treatment for symptomatic moyamoya disease (MMD) and has been shown to reduce the frequency of future ischemic events and improve quality of life in affected patients. The authors sought to investigate the occurrence of acute perioperative occlusion of the contralateral internal carotid artery (ICA) with contralateral stroke following revascularization surgery, a rare complication that has not been previously reported.METHODSThis study is a retrospective review of a prospective database of a single surgeon's series of revascularization operations in patients with MMD. From 1991 to 2016, 1446 bypasses were performed in 905 patients, 89.6% of which involved direct anastomosis of the superficial temporal artery (STA) to a distal branch of the middle cerebral artery (MCA). Demographic, surgical, and radiographic data were collected prospectively in all treated patients.RESULTSSymptomatic contralateral hemispheric infarcts occurred during the postoperative period in 34 cases (2.4%). Digital subtraction angiography (DSA) was performed in each of these patients. In 8 cases (0.6%), DSA during the immediate postoperative period revealed associated new occlusion of the contralateral ICA. In each of these cases, revascularization surgery involved direct anastomosis of the STA to an M4 branch of the MCA. Preoperative DSA revealed moderate (n = 1) or severe (n = 3) stenosis or occlusion (n = 4) of the ipsilateral ICA and mild (n = 2), moderate (n = 4), or severe (n = 2) stenosis of the contralateral ICA. The baseline Suzuki stage was 4 (n = 7) or 5 (n = 1). The collateral supply originated exclusively from the intracranial circulation in 4/8 patients (50%), and from both the intracranial and extracranial circulation in the remaining 50% of patients. Seven (88%) of 8 patients improved symptomatically during the acute postoperative period with induced hypertension. The modified Rankin Scale (mRS) score at discharge was worse than baseline in 7/8 patients (88%), whereas 1 patient had only minor deficits that did not affect the mRS score. At the 3-year follow-up, 3/8 patients (38%) were at their baseline mRS score or better, 1 patient had significant disability compared with preoperatively, 2 patients had died, and 1 patient was lost to follow-up. Three-year follow-up is not yet available in 1 patient.CONCLUSIONSAcute occlusion of the ICA on the contralateral side from an STA-MCA bypass is a rare, but potentially serious, complication of revascularization surgery for MMD. It highlights the importance of the hemodynamic interrelationships that exist between the two hemispheres, a concept that has been previously underappreciated. Induced hypertension during the acute period may provide adequate cerebral blood flow via developing collateral vessels, and good outcomes may be achieved with aggressive supportive management and expedited contralateral revascularization.

    View details for DOI 10.3171/2018.8.JNS18951

    View details for Web of Science ID 000500253800003

    View details for PubMedID 30554188

  • Outcomes After Cervical Disc Arthroplasty Versus Stand-Alone Anterior Cervical Discectomy and Fusion: A Meta-Analysis GLOBAL SPINE JOURNAL Gendreau, J. L., Kim, L. H., Prins, P. N., D'Souza, M., Rezaii, P., Pendharkar, A., Sussman, E. S., Ho, A. L., Desai, A. M. 2019

    View details for DOI 10.1177/2192568219888448

    View details for Web of Science ID 000498222100001

  • Conventional Versus Stereotactic Image-guided Pedicle Screw Placement During Posterior Lumbar Fusions: A Retrospective Propensity Score-matched Study of a National Longitudinal Database. Spine Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2019; 44 (21): E1272?E1280

    Abstract

    STUDY DESIGN: Retrospective 1:1 propensity score-matched analysis on a national longitudinal database between 2007 and 2016.OBJECTIVE: The aim of this study was to compare complication rates, revision rates, and payment differences between navigated and conventional posterior lumbar fusion (PLF) procedures with instrumentation.SUMMARY OF BACKGROUND DATA: Stereotactic navigation techniques for spinal instrumentation have been widely demonstrated to improve screw placement accuracies and decrease perforation rates when compared to conventional fluoroscopic and free-hand techniques. However, the clinical utility of navigation for instrumented PLF remains controversial.METHODS: Patients who underwent elective laminectomy and instrumented PLF were stratified into "single level" and "3- to 6-level" cohorts. Navigation and conventional groups within each cohort were balanced using 1:1 propensity score matching, resulting in 1786 navigated and conventional patients in the single-level cohort and 2060 in the 3 to 6 level cohort. Outcomes were compared using bivariate analysis.RESULTS: For the single-level cohort, there were no significant differences in rates of complications, readmissions, revisions, and length of stay between the navigation and conventional groups. For the 3- to 6-level cohort, length of stay was significantly longer in the navigation group (P?

    View details for DOI 10.1097/BRS.0000000000003130

    View details for PubMedID 31634303

  • Perfusion Computed Tomography in Acute Ischemic Stroke. Radiologic clinics of North America Heit, J. J., Sussman, E. S., Wintermark, M. 2019; 57 (6): 1109?16

    Abstract

    Occlusion of a cervical or cerebral artery may cause acute ischemic stroke (AIS). Recent advances in AIS treatment by endovascular thrombectomy have led to more widespread use of advanced computed tomography (CT) imaging, including perfusion CT (PCT). This article reviews PCT for the evaluation of AIS patients.

    View details for DOI 10.1016/j.rcl.2019.06.003

    View details for PubMedID 31582038

  • Propensity-matched Comparison of Outcomes and Costs After Macroscopic and Microscopic Anterior Cervical Corpectomy Using a National Longitudinal Database. Spine Ho, A. L., Rezaii, P. G., Pendharkar, A. V., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2019; 44 (21): E1281?E1288

    Abstract

    STUDY DESIGN: A retrospective analysis of national longitudinal database.OBJECTIVE: The aim of this study was to examine the outcomes and cost-effectiveness of operating microscope utilization in anterior cervical corpectomy (ACC).SUMMARY OF BACKGROUND DATA: The operating microscope allows for superior visualization and facilitates ACC with less manipulation of tissue and improved decompression of neural elements. However, many groups report no difference in outcomes with increased cost associated with microscope utilization.METHODS: A longitudinal database (MarketScan) was utilized to identify patients undergoing ACC with or without microscope between 2007 and 2016. Propensity matching was performed to normalize differences between the two cohorts. Outcomes and costs were subsequently compared.RESULTS: A total of 11,590 patients were identified for the "macroscopic" group, while 4299 patients were identified for the "microscopic" group. For the propensity-matched analysis, 4298 patients in either cohort were successfully matched according to preoperative characteristics. Hospital length of stay was found to be significantly longer in the macroscopic group than the microscopic group (1.86 nights vs. 1.56 nights, P?

    View details for DOI 10.1097/BRS.0000000000003147

    View details for PubMedID 31634304

  • Grade II Spondylolisthesis: Reverse Bohlman Procedure with Trans-Discal S1-L5 and S2Ai Screws Placed with Robotic Guidance. World neurosurgery Ho, A. L., Varshneya, K., Medress, Z. A., Pendharkar, A. V., Sussman, E. S., Cheng, I., Veeravagu, A. 2019

    Abstract

    STUDY DESIGN: Technical Report with two illustrative cases.OBJECTIVE: Grade II spondylolisthesis remains a complex surgical pathology for which there is no consensus regarding optimal surgical strategies. Surgical strategies vary regarding extent of reduction, utilization of instrumentation/interbody support, and anterior versus posterior approaches with or without decompression. The objective of this study is to provide the first report on the efficacy of robotic spinal surgery systems in supporting the treatment of grade II spondylolisthesis.METHODS: Utilizing two illustrative cases, we provide a technical report of how a robotic spinal surgery platform can be utilized to treatment grade II spondylolisthesis with a novel instrumentation strategy.RESULTS: We describe how utilization of the "Reverse Bohlman" technique to achieve a large anterior fusion construct spanning the pathologic level and buttressed by the adjacent level above, coupled with a novel, high fidelity posterior fixation scheme with transdiscal S1-L5 and S2Ai screws placed in a minimally invasive fashion with robot guidance allows for the best chance of fusion in situ.CONCLUSIONS: The "Reverse Bohlman" technique coupled with transdiscal S1-L5 and S2Ai screw fixation accomplishes the surgical goals of creating a solid fusion construct, avoiding neurologic injury with aggressive reduction, and halting the progression of anterolisthesis. Utilization of robot guidance allows for efficient placement of these difficult screw trajectories in a minimally invasive fashion.

    View details for DOI 10.1016/j.wneu.2019.07.229

    View details for PubMedID 31398524

  • Preoperative Risk Stratification in Spine Tumor Surgery: A Comparison of the Modified Charlson Index, Frailty Index, and ASA Score. Spine Lakomkin, N., Zuckerman, S. L., Stannard, B., Montejo, J., Sussman, E. S., Virojanapa, J., Kuzmik, G., Goz, V., Hadjipanayis, C. G., Cheng, J. S. 2019; 44 (13): E782?E787

    Abstract

    STUDY DESIGN: A retrospective review of prospectively collected data.OBJECTIVE: The purpose of this study is to compare and validate several preoperative scores for predicting outcomes following spine tumor resection.SUMMARY OF BACKGROUND DATA: Preoperative risk assessment for patients undergoing spinal tumor resection remains challenging. At present, few risk assessment tools have been validated in this high-risk population.METHODS: The 2008 to 2014 National Surgical Quality Improvement database was used to identify all patients undergoing surgical resection of spinal tumors, stratified as extradural, intradural extramedullary, and intramedullary based on CPT codes. American Society of Anesthesiologists (ASA) score, modified Charlson Comorbidity Index (CCI), and modified Frailty Index (mFI) were computed. A binary logistic regression model was used to explore the relationship between these variables and postoperative outcomes, including mortality, major and minor adverse events, and hospital length of stay (LOS). Other significant variables such as demographics, operative time, and tumor location were controlled for in each model.RESULTS: Two thousand one hundred seventy patients met the inclusion criteria. Higher CCI scores were independent predictors of mortality (OR?=?1.24, 95% CI: 1.14-1.36, P?

    View details for DOI 10.1097/BRS.0000000000002970

    View details for PubMedID 31205174

  • Focal Intramedullary Spinal Cord Lesion in Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome: Toxoplasmosis Versus Lymphoma WORLD NEUROSURGERY Mohole, J., Ho, A. L., Sussman, E. S., Pendharkar, A. V., Lee, M. 2019; 127: 227?31

    View details for DOI 10.1016/j.wneu.2019.04.057

    View details for Web of Science ID 000473128300201

  • Deep Brain Stimulation for Chronic Cluster Headache: A Review NEUROMODULATION Vyas, D. B., Ho, A. L., Dadey, D. Y., Pendharkar, A. V., Sussman, E. S., Cowan, R., Halpern, C. H. 2019; 22 (4): 388?97

    View details for DOI 10.1111/ner.12869

    View details for Web of Science ID 000471831000003

  • Image-guided Percutaneous Polymethylmethacrylate-augmented Spondylodesis for Painful Metastasis in the Veteran Population CUREUS Sussman, E. S., Ho, A., Pendharkar, A., Tharin, S. 2019; 11 (4)

    View details for DOI 10.7759/cureus.4509

    View details for Web of Science ID 000467806100007

  • Focal Intramedullary Spinal Cord Lesion in HIV/AIDs: Toxoplasmosis vs. Lymphoma. World neurosurgery Mohole, J., Ho, A. L., Sussman, E. S., Pendharkar, A. V., Lee, M. 2019

    Abstract

    BACKGROUND: Neurological complications are common in HIV/AIDS patients.1 While both the central nervous system (CNS) and the peripheral nervous system (PNS) can be affected, up to 80% of HIV/AIDS patients have CNS involvement during the course of their illness.2,3 The brain is the primary site of HIV/AIDS associated CNS complications. Spinal cord involvement is rare, particularly focal intramedullary spinal cord lesions without any associated cerebral lesions.4-6 Amongst various opportunistic infections and malignancies, toxoplasmosis and CNS lymphoma represent the most common cause of focal neurological disease in HIV/AIDS patients.4,5,7 However, distinguishing between toxoplasmosis and CNS lymphoma is challenging as both diseases have similar clinical presentations.CASE DESCRIPTION: This report demonstrates a case of myelopathy presenting as an isolated, single intramedullary spinal cord lesion in a newly diagnosed HIV positive female. Additionally, we discuss common methods of diagnostic distinction between the toxoplasmosis and CNS lymphoma.CONCLUSION: We suggest that there should be a high-index of suspicion for toxoplasmosis in HIV/AIDS patients presenting with a focal intramedullary spinal cord lesion.

    View details for PubMedID 30981796

  • Analysis of Outcomes and Cost of Inpatient and Ambulatory Anterior Cervical Disk Replacement Using a State-level Database. Clinical spine surgery Purger, D. A., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2019

    Abstract

    Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures.The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR.Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001).ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.

    View details for DOI 10.1097/BSD.0000000000000840

    View details for PubMedID 31180992

  • Thrombectomy for acute ischemic stroke in nonagenarians compared with octogenarians. Journal of neurointerventional surgery Sussman, E. S., Martin, B., Mlynash, M., Marks, M. P., Marcellus, D., Albers, G., Lansberg, M., Dodd, R., Do, H. M., Heit, J. J. 2019

    Abstract

    Multiple randomized trials have shown that endovascular thrombectomy (EVT) leads to improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Elderly patients were poorly represented in these trials, and the efficacy of EVT in nonagenarian patients remains uncertain.We performed a retrospective cohort study at a single center. Inclusion criteria were: age 80-99, LVO, core infarct <70?mL, and salvageable penumbra. Patients were stratified into octogenarian (80-89) and nonagenarian (90-99) cohorts. The primary outcome was the ordinal score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included dichotomized functional outcome (mRS ?2?vs mRS ?3), successful revascularization, symptomatic intracranial hemorrhage (ICH), and mortality.108 patients met the inclusion criteria, including 79 octogenarians (73%) and 29 nonagenarians (27%). Nonagenarians were more likely to be female (86% vs 58%; p<0.01); there were no other differences between groups in terms of demographics, medical comorbidities, or treatment characteristics. Successful revascularization (TICI 2b-3) was achieved in 79% in both cohorts. Median mRS at 90 days was 5 in octogenarians and 6 in nonagenarians (p=0.09). Functional independence (mRS ?2) at 90 days was achieved in 12.5% and 19.7% of nonagenarians and octogenarians, respectively (p=0.54). Symptomatic ICH occurred in 21.4% and 6.4% (p=0.03), and 90-day mortality rate was 63% and 40.9% (p=0.07) in nonagenarians and octogenarians, respectively.Nonagenarians may be at higher risk of symptomatic ICH than octogenarians, despite similar stroke- and treatment-related factors. While there was a trend towards higher mortality and worse functional outcomes in nonagenarians, the difference was not statistically significant in this relatively small retrospective study.

    View details for DOI 10.1136/neurintsurg-2019-015147

    View details for PubMedID 31350369

  • Image-guided Percutaneous Polymethylmethacrylate-augmented Spondylodesis for Painful Metastasis in the Veteran Population. Cureus Sussman, E. S., Ho, A., Pendharkar, A. V., Tharin, S. 2019; 11 (4): e4509

    Abstract

    The treatment of painful spinal metastases in patients with limited life-expectancy, significant perioperative risks, and poor bone quality poses a surgical challenge. Recent advances in minimal-access spine surgery allow for the surgical treatment of patients previously considered not to be operative candidates. The addition of fenestrated screws for cement augmentation to existing image-guided percutaneous pedicle screw fixation can enhance efficiency, decrease risk of hardware complications, and improve back pain in this patient population. The patient is a 70-year-old man with severe axial back pain due to metastatic prostate cancer and L5 pathologic fractures not amenable to kyphoplasty. In the setting of a 6-12-month life-expectancy, the primary goal of surgery was relief of back pain associated with instability with minimal operative morbidity and post-operative recovery time. This was achieved with an internal fixation construct including percutaneously placed cement-augmented fenestrated pedicle screws at L4 and S1. The patient was discharged to home on post-operative day 1 with substantial improvement of his low back pain. Image-guided, percutaneous placement of fenestrated, cement-augmented pedicle screws is an emerging treatment for back pain associated with metastasis. Fenestrated screws allow for integrated cement augmentation. The minimal associated blood loss and recovery time make this approach an option even for patients with limited life-expectancy. This is the first report of utilization of this technique for the veteran population.

    View details for DOI 10.7759/cureus.4509

    View details for PubMedID 31259118

    View details for PubMedCentralID PMC6590854

  • Topical Vancomycin for Surgical Prophylaxis in Pediatric Craniofacial Surgeries. The Journal of craniofacial surgery Mohole, J., Ho, A. L., Cannon, J. G., Pendharkar, A. V., Sussman, E. S., Hong, D. S., Cheshier, S. H., Grant, G. A. 2019

    Abstract

    Topical vancomycin has been demonstrated to be safe and effective for reducing surgical site infections (SSIs) following spine surgery in both adults and children, however, there are no studies of its efficacy in reducing SSIs in craniofacial surgery. The SSIs are one of the most common complications following craniofacial surgery. The complexity of craniofacial procedures, use of grafts and implants, long operative durations and larger surgical wounds all contribute to the heightened risk of SSIs in pediatric craniofacial cases. A retrospective review of all open and endoscopic pediatric craniofacial procedures performed between May 2014 and December 2017 at a single children's hospital was conducted to examine SSI rates between patients receiving topical vancomycin and a historical control group. The treatment group received topical vancomycin irrigation before wound closure. An ad-hoc cost analysis was performed to determine the cost-savings associated with topical vancomycin use. A total of 132 craniofacial procedures were performed during the study period, with 50 cases in the control group and 82 cases in the vancomycin group. Overall, SSI rate was 3.03%. Use of topical vancomycin irrigation led to a significant reduction in SSIs (4/50 SSI or 8.0% in control group vs 0/82 or 0% in vancomycin group, P?=?0.04). No adverse events were observed with topical vancomycin use. The potential cost-savings associated with the use of topical vancomycin as SSI prophylaxis in this study was $102,152. Addition of topical vancomycin irrigation as routine surgical infection prophylaxis can be an effective and low-cost method for reducing SSI in pediatric craniofacial surgery.

    View details for DOI 10.1097/SCS.0000000000005708

    View details for PubMedID 31261326

  • Topical vancomycin for surgical prophylaxis in non-instrumented pediatric spinal surgeries CHILDS NERVOUS SYSTEM Cannon, J. D., Ho, A. L., Mohole, J., Pendharkar, A. V., Sussman, E. S., Cheshier, S. H., Grant, G. A. 2019; 35 (1): 107?11

    View details for DOI 10.1007/s00381-018-3881-z

    View details for Web of Science ID 000456311300016

  • Brain abscess caused by Trueperella bernardiae in a child. Surgical neurology international Pan, J., Ho, A. L., Pendharkar, A. V., Sussman, E. S., Casazza, M., Cheshier, S. H., Grant, G. A. 2019; 10: 35

    Abstract

    Background: Recurrent intracranial abscesses secondary to refractory otitis media present a challenge which demands multidisciplinary collaboration.Case Description: We present the first known case of pediatric brain abscess caused by a polymicrobial infection of Trueperella bernardiae, Actinomyces europaeus, and mixed anaerobic species resulting from acute-on-chronic suppurative left otitis media. This patient required two separate stereotactic abscess drainages and a complex course of antibiotics for successful management.Conclusion: Surgery is essential in the management of cerebral abscess both in agent identification and therapeutic drainage. Management of abscesses secondary to unusual and polymicrobial organisms often requires consultation from other medical and surgical specialties.

    View details for DOI 10.4103/sni.sni_376_17

    View details for PubMedID 31528373

  • Milestones in stereotactic radiosurgery for the central nervous system. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia Mitrasinovic, S., Zhang, M., Appelboom, G., Sussman, E., Moore, J. M., Hancock, S. L., Adler, J. R., Kondziolka, D., Steinberg, G. K., Chang, S. D. 2019; 59: 12?19

    Abstract

    INTRODUCTION: Since Lars Leksell developed the first stereotactic radiosurgery (SRS) device in 1951, there has been growth in the technologies available and clinical indications for SRS. This expansion has been reflected in the medical literature, which is built upon key articles and institutions that have significantly impacted SRS applications. Our aim was to identify these prominent works and provide an educational tool for training and further inquiry.METHOD: A list of search phrases relating to central nervous system applications of stereotactic radiosurgery was compiled. A topic search was performed using PubMed and Scopus databases. The journal, year of publication, authors, treatment technology, clinical subject, study design and level of evidence for each article were documented. Influence was proposed by citation count and rate.RESULTS: Our search identified a total of 10,211 articles with the top 10 publications overall on the study of SRS spanning 443-1313 total citations. Four articles reported on randomized controlled trials, all of which evaluated intracranial metastases. The most prominent subtopics included SRS for arteriovenous malformation, glioblastoma, and acoustic neuroma. Greatest representation by treatment modality included Gamma Knife, LINAC, and TomoTherapy.CONCLUSIONS: This systematic reporting of the influential literature on SRS for intracranial and spinal pathologies underscores the technology's rapid and wide reaching clinical applications. Moreover the findings provide an academic guide to future health practitioners and engineers in their study of SRS for neurosurgery.

    View details for PubMedID 30595165

  • Preoperative Risk Stratification in Spine Tumor Surgery - A Comparison of the Modified Charlson Index, Frailty Index, and ASA Score. Spine Lakomkin, N., Zuckerman, S. L., Stannard, B., Montejo, J., Sussman, E. S., Virojanapa, J., Kuzmik, G., Goz, V., Hadjipanayis, C. G., Cheng, J. S. 2018

    Abstract

    STUDY DESIGN: Retrospective review of prospectively collected data.OBJECTIVE: The purpose of this study is to compare and validate several preoperative scores for predicting outcomes following spine tumor resection.SUMMARY OF BACKGROUND DATA: Preoperative risk assessment for patients undergoing spinal tumor resection remains challenging. At present, few risk assessment tools have been validated in this high-risk population.METHODS: The 2008-2014 National Surgical Quality Improvement database was used to identify all patients undergoing surgical resection of spinal tumors, stratified as extradural, intradural extramedullary, and intramedullary based on CPT codes. ASA score, modified Charlson Comorbidity Index (CCI), and modified Frailty Index (mFI) were computed. A binary logistic regression model was used to explore the relationship between these variables and postoperative outcomes including mortality, major and minor adverse events, and hospital length of stay (LOS). Other significant variables such as demographics, operative time, and tumor location were controlled for in each model.RESULTS: 2,170 patients met the inclusion criteria. Higher CCI scores were independent predictors of mortality (OR?=?1.24, 95%CI: 1.14-1.36, P?

    View details for PubMedID 30601357

  • Minimally invasive approaches to craniosynostosis JOURNAL OF NEUROSURGICAL SCIENCES Pendharkar, A. V., Shahin, M. N., Cavallo, C., Zhao, X., Ho, A. L., Sussman, E. S., Grant, G. A. 2018; 62 (6): 745?64

    View details for DOI 10.23736/S0390-5616.18.04483-1

    View details for Web of Science ID 000456647700013

  • Topical vancomycin surgical prophylaxis in pediatric open craniotomies: an institutional experience JOURNAL OF NEUROSURGERY-PEDIATRICS Ho, A. L., Cannon, J. D., Mohole, J., Pendharkar, A., Sussman, E. S., Li, G., Edwards, M. B., Cheshier, S. H., Grant, G. A. 2018; 22 (6): 710?15

    View details for DOI 10.3171/2018.5.PEDS17719

    View details for Web of Science ID 000453578500017

  • Robot guided pediatric stereoelectroencephalography: single-institution experience JOURNAL OF NEUROSURGERY-PEDIATRICS Ho, A. L., Muftuoglu, Y., Pendharkar, A., Sussman, E. S., Porter, B. E., Halpern, C. H., Grant, G. A. 2018; 22 (5): 489?96

    View details for DOI 10.3171/2018.5.PEDS17718

    View details for Web of Science ID 000448982800004

  • Deep Brain Stimulation for Chronic Cluster Headache: A Review. Neuromodulation : journal of the International Neuromodulation Society Vyas, D. B., Ho, A. L., Dadey, D. Y., Pendharkar, A. V., Sussman, E. S., Cowan, R., Halpern, C. H. 2018

    Abstract

    OBJECTIVES: Cluster headaches are a set of episodic and chronic pain syndromes that are sources of significant morbidity for patients. The standard of care for cluster headaches remains medication therapy, however a minority of patients will remain refractory to treatment despite changes to dosage and therapeutic combinations. In these patients, functional neuromodulation using Deep Brain Stimulation (DBS) presents the opportunity to alleviate the significant pain that is experienced by targeting the neurophysiological substrates that mediate pain.MATERIAL AND METHODS: We review the literature on chronic cluster headache, including the growing number of DBS case reports and series that describe the alleviation of pain in a majority of patients through conventional or endoventricular targeting of the posterior hypothalamus and ventral tegmental area, with a minimal side effect profile.RESULTS: In this review, the history and outcomes of DBS use for medication-refractory cluster headaches are examined, with discussion on future directions for improving this novel treatment modality and providing efficacious, longer-lasting pain relief in headache patients.CONCLUSION: In patients with chronic cluster headache, functional neuromodulation using DBS presents the opportunity to alleviate the significant pain that is experienced by targeting the neurophysiological substrates that mediate pain.

    View details for PubMedID 30303584

  • Stereoelectroencephalography in children: a review. Neurosurgical focus Ho, A. L., Feng, A. Y., Kim, L. H., Pendharkar, A. V., Sussman, E. S., Halpern, C. H., Grant, G. A. 2018; 45 (3): E7

    Abstract

    Stereoelectroencephalography (SEEG) is an intracranial diagnostic measure that has grown in popularity in the United States as outcomes data have demonstrated its benefits and safety. The main uses of SEEG include 1) exploration of deep cortical/sulcal structures; 2) bilateral recordings; and 3) 3D mapping of epileptogenic zones. While SEEG has gradually been accepted for treatment in adults, there is less consensus on its utility in children. In this literature review, the authors seek to describe the current state of SEEG with a focus on the more recent technology-enabled surgical techniques and demonstrate its efficacy in the pediatric epilepsy population.

    View details for PubMedID 30173607

  • Robot-guided pediatric stereoelectroencephalography: single-institution experience. Journal of neurosurgery. Pediatrics Ho, A. L., Muftuoglu, Y., Pendharkar, A. V., Sussman, E. S., Porter, B. E., Halpern, C. H., Grant, G. A. 2018: 1?8

    Abstract

    OBJECTIVE Stereoelectroencephalography (SEEG) has increased in popularity for localization of epileptogenic zones in drug-resistant epilepsy because safety, accuracy, and efficacy have been well established in both adult and pediatric populations. Development of robot-guidance technology has greatly enhanced the efficiency of this procedure, without sacrificing safety or precision. To date there have been very limited reports of the use of this new technology in children. The authors present their initial experience using the ROSA platform for robot-guided SEEG in a pediatric population. METHODS Between February 2016 and October 2017, 20 consecutive patients underwent robot-guided SEEG with the ROSA robotic guidance platform as part of ongoing seizure localization and workup for medically refractory epilepsy of several different etiologies. Medical and surgical history, imaging and trajectory plans, as well as operative records were analyzed retrospectively for surgical accuracy, efficiency, safety, and epilepsy outcomes. RESULTS A total of 222 leads were placed in 20 patients, with an average of 11.1 leads per patient. The mean total case time (± SD) was 297.95 (± 52.96) minutes and the mean operating time per lead was 10.98 minutes/lead, with improvements in total (33.36 minutes/lead vs 21.76 minutes/lead) and operative (13.84 minutes/lead vs 7.06 minutes/lead) case times/lead over the course of the study. The mean radial error was 1.75 (± 0.94 mm). Clinically useful data were obtained from SEEG in 95% of cases, and epilepsy surgery was indicated and performed in 95% of patients. In patients who underwent definitive epilepsy surgery with at least a 3-month follow-up, 50% achieved an Engel class I result (seizure freedom). There were no postoperative complications associated with SEEG placement and monitoring. CONCLUSIONS In this study, the authors demonstrate that rapid adoption of robot-guided SEEG is possible even at a SEEG-naive institution, with minimal learning curve. Use of robot guidance for SEEG can lead to significantly decreased operating times while maintaining safety, the overall goals of identification of epileptogenic zones, and improved epilepsy outcomes.

    View details for PubMedID 30117789

  • Anterior Techniques in Managing Cervical Disc Disease. Cureus Kim, L. H., D'Souza, M., Ho, A. L., Pendharkar, A. V., Sussman, E. S., Rezaii, P., Desai, A. 2018; 10 (8): e3146

    Abstract

    Surgical treatment may be indicated for select patients with cervical disc disease, whether it is cervical disc herniation or spondylosis due to degenerative changes, acute cervical injury due to trauma, or other underlying cervical pathology.Currently, there are various surgical techniques, including anterior, posterior, or combined approaches, in addition to new interventions being utilized in practice. Ideally, the surgical approach should be selected in consideration of each patient's clinical presentation, imaging findings, and overall medical comorbidities on an individual basis. But the unique advantages and disadvantages of each surgical technique often complicate the therapy choice in managing cervical disc diseases. Although anterior cervical discectomy and fusion (ACDF) is the most widely accepted procedure performed for both single and multi-level cervical disc diseases, there are multiple modifications to this technique. Surgeons have access to different types of plates, screws, and cages and can adopt newer advances in the field such as stand-alone and minimally invasive techniques when indicated. In short, no consensus exists in terms of a single approach that is preferredfor all patients. This article aims to review the standard of care for management of cervical disc disease with a focus on the surgical techniques and, in particular, the anterior approach, exploring the various surgical options within this technique.

    View details for PubMedID 30410821

  • The nucleus accumbens and alcoholism: a target for deep brain stimulation NEUROSURGICAL FOCUS Ho, A. L., Salib, A. N., Pendharkar, A., Sussman, E. S., Giardino, W. J., Halpern, C. H. 2018; 45 (2): E12

    Abstract

    Alcohol use disorder (AUD) is a difficult to treat condition with a significant global public health and cost burden. The nucleus accumbens (NAc) has been implicated in AUD and identified as an ideal target for deep brain stimulation (DBS). There are promising preclinical animal studies of DBS for alcohol consumption as well as some initial human clinical studies that have shown some promise at reducing alcohol-related cravings and, in some instances, achieving long-term abstinence. In this review, the authors discuss the evidence and concepts supporting the role of the NAc in AUD, summarize the findings from published NAc DBS studies in animal models and humans, and consider the challenges and propose future directions for neuromodulation of the NAc for the treatment of AUD.

    View details for PubMedID 30064314

  • Practical Pearl: Use of MRI to Differentiate Pseudo-subarachnoid Hemorrhage from True Subarachnoid Hemorrhage NEUROCRITICAL CARE Ho, A. L., Sussman, E. S., Pendharkar, A. V., Iv, M., Hirsch, K. G., Fischbein, N. J., Dodd, R. L. 2018; 29 (1): 113?18

    View details for DOI 10.1007/s12028-018-0547-3

    View details for Web of Science ID 000440146900017

  • Anterior Techniques in Managing Cervical Disc Disease CUREUS Kim, L. H., D'Souza, M., Ho, A. L., Pendharkar, A. V., Sussman, E. S., Rezaii, P., Desai, A. 2018; 10 (8)

    View details for DOI 10.7759/cureus.3146

    View details for Web of Science ID 000450944400065

  • Intracranial Hemorrhage in Deep Vein Thrombosis/Pulmonary Embolus Patients Without Atrial Fibrillation: Direct Oral Anticoagulants Versus Warfarin. Stroke Lamsam, L., Sussman, E. S., Iyer, A. K., Bhambhvani, H. P., Han, S. S., Skirboll, S., Ratliff, J. K. 2018

    Abstract

    BACKGROUND AND PURPOSE: Deep vein thrombosis (DVTs) is a common disease with high morbidity if it progresses to pulmonary embolus (PE). Anticoagulation is the treatment of choice; warfarin has long been the standard of care. Early experience with direct oral anticoagulants (DOACs) suggests that these agents may be may be a safer and equally effective alternative in the treatment of DVT/PE. Nontraumatic intracranial hemorrhage (ICH) is one of the most devastating potential complications of anticoagulation therapy. We sought to compare the rates of ICH in patients treated with DOACs versus those treated with warfarin for DVT/PE.METHODS: The MarketScan Commercial Claims and Medicare Supplemental databases were used. Adult DVT/PE patients without known atrial fibrillation and with prescriptions for either a DOAC or warfarin were followed for the occurrence of inpatient admission for ICH. Coarsened exact matching was used to balance the treatment cohorts. Cox proportional-hazards regressions and Kaplan-Meier survival curves were used to estimate the association between DOACs and the risk of ICH compared with warfarin.RESULTS: The combined cohort of 218 620 patients had a median follow-up of 3.0 months, mean age of 55.4 years, and was 52.1% women. The DOAC cohort had 26 980 patients and 8 ICH events (1.0 cases per 1000 person-years), and the warfarin cohort had 191 640 patients and 324 ICH events (3.3 cases per 1000 person-years; P<0.0001). The DOAC cohort had a lower hazard ratio for ICH compared with warfarin in both the unmatched (hazard ratio=0.26; P=0.0002) and matched (hazard ratio=0.20; P=0.0001) Cox proportional-hazards regressions.CONCLUSIONS: DOACs show superior safety to warfarin in terms of risk of ICH in patients with DVT/PE.

    View details for PubMedID 29991654

  • Topical vancomycin for surgical prophylaxis in non-instrumented pediatric spinal surgeries. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery Cannon, J. G., Ho, A. L., Mohole, J., Pendharkar, A. V., Sussman, E. S., Cheshier, S. H., Grant, G. A. 2018

    Abstract

    STUDY DESIGN: Retrospective cohort study.OBJECTIVE: To determine if topical vancomycin irrigation reduces the incidence of post-operative surgical site infections following pediatric spinal procedures. Surgical site infections (SSIs) following spinal procedures performed in pediatric patients represent a serious complication. Prophylactic use of topical vancomycin prior to closure has been shown to be effective in reducing incidence of SSIs in adult spinal procedures. Non-instrumented cases make up the majority of spinal procedures in pediatric patients, and the efficacy of prophylactic topical vancomycin in these procedures has not previously been reported.METHODS: This retrospective study reviewed all non-instrumented spinal procedures performed over a period from 05/2014-12/2016 for topical vancomycin use, surgical site infections, and clinical variables associated with SSI. Topical vancomycin was utilized as infection prophylaxis, and applied as a liquid solution within the wound prior to closure.RESULTS: Ninety-five consecutive, non-instrumented, pediatric spinal surgeries were completed between 01/2015 and 12/2016, of which the last 68 utilized topical vancomycin. There was a 11.1% SSI rate in the non-topical vancomycin cohort versus 0% in the topical vancomycin cohort (P=0.005). The number needed to treat was 9. There were no significant differences in risk factors for SSI between cohorts. There were no complications associated topical vancomycin use.CONCLUSIONS: Routine topical vancomycin administration during closure of non-instrumented spinal procedures can be a safe and effective tool for reducing SSIs in the pediatric neurosurgical population.

    View details for PubMedID 29955942

  • Neuromodulatory Treatments for Alcohol Use Disorder: A Review. Brain sciences Salib, A. N., Ho, A. L., Sussman, E. S., Pendharkar, A. V., Halpern, C. H. 2018; 8 (6)

    Abstract

    Alcohol use disorder (AUD) is a prevalent condition characterized by chronic alcohol-seeking behaviors and has become a significant economic burden with global ramifications on public health. While numerous treatment options are available for AUD, many are unable to sustain long-term sobriety. The nucleus accumbens (NAcc) upholds an integral role in mediating reward behavior and has been implicated as a potential target for deep brain stimulation (DBS) in the context of AUD. DBS is empirically thought to disrupt pathological neuronal synchrony, a hallmark of binge behavior. Pre-clinical animal models and pilot human clinical studies utilizing DBS for the treatment of AUD have shown promise for reducing alcohol-related cravings and prolonging abstinence. In this review, we outline the various interventions available for AUD, and the translational potential DBS has to modulate functionality of the NAcc as a treatment for AUD.

    View details for PubMedID 29843426

  • Minimally invasive approaches to craniosynostosis. Journal of neurosurgical sciences Pendharkar, A. V., Shahin, M. N., Cavallo, C., Zhao, X., Ho, A. L., Sussman, E. S., Grant, G. A. 2018

    Abstract

    Craniosynostosis (CS) is defined as the premature fusion of one or more calvarial sutures. This carries several consequences, including abnormal/asymmetric cranial vault development, increased intracranial pressure, compromised neurocognitive development, and craniofacial deformity. Definitive management is surgical with the goal of protecting cerebral development by re-establishing normal cranial vault expansion and correcting cosmetic deformity. In today's practice, CS surgery has advanced radically from simple craniectomies to major cranial vault reconstructive (CVR) procedures. More recently there has been considerable interest in endoscopic assisted surgery (EAS). Theoretical benefits include decreased operative time, morbidity, blood loss, postoperative pain, cost and faster recovery times. In this focused review, we summarize the current body of literature reporting clinical outcomes in EAS and review the data comparing EAS and CVR.

    View details for PubMedID 29790726

  • Outpatient spine surgery: defining the outcomes, value, and barriers to implementation. Neurosurgical focus Pendharkar, A. V., Shahin, M. N., Ho, A. L., Sussman, E. S., Purger, D. A., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2018; 44 (5): E11

    Abstract

    Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

    View details for PubMedID 29712520

  • Propensity-matched comparison of outcomes and cost after macroscopic and microscopic lumbar discectomy using a national longitudinal database. Neurosurgical focus Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Purger, D. A., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2018; 44 (5): E12

    Abstract

    OBJECTIVE There has been considerable debate about the utility of the operating microscope in lumbar discectomy and its effect on outcomes and cost. METHODS A commercially available longitudinal database was used to identify patients undergoing discectomy with or without use of a microscope between 2007 and 2015. Propensity matching was performed to normalize differences between demographics and comorbidities in the 2 cohorts. Outcomes, complications, and cost were subsequently analyzed using bivariate analysis. RESULTS A total of 42,025 patients were identified for the "macroscopic" group, while 11,172 patients were identified for the "microscopic" group. For the propensity-matched analysis, the 11,172 patients in the microscopic discectomy group were compared with a group of 22,340 matched patients who underwent macroscopic discectomy. There were no significant differences in postoperative complications between the groups other than a higher proportion of deep vein thrombosis (DVT) in the macroscopic discectomy cohort versus the microscopic discectomy group (0.4% vs 0.2%, matched OR 0.48 [95% CI 0.26-0.82], p = 0.0045). Length of stay was significantly longer in the macroscopic group compared to the microscopic group (mean 2.13 vs 1.83 days, p < 0.0001). Macroscopic discectomy patients had a higher rate of revision surgery when compared to microscopic discectomy patients (OR 0.92 [95% CI 0.84-1.00], p = 0.0366). Hospital charges were higher in the macroscopic discectomy group (mean $19,490 vs $14,921, p < 0.0001). CONCLUSIONS The present study suggests that the use of the operating microscope in lumbar discectomy is associated with decreased length of stay, lower DVT rate, lower reoperation rate, and decreased overall hospital costs.

    View details for PubMedID 29712527

  • Nurse Telephonic Triage Service for After-hour Patient Calls in Neurosurgery. Annals of surgery Escobedo-Wu, E. L., Dhebar, F., Harsh, G., Steinberg, G., Vyas, A., Katznelson, L., Ho, A. L., Pendharkar, A. V., Sussman, E. S., Rohatgi, N. 2018; 267 (4): e67?e68

    Abstract

    OBJECTIVE: The aim of this study was to report the utilization and experience of the nurse telephonic triage service for after-hour patient calls in Neurosurgery.BACKGROUND: It is challenging for patients to reach their clinicians after-hours in a timely manner. This may result in worse health outcomes for the patients, or inappropriate utilization of emergency rooms and urgent care facilities. Physicians continue to remain overwhelmed with frequent after-hours calls in addition to other clinical responsibilities while on-call.METHODS: In August 2015, our institution launched the Clinical Advice Service (CAS) to provide a patient-centric, nurse-run telephone triage service for after-hour calls from Neurosurgery patients. Clinical protocols were created for use by CAS staff by Neurosurgery clinicians.RESULTS: Between July 2016 and June 2017, CAS has accepted 1021 after-hours calls from Neurosurgery patients. A total of 71.4% of these calls were clinical, and the remaining nonclinical (directions, appointments, general information). CAS escalated 37.3% of the calls to the on-call Neurosurgery physician; 4.8% Neurosurgery patients were triaged to the emergency room by CAS.CONCLUSION: CAS has been able to provide well-coordinated care to Neurosurgery patients while reducing physician workload.

    View details for PubMedID 29064895

  • Nurse Telephonic Triage Service for After-hour Patient Calls in Neurosurgery ANNALS OF SURGERY Escobedo-Wu, E. G., Dhebar, F., Harsh, G., Steinberg, G., Vyas, A., Katznelson, L., Ho, A. L., Pendharkar, A., Sussman, E. S., Rohatgi, N. 2018; 267 (4): E67?E68

    View details for DOI 10.1097/SLA.0000000000002548

    View details for Web of Science ID 000435846900003

  • Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost NEUROSURGERY Purger, D. A., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Yang, L., Desai, M., Veeravagu, A., Ratliff, J. K., Desai, A. 2018; 82 (4): 454?63

    View details for DOI 10.1093/neuros/nyx215

    View details for Web of Science ID 000439686300011

  • Demographic and clinical predictors of multiple intracranial aneurysms in patients with subarachnoid hemorrhage JOURNAL OF NEUROSURGERY McDowell, M. M., Zhao, Y., Kellner, C. P., Barton, S. M., Sussman, E., Claassen, J., Ducruet, A. F., Connolly, E. 2018; 128 (4): 961?68

    Abstract

    OBJECTIVE Pathophysiological differences that underlie the development and subsequent growth of multiple aneurysms may exist. In this study, the authors assessed the factors associated with the occurrence of multiple aneurysms in patients presenting with aneurysmal subarachnoid hemorrhage (SAH). METHODS Consecutive patients presenting with aneurysmal SAH between 1996 and 2012 were prospectively enrolled in the Subarachnoid Hemorrhage Outcome Project. Patients harboring 1, 2, or 3 or more aneurysms were stratified into groups, and the clinical and radiological characteristics of each group were compared using multivariate logistic regression. RESULTS Of 1277 patients with ruptured intracranial aneurysms, 890 had 1 aneurysm, 267 had 2 aneurysms, and 120 had 3 or more aneurysms. On multinomial regression using the single-aneurysm cohort as base case, risk factors for patients presenting with 2 aneurysms were female sex (relative risk ratio [RRR] 1.80, p < 0.001), higher body mass index (BMI) (RRR 1.02, p = 0.003), more years of smoking (RRR = 1.01, p = 0.004), and black race (RRR 1.83, p = 0.001). The risk factors for patients presenting with 3 or more aneurysms were female sex (RRR 3.10, p < 0.001), higher BMI (RRR 1.03, p < 0.001), aneurysm in the posterior circulation (RRR 2.59, p < 0.001), and black race (RRR 2.15, p = 0.001). Female sex, longer smoking history, aneurysms in the posterior circulation, BMI, and black race were independently associated with the development of multiple aneurysms in our adjusted multivariate multinomial model. CONCLUSIONS Significant demographic and clinical differences are found between patients presenting with single and multiple aneurysms in the setting of aneurysmal SAH. These predictors of multiple aneurysms likely reflect a predisposition toward inflammation and endothelial injury.

    View details for PubMedID 28598275

  • Improved operative efficiency using a real-time MRI-guided stereotactic platform for laser amygdalohippocampotomy JOURNAL OF NEUROSURGERY Ho, A. L., Sussman, E. S., Pendharkar, A. V., Le, S., Mantovani, A., Keebaugh, A. C., Drover, D. R., Grant, G. A., Wintermark, M., Halpern, C. H. 2018; 128 (4): 1165?72

    Abstract

    OBJECTIVE MR-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive method for thermal destruction of benign or malignant tissue that has been used for selective amygdalohippocampal ablation for the treatment of temporal lobe epilepsy. The authors report their initial experience adopting a real-time MRI-guided stereotactic platform that allows for completion of the entire procedure in the MRI suite. METHODS Between October 2014 and May 2016, 17 patients with mesial temporal sclerosis were selected by a multidisciplinary epilepsy board to undergo a selective amygdalohippocampal ablation for temporal lobe epilepsy using MRgLITT. The first 9 patients underwent standard laser ablation in 2 phases (operating room [OR] and MRI suite), whereas the next 8 patients underwent laser ablation entirely in the MRI suite with the ClearPoint platform. A checklist specific to the real-time MRI-guided laser amydalohippocampal ablation was developed and used for each case. For both cohorts, clinical and operative information, including average case times and accuracy data, was collected and analyzed. RESULTS There was a learning curve associated with using this real-time MRI-guided system. However, operative times decreased in a linear fashion, as did total anesthesia time. In fact, the total mean patient procedure time was less in the MRI cohort (362.8 ± 86.6 minutes) than in the OR cohort (456.9 ± 80.7 minutes). The mean anesthesia time was significantly shorter in the MRI cohort (327.2 ± 79.9 minutes) than in the OR cohort (435.8 ± 78.4 minutes, p = 0.02). CONCLUSIONS The real-time MRI platform for MRgLITT can be adopted in an expedient manner. Completion of MRgLITT entirely in the MRI suite may lead to significant advantages in procedural times.

    View details for PubMedID 28665249

  • Practical Pearl: Use of MRI to Differentiate Pseudo-subarachnoid Hemorrhage from True Subarachnoid Hemorrhage. Neurocritical care Ho, A. L., Sussman, E. S., Pendharkar, A. V., Iv, M., Hirsch, K. G., Fischbein, N. J., Dodd, R. L. 2018

    View details for PubMedID 29948997

  • Mild traumatic brain injury and concussion: terminology and classification. Handbook of clinical neurology Sussman, E. S., Pendharkar, A. V., Ho, A. L., Ghajar, J. 2018; 158: 21?24

    Abstract

    Traumatic brain injury (TBI) is a major cause of morbidity and mortality throughout the world. Mild TBI, which is typically defined by Glasgow Coma Scale score ?13, accounts for the vast majority of all TBIs, particularly in the setting of sports-related injuries. The terms concussion and TBI are often used interchangeably, both in the medical literature and in clinical care of this patient population. However, the lack of clearly defined definitions of these terms often leads to confusion, and this confusion may lead to delayed diagnosis and inconsistent management of affected patients. Here, we review the current terminology and classification of mild TBI and concussion. We will also discuss recent efforts to stratify these injuries into clinically relevant subtypes or profiles that are both diagnostic- and treatment-targeted.

    View details for PubMedID 30482349

  • Topical vancomycin surgical prophylaxis in pediatric open craniotomies: an institutional experience. Journal of neurosurgery. Pediatrics Ho, A. L., Cannon, J. G., Mohole, J., Pendharkar, A. V., Sussman, E. S., Li, G., Edwards, M. S., Cheshier, S. H., Grant, G. A. 2018: 1?6

    Abstract

    OBJECTIVE Topical antimicrobial compounds are safe and can reduce cost and complications associated with surgical site infections (SSIs). Topical vancomycin has been an effective tool for reducing SSIs following routine neurosurgical procedures in the spine and following adult craniotomies. However, widespread adoption within the pediatric neurosurgical community has not yet occurred, and there are no studies to report on the safety and efficacy of this intervention. The authors present the first institution-wide study of topical vancomycin following open craniotomy in the pediatric population. METHODS In this retrospective study the authors reviewed all open craniotomies performed over a period from 05/2014 to 12/2016 for topical vancomycin use, SSIs, and clinical variables associated with SSI. Topical vancomycin was utilized as an infection prophylaxis and was applied as a liquid solution following replacement of a bone flap or after dural closure when no bone flap was reapplied. RESULTS Overall, 466 consecutive open craniotomies were completed between 05/2014 and 12/2016, of which 43% utilized topical vancomycin. There was a 1.5% SSI rate in the nontopical cohort versus 0% in the topical vancomycin cohort (p = 0.045). The number needed to treat was 66. There were no significant differences in risk factors for SSI between cohorts. There were no complications associated with topical vancomycin use. CONCLUSIONS Routine topical vancomycin administration during closure of open craniotomies can be a safe and effective tool for reducing SSIs in the pediatric neurosurgical population.

    View details for PubMedID 30141749

  • Cervical Stenosis in Adult Arthrogryposis: A Case Report and Review of the Literature. Journal of neurological surgery reports Ho, A. L., Mohole, J., Sussman, E. S., Pendharkar, A. V., Singh, H. 2018; 79 (1): e19?e22

    Abstract

    Arthrogryposis multiplex congenita is a rare, nonprogressive congenital disorder that describes a constellation of conditions characterized by multiple joint contractures. Spinal pathology and deformity are common; however, the majority of the literature on arthrogryposis is focused on pediatric management. There exist very few reports on long-term outcomes and management of adults with arthrogryposis. We present a case of cervical spinal stenosis in an adult female with arthrogryposis that underwent posterior cervical decompression and fusion. A review of spine-related sequelae seen in adults with arthrogryposis and considerations for spinal surgery for these patients is discussed.

    View details for PubMedID 29581933

    View details for PubMedCentralID PMC5860911

  • Diffusion Tensor Imaging in an Infant Undergoing Functional Hemispherectomy: A Surgical Aid. Cureus Ho, A. L., Pendharkar, A. V., Sussman, E. S., Casazza, M., Grant, G. A. 2017; 9 (9): e1697

    Abstract

    Hemispherectomy is a highly effective treatment option for children with severe, unilateral, medically refractory epilepsy. Many patients undergoing hemispherectomy are younger patients with dysmorphic brains, making accomplishing a complete disconnectionchallenging due to anatomic distortion, even with the aid of intraoperative navigation. Diffusion tensor imaging (DTI) has been proposed as a valuable imaging adjunct perioperatively to help guide surgeons intraoperatively, as well as for post-surgical evaluation and confirmation of complete hemispheric disconnection.We present a case of an infant with Otoharra syndrome and hemimegencephaly who underwent a functional hemispherectomy for treatment of severe, refractory seizures. We demonstrate how DTI was utilized both pre-, intra-, and postoperatively to help plan, guide, and confirm surgical disconnection. The application of exquisite DTI for this child led to her being seizure-free, which is a life-changing event with long-lasting benefits and will become even more critical as we now perform these disconnection procedures with a more minimally invasive approach.

    View details for PubMedID 29167751

  • A Focused Review of Clinical and Preclinical Studies of Cell-Based Therapies in Stroke. Neurosurgery Sussman, E. S., Steinberg, G. K. 2017; 64 (CN_suppl_1): 92?96

    View details for PubMedID 28899062

  • Diffusion Tensor Imaging in an Infant Undergoing Functional Hemispherectomy: A Surgical Aid CUREUS Ho, A. L., Pendharkar, A., Sussman, E. S., Casazza, M., Grant, G. A. 2017; 9 (9)

    View details for DOI 10.7759/cureus.1697

    View details for Web of Science ID 000453625000063

  • Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost. Neurosurgery Purger, D. A., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Yang, L., Desai, M., Veeravagu, A., Ratliff, J. K., Desai, A. 2017

    Abstract

    Outpatient anterior cervical discectomy and fusion (ACDF) is a promising candidate for US healthcare cost reduction as several studies have demonstrated that overall complications are relatively low and early discharge can preserve high patient satisfaction, low morbidity, and minimal readmission.To compare clinical outcomes and associated costs between inpatient and ambulatory setting ACDF.Demographics, comorbidities, emergency department (ED) visits, readmissions, reoperation rates, and 90-d charges were retrospectively analyzed for patients undergoing elective ACDF in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.A total of 3135 ambulatory and 46 996 inpatient ACDFs were performed. Mean Charlson comorbidity index, length of stay, and mortality were 0.2, 0.4 d, and 0% in the ambulatory cohort and 0.4, 1.8 d, and 0.04% for inpatients ( P < .0001). Ambulatory patients were younger (48.0 vs 53.1) and more likely to be Caucasian. One hundred sixty-eight ambulatory patients (5.4%) presented to the ED within 30 d (mean 11.3 d), 51 (1.6%) were readmitted, and 5 (0.2%) underwent reoperation. Among inpatient surgeries, 2607 patients (5.5%) presented to the ED within 30 d (mean 9.7 d), 1778 (3.8%) were readmitted (mean 6.3 d), and 200 (0.4%) underwent reoperation. Higher Charlson comorbidity index increased rate of ED visits (ambulatory operating room [OR] 1.285, P < .05; inpatient OR 1.289, P < .0001) and readmission (ambulatory OR 1.746, P < .0001; inpatient OR 1.685, P < .0001). Overall charges were significantly lower for ambulatory ACDFs ($33 362.51 vs $74 667.04; P < .0001).ACDF can be performed in an ambulatory setting with comparable morbidity and readmission rates, and lower costs, to those performed in an inpatient setting.

    View details for DOI 10.1093/neuros/nyx215

    View details for PubMedID 28498922

  • The Use of Vancomycin Powder for Surgical Prophylaxis Following Craniotomy. Neurosurgery Ravikumar, V., Ho, A. L., Pendhakar, A. V., Sussman, E. S., Kwong-Hon Chow, K., Li, G. 2017; 80 (5): 754-758

    Abstract

    Intrawound vancomycin powder has been studied extensively in spinal fusion surgeries and been found to reduce rates of surgical site infections (SSIs) significantly. Despite its success in spinal surgeries, topical vancomycin has not been extensively studied with respect to cranial neurosurgery.To evaluate the efficacy of intrawound topical vancomycin for prevention of SSIs following open craniotomies.We retrospectively analyzed a large series of 350 patients from 2011 to 2015 in a pre/postintervention study of use of topical vancomycin to reduce postoperative craniotomy infection rates. We had a preintervention control group of 225 patients and a postintervention group of 125 patients that received intrawound topical vancomycin.Our preintervention incidence of SSI was 2.2% and this was significantly reduced to 0% following introduction of topical vancomycin ( P < .5). An ad hoc cost analysis suggested a cost savings of $59 965 with the use of topical vancomycin for craniotomies.Our study found a significant reduction in SSI rates after introduction of topical vancomycin. Thus, this simple intervention should be considered in all open craniotomy patients as both infection prophylaxis and a potential cost saving intervention.

    View details for DOI 10.1093/neuros/nyw127

    View details for PubMedID 28327930

  • Image-guided stereotactic radiosurgery for treatment of spinal hemangioblastoma NEUROSURGICAL FOCUS Pan, J., Ho, A. L., D'Astous, M., Sussman, E. S., Thompson, P. A., Tayag, A. T., Pangilinan, L., Soltys, S. G., Gibbs, I. C., Chang, S. D. 2017; 42 (1)

    Abstract

    OBJECTIVE Stereotactic radiosurgery (SRS) has been an attractive treatment option for hemangioblastomas, especially for lesions that are surgically inaccessible and in patients with von Hippel-Lindau (VHL) disease and multiple lesions. Although there has been a multitude of studies examining the utility of SRS in intracranial hemangioblastomas, SRS has only recently been used for spinal hemangioblastomas due to technical limitations. The purpose of this study is to provide a long-term evaluation of the effectiveness of image-guided radiosurgery in halting tumor progression and providing symptomatic relief for spinal hemangioblastomas. METHODS Between 2001 and 2011, 46 spinal hemangioblastomas in 28 patients were treated using the CyberKnife image-guided radiosurgery system at the authors' institution. Fourteen of these patients also had VHL disease. The median age at treatment was 43.5 years (range 19-85 years). The mean prescription radiation dose to the tumor periphery was 21.6 Gy (range 15-35 Gy). The median tumor volume was 0.264 cm(3) (range 0.025-70.9 cm(3)). Tumor response was evaluated on serial, contrast-enhanced CT and MR images. Clinical response was evaluated by clinical and imaging evaluation. RESULTS The mean follow-up for the cohort was 54.3 months. Radiographic follow-up was available for 19 patients with 34 tumors; 32 (94.1%) tumors were radiographically stable or displayed signs of regression. Actuarial control rates at 1, 3, and 5 years were 96.1%, 92.3%, and 92.3%, respectively. Clinical evaluation on follow-up was available for 13 patients with 16 tumors; 13 (81.2%) tumors in 10 patients had symptomatic improvement. No patient developed any complications related to radiosurgery. CONCLUSIONS Image-guided SRS is safe and effective for the primary treatment of spinal hemangioblastomas and is an attractive alternative to resection, especially for those with VHL disease.

    View details for DOI 10.3171/2016.10.FOCUS16361

    View details for Web of Science ID 000392113200012

    View details for PubMedID 28041328

  • DNA methylation analysis for the treatment of meningiomas. Journal of visualized surgery Gendreau, J. L., Chow, K. K., Sussman, E. S., Iyer, A., Pendharkar, A. V., Ho, A. L. 2017; 3: 178

    View details for PubMedID 29302454

  • Laser interstitial thermal therapy for the treatment of epilepsy: evidence to date NEUROPSYCHIATRIC DISEASE AND TREATMENT Shukla, N. D., Ho, A. L., Pendharkar, A. V., Sussman, E. S., Halpern, C. H. 2017; 13: 2469?75

    Abstract

    Medically intractable epilepsy is associated with increased morbidity and mortality. For those with focal epilepsy and correlated electrophysiological or radiographic features, open surgical resection can achieve high rates of seizure control, but can be associated with neurologic deficits and cognitive effects. Recent innovations have allowed for more minimally invasive methods of surgical seizure control such as magnetic resonance-guided laser interstitial therapy (MRgLITT). MRgLITT achieves the goal of ablating seizure foci while preserving neuropsycho-logical function and offering real-time feedback and monitoring of tissue ablation. This review summarizes the utilization of MRgLITT for mesial temporal lobe epilepsy and other seizure disorders. Overall, the efficacy of MRgLITT is comparable to that of open surgery and offers a less invasive approach in patients with significantly less morbidity.

    View details for PubMedID 29026310

  • Radiosurgical ablation of spinal cord arteriovenous malformations. Handbook of clinical neurology Sussman, E. S., Adler, J. R., Dodd, R. L. 2017; 143: 175-187

    Abstract

    Spinal cord arteriovenous malformations (SCAVMs) are rare entities that account for less than 20% of spinal masses. These lesions represent a unique clinical challenge, in that surgical or endovascular treatment is often associated with devastating functional consequences. Over the past few decades, radiosurgery has become a well-established treatment modality for SCAVMs, and may be a first-line treatment in many patients afflicted with this devastating disease. This chapter summarizes the data available regarding radiosurgical treatment of SCAVMs.

    View details for DOI 10.1016/B978-0-444-63640-9.00017-5

    View details for PubMedID 28552140

  • Interventional therapy for brain arteriovenous malformations before and after ARUBA. Journal of clinical neuroscience Sussman, E. S., Iyer, A. K., Teo, M., Pendharkar, A. V., Ho, A. L., Steinberg, G. K. 2016

    Abstract

    The ARUBA trial (2014) concluded that medical management alone is superior to medical management plus interventional therapy for the treatment of unruptured brain arteriovenous malformations (bAVMs). This sparked considerable controversy among involved healthcare providers. Here, we evaluated the impact of ARUBA on the volume, type, and treatment modality of bAVMs referred to a large tertiary care center. This was achieved by conducting a retrospective review of a prospectively maintained database of all bAVMs treated at Stanford Health Care and Stanford Children's Health from January 2012 through July 2015. The case volume of bAVMs treated at Stanford has been relatively unchanged in the period of time leading up to and after ARUBA. Furthermore, there has been no significant change in the proportion of unruptured AVMs treated. Although differences existed in types of interventions administered, these differences are best explained by variations in the SM grades of AVMs treated during each study period, rather than by underlying changes in treatment strategy. Additional research is warranted to more thoroughly characterize the impact of ARUBA on the treatment patterns of bAVMS.

    View details for DOI 10.1016/j.jocn.2016.10.036

    View details for PubMedID 27810415

  • Frameless, electromagnetic image-guided ventriculostomy for ventriculoperitoneal shunt and Ommaya reservoir placement CLINICAL NEUROLOGY AND NEUROSURGERY Xu, L. W., Sussman, E. S., Li, G. 2016; 147: 46-52

    Abstract

    Catheter ventriculostomy is a common neurosurgical procedure for placement of Ommaya reservoirs or ventriculo-peritoneal shunts (VPS). Malpositioning or multiple attempts at catheter placement may lead to complications such as hemorrhage, mechanical obstruction, or tissue injury. Traditional navigation systems to guide placement require head fixation, which can lead to additional risks of pin placement as well as inconvenience, particularly with regard to patient positioning. Here we report our experience using frameless, electromagnetic (EM) image-guidance as a fast and low risk method of ensuring accurate ventriculostomy catheter placement.51 consecutive patients with frameless, EM image-guided Ommaya or VPS placement from 2011 to 2015.We retrospectively reviewed patient charts and recorded case duration and patient post-operative outcomes.Twenty-four (24) patients received Ommayas and 27 received VPS. Average time of operative room set up was 48min. Average case duration was 35min for Ommaya cases and 61min for VPS cases. All catheters were placed with one pass. One patient required revision surgery for obstruction or misplacement. No clinically significant hemorrhages occurred postoperatively.Ventriculostomy with EM image-guidance is a safe and efficient way to ensure proper catheter placement and minimize patient complications.

    View details for DOI 10.1016/j.clineuro.2016.05.024

    View details for Web of Science ID 000381240800009

    View details for PubMedID 27290637

  • Pituitary Apoplexy Associated with Carotid Compression and a Large Ischemic Penumbra. World neurosurgery Sussman, E. S., Ho, A. L., Pendharkar, A. V., Achrol, A. S., Harsh, G. R. 2016; 92: 581 e7-581 e13

    Abstract

    Pituitary apoplexy is an acute clinical syndrome caused by pituitary gland hemorrhage or infarction. Rarely, this clinical syndrome is associated with cerebral infarction secondary to compression of an internal carotid artery. We report an unusual case of pituitary apoplexy associated with a cerebral infarct with a large ischemic penumbra.The patient presented with headaches and visual disturbance and was found to have pituitary apoplexy. Findings of his neurologic examination showed he had rapidly deteriorated, with obtundation, ophthalmoplegia, and left hemiplegia. Computed tomography perfusion images revealed a right hemispheric infarct with a large ischemic penumbra. Emergent decompressive transsphenoidal resection was performed. The patient had dramatic neurologic recovery, and postoperative imaging revealed salvage of most of the previously identified penumbra.Cerebral perfusion imaging is a useful diagnostic tool for identifying the subset of pituitary apoplexy patients that may benefit from emergent surgical intervention.

    View details for DOI 10.1016/j.wneu.2016.06.040

    View details for PubMedID 27319311

  • Optogenetic modulation in stroke recovery NEUROSURGICAL FOCUS Pendharkar, A. V., Levy, S. L., Ho, A. L., Sussman, E. S., Cheng, M. Y., Steinberg, G. K. 2016; 40 (5)

    Abstract

    Stroke is one of the leading contributors to morbidity, mortality, and health care costs in the United States. Although several preclinical strategies have shown promise in the laboratory, few have succeeded in the clinical setting. Optogenetics represents a promising molecular tool, which enables highly specific circuit-level neuromodulation. Here, the conceptual background and preclinical body of evidence for optogenetics are reviewed, and translational considerations in stroke recovery are discussed.

    View details for DOI 10.3171/2016.2.FOCUS163

    View details for Web of Science ID 000375119300003

    View details for PubMedID 27132527

  • Clinical evaluation of concussion: the evolving role of oculomotor assessments NEUROSURGICAL FOCUS Sussman, E. S., Ho, A. L., Pendharkar, A. V., Ghajar, J. 2016; 40 (4)

    Abstract

    Sports-related concussion is a change in brain function following a direct or an indirect force to the head, identified in awake individuals and accounting for a considerable proportion of mild traumatic brain injury. Although the neurological signs and symptoms of concussion can be subtle and transient, there can be persistent sequelae, such as impaired attention and balance, that make affected patients particularly vulnerable to further injury. Currently, there is no accepted definition or diagnostic criteria for concussion, and there is no single assessment that is accepted as capable of identifying all patients with concussion. In this paper, the authors review the available screening tools for concussion, with particular emphasis on the role of visual function testing. In particular, they discuss the oculomotor assessment tools that are being investigated in the setting of concussion screening.

    View details for DOI 10.3171/2016.1.FOCUS15610

    View details for Web of Science ID 000373476500006

    View details for PubMedID 27032924

  • Interventional Therapy for Brain AVMs Before and After ARUBA Sussman, E., Teo, M., Iyer, A., Ho, A., Pendharkar, A., Dodd, R., Steinberg, G. LIPPINCOTT WILLIAMS & WILKINS. 2016

    View details for Web of Science ID 000399956102128

  • National trends in inpatient admissions following stereotactic radiosurgery and the in-hospital patient outcomes in the United States from 1998 to 2011. Journal of radiosurgery and SBRT Ho, A. L., Li, A. Y., Sussman, E. S., Pendharkar, A. V., Iyer, A., Thompson, P. A., Tayag, A. T., Chang, S. D. 2016; 4 (3): 165-176

    Abstract

    This study sought to examine trends in stereotactic radiosurgery (SRS) and in-hospital patient outcomes on a national level by utilizing national administrative data from the Nationwide Inpatient Sample (NIS) database.Using the NIS database, all discharges where patients underwent inpatient SRS were included in our study from 1998 - 2011 as designated by the ICD9-CM procedural codes. Trends in the utilization of primary and adjuvant SRS, in-hospital complications and mortality, and resource utilization were identified and analyzed.Our study included over 11,000 hospital discharges following admission for primary SRS or for adjuvant SRS following admission for surgery or other indication. The most popular indication for SRS continues to be treatment of intracranial metastatic disease (36.7%), but expansion to primary CNS lesions and other non-malignant pathology beyond trigeminal neuralgia has occurred over the past decade. Second, inpatient admissions for primary SRS have declined by 65.9% over this same period of time. Finally, as inpatient admissions for SRS become less frequent, the complexity and severity of illness seen in admitted patients has increased over time with an increase in the average comorbidity score from 1.25 in the year 2002 to 2.29 in 2011, and an increase in over-all in-hospital complication rate of 2.8 times over the entire study period.As the practice of SRS continues to evolve, we have seen several trends in associated hospital admissions. Overall, the number of inpatient admissions for primary SRS has declined while adjuvant applications have remained stable. Over the same period, there has been associated increase in complication rate, length of stay, and mortality in inpatients. These associations may be explained by an increase in the comorbidity-load of admitted patients as more high-risk patients are selected for admission at inpatient centers while more stable patients are increasingly being referred to outpatient centers.

    View details for PubMedID 27795870

    View details for PubMedCentralID PMC5081223

  • Surgical Management of Sacral Chordomas: Illustrative Cases and Current Management Paradigms CUREUS Pendharkar, A. V., Ho, A. L., Sussman, E. S., Desai, A. 2015; 7 (8)

    View details for DOI 10.7759/cureus.301

    View details for Web of Science ID 000453604900008

  • Deep brain stimulation for obesity: rationale and approach to trial design. Neurosurgical focus Ho, A. L., Sussman, E. S., Pendharkar, A. V., Azagury, D. E., Bohon, C., Halpern, C. H. 2015; 38 (6): E8-?

    Abstract

    Obesity is one of the most serious public health concerns in the US. While bariatric surgery has been shown to be successful for treatment of morbid obesity for those who have undergone unsuccessful behavioral modification, its associated risks and rates of relapse are not insignificant. There exists a neurological basis for the binge-like feeding behavior observed in morbid obesity that is believed to be due to dysregulation of the reward circuitry. The authors present a review of the evidence of the neuroanatomical basis for obesity, the potential neural targets for deep brain stimulation (DBS), as well as a rationale for DBS and future trial design. Identification of an appropriate patient population that would most likely benefit from this type of therapy is essential. There are also significant cost and ethical considerations for such a neuromodulatory intervention designed to alter maladaptive behavior. Finally, the authors present a consolidated set of inclusion criteria and study end points that should serve as the basis for any trial of DBS for obesity.

    View details for DOI 10.3171/2015.3.FOCUS1538

    View details for PubMedID 26030708

  • Dual-trajectory Approach for Simultaneous Cyst Fenestration and Endoscopic Third Ventriculostomy for Treatment of a Complex Third Ventricular Arachnoid Cyst. Cureus Ho, A. L., Pendharkar, A. V., Sussman, E. S., Ravikumar, V. K., Li, G. H. 2015; 7 (3)

    Abstract

    We present a case of a multiloculated third ventricular arachnoid cyst to describe a novel technique for definitive management of these lesions via direct endoscopic fenestration and CSF diversion utilizing separate trajectories that offers superior visualization and avoids forniceal injury.We present a case of a 33-year-old woman with progressive headache and worsened vision, a known history of a multiloculated third-ventricular arachnoid cyst, and imaging findings consistent with cyst expansion and worsened obstructive hydrocephalus. We then describe the dual-trajectory approach for simultaneous cyst fenestration and endoscopic third ventriculostomy that ultimately resulted in successful treatment of her cyst and hydrocephalus.Dual-trajectory endoscopic approach utilizing double burr holes should be considered when addressing lesions of the third ventricle causing obstructive hydrocephalus.

    View details for DOI 10.7759/cureus.253

    View details for PubMedID 26180677

  • Deep Brain Stimulation for Obesity. Cureus Ho, A. L., Sussman, E. S., Zhang, M., Pendharkar, A. V., Azagury, D. E., Bohon, C., Halpern, C. H. 2015; 7 (3)

    Abstract

    Obesity is now the third leading cause of preventable death in the US, accounting for 216,000 deaths annually and nearly 100 billion dollars in health care costs. Despite advancements in bariatric surgery, substantial weight regain and recurrence of the associated metabolic syndrome still occurs in almost 20-35% of patients over the long-term, necessitating the development of novel therapies. Our continually expanding knowledge of the neuroanatomic and neuropsychiatric underpinnings of obesity has led to increased interest in neuromodulation as a new treatment for obesity refractory to current medical, behavioral, and surgical therapies. Recent clinical trials of deep brain stimulation (DBS) in chronic cluster headache, Alzheimer's disease, and depression and obsessive-compulsive disorder have demonstrated the safety and efficacy of targeting the hypothalamus and reward circuitry of the brain with electrical stimulation, and thus provide the basis for a neuromodulatory approach to treatment-refractory obesity. In this study, we review the literature implicating these targets for DBS in the neural circuitry of obesity. We will also briefly review ethical considerations for such an intervention, and discuss genetic secondary-obesity syndromes that may also benefit from DBS. In short, we hope to provide the scientific foundation to justify trials of DBS for the treatment of obesity targeting these specific regions of the brain.

    View details for DOI 10.7759/cureus.259

    View details for PubMedID 26180683

  • Cushing's disease: predicting long-term remission after surgical treatment NEUROSURGICAL FOCUS Pendharkar, A. V., Sussman, E. S., Ho, A. L., Gephart, M. G., Katznelson, L. 2015; 38 (2)

    Abstract

    Cushing's disease (CD) is a state of excess glucocorticoid production resulting from an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma. The gold-standard treatment for CD is transsphenoidal adenomectomy. In the hands of an experienced neurosurgeon, gross-total resection is possible in the majority of ACTH-secreting pituitary adenomas, with early postoperative remission rates ranging from 67% to 95%. In contrast to the strong data in support of resection, the clinical course of postsurgical persistent or recurrent disease remains unclear. There is significant variability in recurrence rates, with reports as high as 36% with a mean time to recurrence of 15-50 months. It is therefore important to develop biochemical criteria that define postsurgical remission and that may provide prognosis for long-term recurrence. Despite the use of a number of biochemical assessments, there is debate regarding the accuracy of these tests in predicting recurrence. Here, the authors review the various biochemical criteria and assess their utility in predicting CD recurrence after resection.

    View details for DOI 10.3171/2014.10.FOCUS14682

    View details for Web of Science ID 000349263300013

    View details for PubMedID 25639315

  • Surgical Management of Sacral Chordomas: Illustrative Cases and Current Management Paradigms. Cure¯us Pendharkar, A. V., Ho, A. L., Sussman, E. S., Desai, A. 2015; 7 (8)

    Abstract

    Sacral chordomas represent more than 50% of all sacral tumors. These slow-growing, malignant lesions present insidiously and are often large and intimately involved with sacral neurovascular and pelvic structures. En bloc resection is the only well-established predictor of progression-free survival. Optimal surgical management requires a complex multi-disciplinary approach. Here, we describe two cases of sacral chordoma and review current management paradigms.

    View details for DOI 10.7759/cureus.301

    View details for PubMedID 26430575

  • Cerebral arterial angioplasty in a patient with Loeys-Dietz syndrome JOURNAL OF NEUROINTERVENTIONAL SURGERY Kellner, C. P., Sussman, E. S., Donaldson, C., Connolly, E. S., Meyers, P. M. 2015; 7 (1): E2-U10

    Abstract

    A 14-year-old boy with Loeys-Dietz syndrome (LDS) had an acute neurologic decline 6?days after a subarachnoid hemorrhage. Cerebral angiography at presentation did not show an aneurysmal source of the hemorrhage. However, on post-bleed day 6 the patient experienced an acutely worsening headache and subsequently lost consciousness. Head CT showed new subarachnoid blood and repeat angiography demonstrated a basilar tip aneurysm. Endovascular coil embolization was performed and his neurologic status improved postoperatively until post-bleed day 9 when he became unresponsive. A CT angiogram demonstrated severe proximal vasospasm. After an unsuccessful attempt to treat the vasospasm medically, the patient was transported to the neurointerventional suite for intra-arterial vasodilator treatment, which also failed to ameliorate the vasospasm. The endovascular surgeons were then faced with the conundrum of attempting a high-risk cerebral angioplasty in a pediatric patient with LDS or returning to maximal medical treatment for severe refractory vasospasm.

    View details for DOI 10.1136/neurintsurg-2013-010857.rep

    View details for Web of Science ID 000346242600002

    View details for PubMedID 24431245

  • Radiographic absence of the posterior communicating arteries and the prediction of cognitive dysfunction after carotid endarterectomy Clinical article JOURNAL OF NEUROSURGERY Sussman, E. S., Kellner, C. P., Mergeche, J. L., Bruce, S. S., McDowell, M. M., Heyer, E. J., Connolly, E. S. 2014; 121 (3): 593-598

    View details for DOI 10.3171/2014.5.JNS131736

    View details for Web of Science ID 000340688700013

  • A critical assessment of approaches to outpatient monitoring CURRENT MEDICAL RESEARCH AND OPINION Appelboom, G., Sussman, E. S., Raphael, P., Juilliere, Y., Reginster, J., Connolly, E. S. 2014; 30 (7): 1383-1384

    View details for DOI 10.1185/03007995.2014.904774

    View details for Web of Science ID 000338516700021

    View details for PubMedID 24627950

  • Schwannomas of the Foot and Ankle: A Technical Report JOURNAL OF FOOT & ANKLE SURGERY Kellner, C. P., Sussman, E., Bar-David, T., Winfree, C. J. 2014; 53 (4): 505-510

    Abstract

    The present technical report provides a detailed description of open surgical resection of peripheral nerve sheath tumors in the foot and ankle. We present 3 cases to illustrate important differences in the technique based on the presentation, anatomic location, and intraoperative neurophysiologic monitoring findings. It is important for surgeons to understand that surgical excision of many peripheral nerve sheath tumors can be undertaken without en bloc resection of the entire nerve trunk.

    View details for DOI 10.1053/j.jfas.2013.05.007

    View details for Web of Science ID 000338478900024

    View details for PubMedID 23932119

  • Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage JOURNAL OF NEUROSURGERY Sussman, E. S., Kellner, C. P., Nelson, E., McDowell, M. M., Bruce, S. S., Bruce, R. A., Zhuang, Z., Connolly, E. S. 2014; 120 (4): 931-936

    Abstract

    Ventriculostomy--the placement of an external ventricular drain (EVD)--is a common procedure performed in patients with acute neurological injury. Although generally considered a low-risk intervention, recent studies have cited higher rates of hemorrhagic complications than those previously reported. The authors sought to determine the rate of postventriculostomy hemorrhage in a cohort of patients with intracerebral hemorrhage (ICH) and to identify predictors of hemorrhagic complications of EVD placement.Patients with ICH who underwent EVD placement and had both pre- and postprocedural imaging available for analysis were included in this study. Relevant data were prospectively collected for each patient who satisfied inclusion criteria. Variables with a p < 0.20 on univariate analyses were included in a stepwise logistic regression model to identify predictors of postventriculostomy hemorrhage.Sixty-nine patients were eligible for this analysis. Postventriculostomy hemorrhage occurred in 31.9% of patients. Among all patients with intraparenchymal hemorrhage, the mean hemorrhage volume was 0.66 ± 1.06 cm(3). Stratified according to ventricular catheter diameter, patients treated with smaller-diameter catheters had a significantly greater mean hemorrhage volume than patients treated with larger-diameter catheters (0.84 ± 1.2 cm(3) vs 0.14 ± 0.12 cm(3), p = 0.049). Postventriculostomy hemorrhage was clinically significant in only 1 patient (1.4%). Overall, postventriculostomy hemorrhage was not associated with functional outcome or mortality at either discharge or 90 days. In the multivariate model, an age > 75 years was the only independent predictor of EVD-associated hemorrhage.Advanced age is predictive of EVD-related hemorrhage in patients with ICH. While postventriculostomy hemorrhage is common, it appears to be of minor clinical significance in the majority of patients.

    View details for DOI 10.3171/2013.12.JNS131685

    View details for Web of Science ID 000333438800019

    View details for PubMedID 24410156

  • The role of admission timing in the outcome of intracerebral hemorrhage patients at a specialized stroke center NEUROLOGICAL RESEARCH McDowell, M. M., Kellner, C. P., Sussman, E. S., Bruce, S. S., Bruce, R. A., Heuts, S. G., Connolly, E. S. 2014; 36 (2): 95-101

    View details for DOI 10.1179/1743132813Y.0000000263

    View details for Web of Science ID 000337108700001

  • Transnasal endoscopic approach to the pediatric craniovertebral junction and rostral cervical spine: case series and literature review NEUROSURGICAL FOCUS Hickman, Z. L., McDowell, M. M., Barton, S. M., Sussman, E. S., Grunstein, E., Anderson, R. C. 2013; 35 (2)

    Abstract

    The endoscopic transnasal approach to the rostral pediatric spine and craniovertebral junction is a relatively new technique that provides an alternative to the traditional transoral approach to the anterior pediatric spine. In this case series, the authors provide 2 additional examples of patients undergoing endoscopic transnasal odontoidectomies for ventral decompression of the spinal cord. Both patients would have required transection of the palate to undergo an effective transoral operation, which can be a cause of significant morbidity. In one case, transnasal decompression was initially incomplete, and decompression was successfully achieved via a second endoscopic transnasal operation. Both cases resulted in significant neurological recovery and stable long-term spinal alignment. The transnasal approach benefits from entering into the posterior pharynx at an angle that often reduces the length of postoperative intubation and may speed a patient's return to oral intake. Higher reoperation rates are a concern for many endoscopic approaches, but there are insufficient data to conclude if this is the case for this procedure. Further experience with this technique will provide a better understanding of the indications for which it is most effective. Transcervical and transoral endoscopic approaches have also been reported and provide additional options for pediatric anterior cervical spine surgery.

    View details for DOI 10.3171/2013.5.FOCUS13147

    View details for Web of Science ID 000322633300015

    View details for PubMedID 23905952

  • Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis NEUROSURGICAL FOCUS Heuts, S. G., Bruce, S. S., Zacharia, B. E., Hickman, Z. L., Kellner, C. P., Sussman, E. S., McDowell, M. M., Bruce, R. A., Connolly, E. S. 2013; 34 (5)

    Abstract

    Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions.From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected.The patients' median age was 43 years (range 30-55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5-9). The median ICH volume was 53 cm(3) (range 28-79 cm(3)), and the median midline shift was 7.6 mm (range 3.0-11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5-4.6 mm), and the median change in GCS score was +1 (range -3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9-11), the median modified Rankin Scale (mRS) score was 5 (range 5-5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17-27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4-5), and 2 were functionally independent (mRS Score 0-3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5-9, ICH volume 28-79 cm(3), age < 60 years) whose cases were managed nonoperatively (n = 5).Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.

    View details for DOI 10.3171/2013.2.FOCUS1326

    View details for Web of Science ID 000318489300005

    View details for PubMedID 23634923

  • Alpha-7 nicotinic acetylcholine receptor agonists in intracerebral hemorrhage: an evaluation of the current evidence for a novel therapeutic agent NEUROSURGICAL FOCUS Sussman, E. S., Kellner, C. P., McDowell, M. M., Bruce, S. S., Heuts, S. G., Zhuang, Z., Bruce, R. A., Claassen, J., Connolly, E. S. 2013; 34 (5)

    Abstract

    Intracerebral hemorrhage (ICH) is the most deadly and least treatable subtype of stroke, and at the present time there are no evidence-based therapeutic interventions for patients with this disease. Secondary injury mechanisms are known to cause substantial rates of morbidity and mortality following ICH, and the inflammatory cascade is a major contributor to this post-ICH secondary injury. The alpha-7 nicotinic acetylcholine receptor (?7-nAChR) agonists have a well-established antiinflammatory effect and have been shown to attenuate perihematomal edema volume and to improve functional outcome in experimental ICH. The authors evaluate the current evidence for the use of an ?7-nAChR agonist as a novel therapeutic agent in patients with ICH.

    View details for DOI 10.3171/2013.2.FOCUS1315

    View details for Web of Science ID 000318489300011

    View details for PubMedID 23634914

  • Endovascular thrombectomy following acute ischemic stroke: a single-center case series and critical review of the literature. Brain sciences Sussman, E., Kellner, C., McDowell, M., Yang, P., Nelson, E., Greenberg, S., Sahlein, D., LaVine, S., Meyers, P., Connolly, E. S. 2013; 3 (2): 521-539

    Abstract

    Acute ischemic stroke (AIS) due to thrombo-embolic occlusion in the cerebral vasculature is a major cause of morbidity and mortality in the United States and throughout the world. Although the prognosis is poor for many patients with AIS, a variety of strategies and devices are now available for achieving recanalization in patients with this disease. Here, we review the treatment options for cerebrovascular thromboembolic occlusion with a focus on the evolution of strategies and devices that are utilized for achieving endovascular clot extraction. In order to demonstrate the progression of this treatment strategy over the past decade, we will also present a single-center case series of AIS patients treated with endovascular thrombectomy.

    View details for DOI 10.3390/brainsci3020521

    View details for PubMedID 24961413

    View details for PubMedCentralID PMC4061858

  • The role of advanced neuroimaging in intracerebral hemorrhage NEUROSURGICAL FOCUS McDowell, M. M., Kellner, C. P., Barton, S. M., Mikell, C. B., Sussman, E. S., Heuts, S. G., Connolly, E. S. 2013; 34 (4)

    Abstract

    In this report, the authors sought to summarize existing literature to provide an overview of the currently available techniques and to critically assess the evidence for or against their application in intracerebral hemorrhage (ICH) for management, prognostication, and research. Functional imaging in ICH represents a potential major step forward in the ability of physicians to assess patients suffering from this devastating illness due to the advantages over standing imaging modalities focused on general tissue structure alone, but its use is highly controversial due to the relative paucity of literature and the lack of consolidation of the predominantly small data sets that are currently in existence. Current data support that diffusion tensor imaging and tractography, diffusion-perfusion weighted MRI techniques, and functional MRI all possess major potential in the areas of highlighting motor deficits, motor recovery, and network reorganization. Novel clinical studies designed to objectively assess the value of each of these modalities on a wider scale in conjunction with other methods of investigation and management will allow for their rapid incorporation into standard practice.

    View details for DOI 10.3171/2013.1.FOCUS12409

    View details for Web of Science ID 000316955700003

    View details for PubMedID 23544408

  • Hemorrhagic transformation: a review of the rate of hemorrhage in the major clinical trials of acute ischemic stroke FRONTIERS IN NEUROLOGY Sussman, E. S., Connolly, E. S. 2013; 4

    View details for DOI 10.3389/fneur.2013.00069

    View details for Web of Science ID 000209629000068

  • The surgical management of chronic subdural hematoma NEUROSURGICAL REVIEW Ducruet, A. F., Grobelny, B. T., Zacharia, B. E., Hickman, Z. L., Derosa, P. L., Anderson, K., Sussman, E., Carpenter, A., Connolly, E. S. 2012; 35 (2): 155-169

    Abstract

    Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: "subdural hematoma", "craniotomy", "burr-hole", "management", "anticoagulation", "seizure prophylaxis", "antiplatelet", "mobilization", and "surgical evacuation", alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.

    View details for DOI 10.1007/s10143-011-0349-y

    View details for Web of Science ID 000301707000003

    View details for PubMedID 21909694

  • Postoperative Antibiotics Correlate with Worse Outcomes after Appendectomy for Nonperforated Appendicitis JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Coakley, B. A., Sussman, E. S., Wolfson, T. S., Bhagavath, A. S., Choi, J. J., Ranasinghe, N. E., Lynn, E. T., Divino, C. M. 2011; 213 (6): 778-783

    Abstract

    Acute appendicitis remains the most common cause of acute abdominal pain necessitating operative intervention. Although postoperative antibiotics are universally used for perforated appendicitis, no consensus exists on whether postoperative antibiotics are beneficial for preventing surgical site infections (SSIs) in nonperforated cases. We set out to determine how postoperative antibiotic therapy affects outcomes after appendectomy for nonperforated appendicitis.The medical records of 1,000 patients undergoing appendectomy for nonperforated appendicitis at The Mount Sinai Medical Center from January 2005 through July 2010 were retrospectively reviewed.In total, 728 cases contained sufficient follow-up data for analysis; 334 of these patients received postoperative antibiotics and 394 did not. There were no significant differences in patient demographics, medical comorbidities, American Society of Anesthesiologists (ASA) class, admission temperature, preoperative antibiotic treatment, operating room time, estimated blood loss, appendiceal diameter, or intraoperative transfusion between the two groups, although WBC was higher for patients receiving postoperative antibiotics (12.3 vs 14 cells/mm(3), p = 0.001). Postoperative antibiotics did not alter the incidence of superficial SSIs, deep SSIs, or organ space SSIs (all p = 0.1), but did correlate with higher rates of Clostridium difficile infection (p = 0.02), urinary tract infection (p = 0.05), postoperative diarrhea (p < 0.001), and longer length of stay (LOS) (1.1 vs 2.4 days, p < 0.001). Patients receiving postoperative antibiotics also showed trends toward higher readmission and reoperation rates (both p = 0.06).Postoperative antibiotic treatment for nonperforated appendicitis did not reduce infectious complications and prolonged LOS while increasing postoperative morbidity. Therefore, postoperative antibiotics likely increase the treatment cost for nonperforated appendicitis while not adding an appreciable clinical benefit and, in some cases, actually worsening outcomes.

    View details for DOI 10.1016/j.jamcollsurg.2011.08.018

    View details for Web of Science ID 000298003700015

    View details for PubMedID 21958510

  • Preoperative antiepileptic drug administration and the incidence of postoperative seizures following bur hole-treated chronic subdural hematoma Clinical article JOURNAL OF NEUROSURGERY Grobelny, B. T., Ducruet, A. F., Zacharia, B. E., Hickman, Z. L., Andersen, K. N., Sussman, E., Carpenter, A., Connolly, E. S. 2009; 111 (6): 1257-1262

    Abstract

    Despite the prevalence of chronic subdural hematoma (CSDHs) in the rapidly growing elderly population, several aspects of disease management remain unclear. In particular, there is still conflicting evidence regarding the efficacy of antiepileptic drug (AED) prophylaxis in patients with CSDH who undergo bur hole drainage. The authors endeavored to evaluate the efficacy of AED prophylaxis in reducing the incidence of seizures and improving outcome in this patient population.A single surgeon's clinical database (E.S.C.) was analyzed for cases involving bur hole drainage for CSDH. Cases involving nonhemorrhagic subdural effusions as well as acute subdural hemorrhages evacuated by craniotomy were excluded from this study. Patient medical records were evaluated for relevant demographic data, medical history, imaging characteristics, clinical details of the treatment, hospital stay, and discharge summaries.The authors included 88 patients with bur hole-treated CSDH. Eleven patients (12.5%) suffered at least 1 seizure between hemorrhage onset and discharge from their treatment hospital admission. Seizures were more frequent in women than men (p = 0.030) and least frequent in patients with right-sided lesions (p = 0.030). In a multiple logistic regression model, preoperative initiation of AED prophylaxis was the only significant predictor of the lower incidence of postoperative seizures (OR 0.10, p = 0.013). However, preoperative initiation of AED prophylaxis did not significantly affect outcome at discharge.The finding in this study demonstrates that preoperative AED prophylaxis likely reduces the incidence of postoperative seizures in patients with CSDH treated with bur hole drainage. A future prospective randomized study is necessary to evaluate the effect of seizure reduction on clinical outcome.

    View details for DOI 10.3171/2009.6.JNS0928

    View details for Web of Science ID 000272493300028

    View details for PubMedID 19558304

Footer Links:

Stanford Medicine Resources: