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Development of an online calculator for the prediction of seizure freedom following pediatric hemispherectomy using HOPS

Weil, Alexander G; Dimentberg, Evan; Lewis, Evan; Ibrahim, George M; Kola, Olivia; Tseng, Chi-Hong; Chen, Jia-Shu; Lin, Kao-Min; Cai, Li-Xin; Liu, Qing-Zhu; Lin, Jiu-Luan; Zhou, Wen-Jing; Mathern, Gary W; Smyth, Matthew D; O'Neill, Brent R; Dudley, Roy; Ragheb, John; Bhatia, Sanjiv; Delev, Daniel; Ramantani, Georgia; Zentner, Josef; Wang, Anthony C; Dorfer, Christian; Feucht, Martha; Czech, Thomas; Bollo, Robert J; Issabekov, Galymzhan; Zhu, Hongwei; Connolly, Mary; Steinbok, Paul; Zhang, Jian-Guo; Zhang, Kai; Hidalgo, Eveline Teresa; Weiner, Howard L; Wong-Kisiel, Lily; Lapalme-Remis, Samuel; Tripathi, Manjari; Chandra, P Sarat; Hader, Walter; Wang, Feng-Peng; Yao, Yi; Champagne, Pierre Olivier; Brunette-Clément, Tristan; Guo, Qiang; Li, Shao-Chun; Budke, Marcelo; Pérez-Jiménez, Maria Angeles; Raftopoulos, Christian; Finet, Patrice; Michel, Pauline; Schaller, Karl; Stienen, Martin N; Baro, Valentina; Malone, Christian Cantillano; Pociecha, Juan; Chamorro, Noelia; Muro, Valeria L; von Lehe, Marec; Vieker, Silvia; Oluigbo, Chima; Gaillard, William D; Al Khateeb, Mashael; Al Otaibi, Faisal; Krayenbühl, Niklaus; Bolton, Jeffrey; Pearl, Phillip L; Fallah, Aria
OBJECTIVES/OBJECTIVE:Although hemispheric surgeries are among the most effective procedures for drug-resistant epilepsy (DRE) in the pediatric population, a large variability in outcomes remains. Identifying ideal hemispherectomy candidates is imperative to maximize the potential for seizure freedom. The objective was to develop an online, freely-accesible tool that accurately predicts the probability of seizure freedom for any patient at 1-, 2-, and 5-years post-hemispherectomy to provide clinicians accessible and reliable prognostic information to complement clinical judgement. METHODS:Retrospective data of all pediatric patients with DRE and seizure outcome data from the original Hemispherectomy Outcome Prediction Scale (HOPS) study were included. The primary outcome of interest was time-to-seizure recurrence. A multivariate Cox proportional-hazards regression model was developed to predict the likelihood of post-hemispheric surgery seizure freedom duration based on a combination of variables identified by clinical judgement and inferential statistics as predictive of the primary outcome. The final model from this study was encoded in a publicly accessible online calculator on the (iNEST) website. RESULTS:The selected variables for inclusion in the final model included the 5 original HOPS variables (age at seizure onset, etiologic substrate, seizure semiology, prior non-hemispheric resective surgery, and contralateral FDG-PET hypometabolism) and 3 additional variables (age at surgery, history of infantile spasms, and magnetic resonance (MR) imaging lesion). Predictors of shorter time-to-seizure recurrence included younger age at seizure onset, older age at surgery, prior resective surgery, generalized seizure semiology, FDG-PET hypometabolism contralateral to side of surgery, contralateral MR imaging lesion, non-lesional MR imaging, non-stroke etiologies, and history of infantile spasms. The area under the curve (AUC) of the final model was 73.0%. SIGNIFICANCE/CONCLUSIONS:Online calculators are efficient, cost-free tools that can facilitate physicians in risk-estimation and inform joint decision-making with families, potentially leading to greater satisfaction. Although the HOPS data was previously validated in the first analysis, the authors encourage prospective external validation of this new tool.
PMID: 37347512
ISSN: 1528-1167
CID: 5542872

Comparison of the real-world effectiveness of vertical versus lateral functional hemispherotomy techniques for pediatric drug-resistant epilepsy: A post hoc analysis of the HOPS study

Fallah, Aria; Lewis, Evan; Ibrahim, George M; Kola, Olivia; Tseng, Chi-Hong; Harris, William B; Chen, Jia-Shu; Lin, Kao-Min; Cai, Li-Xin; Liu, Qing-Zhu; Lin, Jiu-Luan; Zhou, Wen-Jing; Mathern, Gary W; Smyth, Matthew D; O'Neill, Brent R; Dudley, Roy W R; Ragheb, John; Bhatia, Sanjiv; Delev, Daniel; Ramantani, Georgia; Zentner, Josef; Wang, Anthony C; Dorfer, Christian; Feucht, Martha; Czech, Thomas; Bollo, Robert J; Issabekov, Galymzhan; Zhu, Hongwei; Connolly, Mary; Steinbok, Paul; Zhang, Jian-Guo; Zhang, Kai; Hidalgo, Eveline Teresa; Weiner, Howard L; Wong-Kisiel, Lily; Lapalme-Remis, Samuel; Tripathi, Manjari; Sarat Chandra, Poodipedi; Hader, Walter; Wang, Feng-Peng; Yao, Yi; Champagne, Pierre-Olivier; Brunette-Clément, Tristan; Guo, Qiang; Li, Shao-Chun; Budke, Marcelo; Pérez-Jiménez, Maria Angeles; Raftopoulos, Christian; Finet, Patrice; Michel, Pauline; Schaller, Karl; Stienen, Martin N; Baro, Valentina; Cantillano Malone, Christian; Pociecha, Juan; Chamorro, Noelia; Muro, Valeria L; von Lehe, Marec; Vieker, Silvia; Oluigbo, Chima; Gaillard, William D; Al-Khateeb, Mashael; Al Otaibi, Faisal; Krayenbühl, Niklaus; Bolton, Jeffrey; Pearl, Phillip L; Weil, Alexander G
OBJECTIVE:This study was undertaken to determine whether the vertical parasagittal approach or the lateral peri-insular/peri-Sylvian approach to hemispheric surgery is the superior technique in achieving long-term seizure freedom. METHODS:We conducted a post hoc subgroup analysis of the HOPS (Hemispheric Surgery Outcome Prediction Scale) study, an international, multicenter, retrospective cohort study that identified predictors of seizure freedom through logistic regression modeling. Only patients undergoing vertical parasagittal, lateral peri-insular/peri-Sylvian, or lateral trans-Sylvian hemispherotomy were included in this post hoc analysis. Differences in seizure freedom rates were assessed using a time-to-event method and calculated using the Kaplan-Meier survival method. RESULTS:Data for 672 participants across 23 centers were collected on the specific hemispherotomy approach. Of these, 72 (10.7%) underwent vertical parasagittal hemispherotomy and 600 (89.3%) underwent lateral peri-insular/peri-Sylvian or trans-Sylvian hemispherotomy. Seizure freedom was obtained in 62.4% (95% confidence interval [CI] = 53.5%-70.2%) of the entire cohort at 10-year follow-up. Seizure freedom was 88.8% (95% CI = 78.9%-94.3%) at 1-year follow-up and persisted at 85.5% (95% CI = 74.7%-92.0%) across 5- and 10-year follow-up in the vertical subgroup. In contrast, seizure freedom decreased from 89.2% (95% CI = 86.3%-91.5%) at 1-year to 72.1% (95% CI = 66.9%-76.7%) at 5-year to 57.2% (95% CI = 46.6%-66.4%) at 10-year follow-up for the lateral subgroup. Log-rank test found that vertical hemispherotomy was associated with durable seizure-free progression compared to the lateral approach (p = .01). Patients undergoing the lateral hemispherotomy technique had a shorter time-to-seizure recurrence (hazard ratio = 2.56, 95% CI = 1.08-6.04, p = .03) and increased seizure recurrence odds (odds ratio = 3.67, 95% CI = 1.05-12.86, p = .04) compared to those undergoing the vertical hemispherotomy technique. SIGNIFICANCE/CONCLUSIONS:This pilot study demonstrated more durable seizure freedom of the vertical technique compared to lateral hemispherotomy techniques. Further studies, such as prospective expertise-based observational studies or a randomized clinical trial, are required to determine whether a vertical approach to hemispheric surgery provides superior long-term seizure outcomes.
PMID: 34510448
ISSN: 1528-1167
CID: 5012172

Epilepsy surgery in infants up to 3 months of age: Safety, feasibility, and outcomes: A multicenter, multinational study

Roth, Jonathan; Constantini, Shlomi; Ekstein, Margaret; Weiner, Howard L; Tripathi, Manjari; Chandra, Poodipedi Sarat; Cossu, Massimo; Rizzi, Michele; Bollo, Robert J; Machado, Hélio Rubens; Santos, Marcelo Volpon; Keating, Robert F; Oluigbo, Chima O; Rutka, James T; Drake, James M; Jallo, George I; Shimony, Nir; Treiber, Jeffrey M; Consales, Alessandro; Mangano, Francesco T; Wisoff, Jeffrey H; Teresa Hidalgo, Eveline; Bingaman, William E; Gupta, Ajay; Erdemir, Gozde; Sundar, Swetha J; Benifla, Mony; Shapira, Vladimir; Lam, Sandi K; Fallah, Aria; Maniquis, Cassia A B; Tisdall, Martin; Chari, Aswin; Cinalli, Giuseppe; Blount, Jeffrey P; Dorfmüller, Georg; Uliel-Sibony, Shimrit
OBJECTIVE:Drug-resistant epilepsy (DRE) during the first few months of life is challenging and necessitates aggressive treatment, including surgery. Because the most common causes of DRE in infancy are related to extensive developmental anomalies, surgery often entails extensive tissue resections or disconnection. The literature on "ultra-early" epilepsy surgery is sparse, with limited data concerning efficacy controlling the seizures, and safety. The current study's goal is to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months. METHODS:To achieve a large sample size and external validity, a multinational, multicenter retrospective study was performed, focusing on epilepsy surgery for infants younger than 3 months of age. Collected data included epilepsy characteristics, surgical details, epilepsy outcome, and complications. RESULTS:Sixty-four patients underwent 69 surgeries before the age of 3 months. The most common pathologies were cortical dysplasia (28), hemimegalencephaly (17), and tubers (5). The most common procedures were hemispheric surgeries (48 procedures). Two cases were intentionally staged, and one was unexpectedly aborted. Nearly all patients received blood products. There were no perioperative deaths and no major unexpected permanent morbidities. Twenty-five percent of patients undergoing hemispheric surgeries developed hydrocephalus. Excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I) was achieved in 66% of cases over a median follow-up of 41 months (19-104 interquartile range [IQR]). The number of antiseizure medications was significantly reduced (median 2 drugs, 1-3 IQR, p < .0001). Outcome was not significantly associated with the type of surgery (hemispheric or more limited resections). SIGNIFICANCE/CONCLUSIONS:Epilepsy surgery during the first few months of life is associated with excellent seizure control, and when performed by highly experienced teams, is not associated with more permanent morbidity than surgery in older infants. Thus surgical treatment should not be postponed to treat DRE in very young infants based on their age.
PMID: 34128544
ISSN: 1528-1167
CID: 4911572

Gut Microbiome in Progressive Multiple Sclerosis

Cox, Laura M; Maghzi, Amir Hadi; Liu, Shirong; Tankou, Stephanie K; Dhang, Fyonn H; Willocq, Valerie; Song, Anya; Wasén, Caroline; Tauhid, Shahamat; Chu, Renxin; Anderson, Mark C; De Jager, Philip L; Polgar-Turcsanyi, Mariann; Healy, Brian C; Glanz, Bonnie I; Bakshi, Rohit; Chitnis, Tanuja; Weiner, Howard L
OBJECTIVE:This study was undertaken to investigate the gut microbiome in progressive multiple sclerosis (MS) and how it relates to clinical disease. METHODS:We sequenced the microbiota from healthy controls and relapsing-remitting MS (RRMS) and progressive MS patients and correlated the levels of bacteria with clinical features of disease, including Expanded Disability Status Scale (EDSS), quality of life, and brain magnetic resonance imaging lesions/atrophy. We colonized mice with MS-derived Akkermansia and induced experimental autoimmune encephalomyelitis (EAE). RESULTS:Microbiota β-diversity differed between MS patients and controls but did not differ between RRMS and progressive MS or differ based on disease-modifying therapies. Disease status had the greatest effect on the microbiome β-diversity, followed by body mass index, race, and sex. In both progressive MS and RRMS, we found increased Clostridium bolteae, Ruthenibacterium lactatiformans, and Akkermansia and decreased Blautia wexlerae, Dorea formicigenerans, and Erysipelotrichaceae CCMM. Unique to progressive MS, we found elevated Enterobacteriaceae and Clostridium g24 FCEY and decreased Blautia and Agathobaculum. Several Clostridium species were associated with higher EDSS and fatigue scores. Contrary to the view that elevated Akkermansia in MS has a detrimental role, we found that Akkermansia was linked to lower disability, suggesting a beneficial role. Consistent with this, we found that Akkermansia isolated from MS patients ameliorated EAE, which was linked to a reduction in RORγt+ and IL-17-producing γδ T cells. INTERPRETATION/CONCLUSIONS:Whereas some microbiota alterations are shared in relapsing and progressive MS, we identified unique bacteria associated with progressive MS and clinical measures of disease. Furthermore, elevated Akkermansia in MS may be a compensatory beneficial response in the MS microbiome. ANN NEUROL 2021.
PMID: 33876477
ISSN: 1531-8249
CID: 4852082

Hemispherectomy Outcome Prediction Scale: Development and validation of a seizure freedom prediction tool

Weil, Alexander G; Lewis, Evan C; Ibrahim, George M; Kola, Olivia; Tseng, Chi-Hong; Zhou, Xinkai; Lin, Kao-Min; Cai, Li-Xin; Liu, Qing-Zhu; Lin, Jiu-Luan; Zhou, Wen-Jing; Mathern, Gary W; Smyth, Matthew D; O'Neill, Brent R; Dudley, Roy; Ragheb, John; Bhatia, Sanjiv; Delev, Daniel; Ramantani, Georgia; Zentner, Josef; Ojemann, Jeffrey; Wang, Anthony C; Dorfer, Christian; Feucht, Martha; Czech, Thomas; Bollo, Robert J; Issabekov, Galymzhan; Zhu, Hongwei; Connelly, Mary; Steinbok, Paul; Zhang, Jian-Guo; Zhang, Kai; Hidalgo, Eveline Teresa; Weiner, Howard L; Wong-Kisiel, Lily; Lapalme-Remis, Samuel; Tripathi, Manjari; Sarat Chandra, Poodipedi; Hader, Walter; Wang, Feng-Peng; Yao, Yi; Olivier Champagne, Pierre; Guo, Qiang; Li, Shao-Chun; Budke, Marcelo; Pérez-Jiménez, Maria Angeles; Raftapoulos, Christian; Finet, Patrice; Michel, Pauline; Schaller, Karl; Stienen, Martin N; Baro, Valentina; Cantillano Malone, Christian; Pociecha, Juan; Chamorro, Noelia; Muro, Valeria L; von Lehe, Marec; Vieker, Silvia; Oluigbo, Chima; Gaillard, William D; Al Khateeb, Mashael; Al Otaibi, Faisal; Krayenbühl, Niklaus; Bolton, Jeffrey; Pearl, Phillip L; Fallah, Aria
OBJECTIVE:To develop and validate a model to predict seizure freedom in children undergoing cerebral hemispheric surgery for the treatment of drug-resistant epilepsy. METHODS:We analyzed 1267 hemispheric surgeries performed in pediatric participants across 32 centers and 12 countries to identify predictors of seizure freedom at 3 months after surgery. A multivariate logistic regression model was developed based on 70% of the dataset (training set) and validated on 30% of the dataset (validation set). Missing data were handled using multiple imputation techniques. RESULTS:Overall, 817 of 1237 (66%) hemispheric surgeries led to seizure freedom (median follow-up = 24 months), and 1050 of 1237 (85%) were seizure-free at 12 months after surgery. A simple regression model containing age at seizure onset, presence of generalized seizure semiology, presence of contralateral 18-fluoro-2-deoxyglucose-positron emission tomography hypometabolism, etiologic substrate, and previous nonhemispheric resective surgery is predictive of seizure freedom (area under the curve = .72). A Hemispheric Surgery Outcome Prediction Scale (HOPS) score was devised that can be used to predict seizure freedom. SIGNIFICANCE/CONCLUSIONS:Children most likely to benefit from hemispheric surgery can be selected and counseled through the implementation of a scale derived from a multiple regression model. Importantly, children who are unlikely to experience seizure control can be spared from the complications and deficits associated with this surgery. The HOPS score is likely to help physicians in clinical decision-making.
PMID: 33713438
ISSN: 1528-1167
CID: 4836542

Improved relapse recovery in paediatric compared to adult multiple sclerosis

Chitnis, Tanuja; Aaen, Greg; Belman, Anita; Benson, Leslie; Gorman, Mark; Goyal, Manu S; Graves, Jennifer S; Harris, Yolanda; Krupp, Lauren; Lotze, Timothy; Mar, Soe; Ness, Jayne; Rensel, Mary; Schreiner, Teri; Tillema, Jan-Mendelt; Waubant, Emmanuelle; Weinstock-Guttman, Bianca; Roalstad, Shelly; Rose, John; Weiner, Howard L; Casper, T Charles; Rodriguez, Moses
Incomplete relapse recovery contributes to disability accrual and earlier onset of secondary progressive multiple sclerosis. We sought to investigate the effect of age on relapse recovery. We identified patients with multiple sclerosis from two longitudinal prospective studies, with an Expanded Disability Status Scale (EDSS) score within 30 days after onset of an attack, and follow-up EDSS 6 months after attack. Adult patients with multiple sclerosis (n = 632) were identified from the Comprehensive Longitudinal Investigations in Multiple Sclerosis at Brigham study (CLIMB), and paediatric patients (n = 132) from the US Network of Paediatric Multiple Sclerosis Centers (NPMSC) registry. Change in EDSS was defined as the difference in EDSS between attack and follow-up. Change in EDSS at follow-up compared to baseline was significantly lower in children compared to adults (P = 0.001), as were several functional system scores. Stratification by decade at onset for change in EDSS versus age found for every 10 years of age, EDSS recovery is reduced by 0.15 points (P < 0.0001). A larger proportion of children versus adults demonstrated improvement in EDSS following an attack (P = 0.006). For every 10 years of age, odds of EDSS not improving increase by 1.33 times (P < 0.0001). Younger age is associated with improved recovery from relapses. Age-related mechanisms may provide novel therapeutic targets for disability accrual in multiple sclerosis.
PMID: 32810215
ISSN: 1460-2156
CID: 4614382

Calorie restriction slows age-related microbiota changes in an Alzheimer's disease model in female mice

Cox, Laura M; Schafer, Marissa J; Sohn, Jiho; Vincentini, Julia; Weiner, Howard L; Ginsberg, Stephen D; Blaser, Martin J
Alzheimer's disease (AD) affects an estimated 5.8 million Americans, and advanced age is the greatest risk factor. AD patients have altered intestinal microbiota. Accordingly, depleting intestinal microbiota in AD animal models reduces amyloid-beta (Aβ) plaque deposition. Age-related changes in the microbiota contribute to immunologic and physiologic decline. Translationally relevant dietary manipulations may be an effective approach to slow microbiota changes during aging. We previously showed that calorie restriction (CR) reduced brain Aβ deposition in the well-established Tg2576 mouse model of AD. Presently, we investigated whether CR alters the microbiome during aging. We found that female Tg2576 mice have more substantial age-related microbiome changes compared to wildtype (WT) mice, including an increase in Bacteroides, which were normalized by CR. Specific gut microbiota changes were linked to Aβ levels, with greater effects in females than in males. In the gut, Tg2576 female mice had an enhanced intestinal inflammatory transcriptional profile, which was reversed by CR. Furthermore, we demonstrate that Bacteroides colonization exacerbates Aβ deposition, which may be a mechanism whereby the gut impacts AD pathogenesis. These results suggest that long-term CR may alter the gut environment and prevent the expansion of microbes that contribute to age-related cognitive decline.
PMID: 31784610
ISSN: 2045-2322
CID: 4216332

Invasive monitoring after resection of epileptogenic neocortical lesions in multistaged epilepsy surgery in children

Hidalgo, Eveline Teresa; Frankel, Hyman Gregory; Rodriguez, Crystalann; Orillac, Cordelia; Phillips, Sophie; Patel, Neel; Devinsky, Orrin; Friedman, Daniel; Weiner, Howard L
OBJECTIVE:Incomplete resection of neocortical epileptogenic foci correlates with failed epilepsy surgery in children. We often treat patients with neocortical epilepsy with a staged approach using invasive monitoring to localize the focus, resect the seizure onset zone, and, in select cases, post-resection invasive monitoring (PRM). We report the technique and the outcomes of children treated with staged surgery including PRM. METHODS:We retrospectively reviewed the charts of pediatric patients with neocortical epilepsy who underwent resective surgery with PRM. RESULTS:We identified 71 patients, 5 patients with MRI-negative epilepsy and 66 patients with MRI-identified neocortical lesions; 64/66 (97%) patients had complete lesionectomy. In 61/71 (86%) patients PRM was associated with positive outcomes. Those findings were: 1) clinical seizures with electrographic involvement at resection margins (47%); 2) subclinical seizures and interictal discharges at resection margins (29%); and 3) clinical and subclinical seizures revealing a new epileptogenic focus (20%). In 55/71 (77%) patients, PRM data led to additional resection (re-resection; RR). Six additional patients had no further resection due to overlap with eloquent cortex. Histopathology showed tuberous sclerosis complex (TSC; n = 46), focal cortical dysplasia (FCD; n = 16)), gliosis (n = 4), tumors (n = 4), and Sturge-Weber syndrome (n = 1). There were no major complications. Seizure-free outcome in children with TSC was 63% at 1-year follow-up and 56% at 2-year follow-up. In FCD, seizure freedom after 1 and 2 years was 85%. SIGNIFICANCE/CONCLUSIONS:Post-resection monitoring may provide additional information about the extent of the epileptogenic zone, such as residual epileptogenic activity at the margins of the resection cavity, and may unmask additional seizure foci. This method may be especially useful in achieving long-term stable seizure-free outcome.
PMID: 30384114
ISSN: 1872-6844
CID: 3400002

Epilepsy surgery in Panama: Establishment of a successful hybrid program as a model for small middle-income countries

Kuzniecky, Ruben; Baez, Carmen; Aranda, Guzmán; Hidalgo, Eveline Teresa; Grover, Ameeta; Orillac, Cordelia; Zelenka, Yvonne; Weiner, Howard L
OBJECTIVE:The majority of the 65 million people worldwide with epilepsy live in low- and middle-income countries. Many of these countries have inadequate resources to serve the large patient population affected by epilepsy. Panama is a middle-income country that currently has only 2 facilities that can provide basic epilepsy services and no epilepsy surgery services. To address this need, a group of Panamanian physicians partnered with U.S. epilepsy health care providers to test a hybrid epilepsy surgery program, combining resources and expertise. METHODS:From 2011 to 2017, a multidisciplinary team of neurologists, neurosurgeons, and an electroencephalography (EEG) technician from the United States traveled to Panama 6 times and, in collaboration with the local team, performed surgical procedures for intractable epilepsy at the national children's hospital. Resective surgeries were performed with intraoperative electrocorticography and/or implantation of subdural and depth electrodes and extra-operative monitoring. Cost was calculated using Panama government data. RESULTS:Twenty-seven children with intractable epilepsy were surgically treated. Fifteen children are seizure-free (Engle class I), 11 children are Engel II, and one child is Engel III. No major morbidity or mortality occurred, with only one postoperative infection. The average cost of treatment was calculated at $9850 per patient. SIGNIFICANCE/CONCLUSIONS:This program is a model for creating a multinational and multi-institutional collaboration to provide surgical epilepsy treatment in a middle-income country without an adequate infrastructure. To be successful, this collaboration needed to address medical, technical, and cultural challenges. This partnership helps to alleviate some of the present need for surgical epilepsy services while laying the groundwork for the development of a future local independent epilepsy surgery program.
PMID: 30338512
ISSN: 1528-1167
CID: 3370092

Resection of a Pediatric Thalamic Juvenile Pilocytic Astrocytoma with Whole Brain Tractography

Weiner, Howard L; Placantonakis, Dimitris G
The resection of deep-seated brain tumors has been associated with morbidity due to injury to critical neural structures during the approach. Recent technological advancements in navigation and stereotaxy, surgical planning, brain tractography and minimal-access brain ports present the opportunity to overcome such limitations. Here, we present the case of a pediatric patient with a left thalamic/midbrain juvenile pilocytic astrocytoma (JPA). The tumor displaced the corticospinal fibers posteriorly and resulted in hemiparesis. Using whole brain tractography to plan a corridor for the approach, neuronavigation, a tubular retractor and an exoscope for visualization, we obtained gross total resection of the tumor, while minimizing injury to white matter bundles, including the corticospinal fibers. We propose that surgical planning with whole brain tractography is essential for reducing morbidity while accessing deep-lying brain lesions via retractor tubes, by means of sparing critical fiber tracts.
PMCID:5724810
PMID: 29234572
ISSN: 2168-8184
CID: 2844332