Faculty Bibliography

BACKGROUND:Although gliomas during pregnancy are rare, they present significant clinical and ethical challenges due to the potential effects of pregnancy on tumor behavior and the risks associated with the standard of care. Given the peak incidence of IDH-mutant glioma in the 3rd and 4th decades of life, clinicians face a challenge in balancing maternal oncological outcomes with fetal safety, while navigating the uncertainty surrounding the effects of standard treatment modalities on fetal development. OBSERVATIONS/METHODS:A 31-year-old woman at 23 weeks of gestation with a history of IDH-mutant glioma presented to the authors' institution with worsening neurological symptoms. MRI indicated tumor progression, and re-resection was performed via awake craniotomy with functional mapping. The maternal-fetal medicine team was consulted to guide the selection of anesthesia and optimize intraoperative positioning, ensuring the safety of both the patient and fetus. Postoperative recovery was uneventful, with stable maternal and fetal outcomes. Pathological analysis confirmed progression to a grade 4 astrocytoma. LESSONS/CONCLUSIONS:This case highlights the feasibility of awake craniotomy with functional mapping during pregnancy. Management of gliomas in pregnancy requires a multidisciplinary approach, balancing maternal health and fetal safety, with careful consideration of treatment timing and anesthetic strategies. https://thejns.org/doi/10.3171/CASE2696.

Tafazzin is a phospholipid-lysophospholipid acyltransferase that remodels fatty acids of mitochondrial phospholipids. To study the tafazzin mechanism, we expressed and purified the enzyme, measured its kinetics with different pairs of phosphatidylcholine (PC) and lysophosphatidylcholine (LPC) species, and simulated the reactions in a mathematical model based on the mass-action law. Variations in chain length and PC:LPC ratio showed that tafazzin reacts with micelles but not with bilayers. In the presence of micellar substrates (LPC + short-chain PC), transacylation rates measured at different substrate ratios suggested similar affinities for PC and LPC. Surprisingly, tafazzin catalyzed both transacylation and hydrolysis of fatty acids, the former preferring oleoyl over palmitoyl and the latter preferring palmitoyl over oleoyl groups. To study the remodeling of cardiolipin, we measured the reaction of trilinoleoyl-monolyso-cardiolipin with palmitoyl-oleoyl-PC and simulated it in a mathematical model. Simulations predicted and measurements confirmed a large number of bidirectional transacylations between the initial substrates, between substrates and products, and between different products. This led to a gradual diversification of the lipid composition from 2 to more than 15 species. Discrepancies between observed and simulated compositions demonstrated transacylation preference for oleoyl over palmitoyl groups. The data are consistent with a bidirectional ping-pong mechanism that operates through a single low-affinity binding site and suggest that transacylation specificity can at least in part be explained by selective loss of fatty acids through hydrolysis.

Tafazzin is a phospholipid-lysophospholipid acyltransferase that remodels fatty acids of mitochondrial phospholipids. To study the tafazzin mechanism, we expressed and purified the enzyme, measured its kinetics with different pairs of phosphatidylcholine (PC) and lysophosphatidylcholine (LPC) species, and simulated the reactions in a mathematical model based on the mass-action law. Variations in chain length and PC:LPC ratio showed that tafazzin reacts with micelles but not with bilayers. In the presence of micellar substrates (LPC + short-chain PC), transacylation rates measured at different substrate ratios suggested similar affinities for PC and LPC. Surprisingly, tafazzin catalyzed both transacylation and hydrolysis of fatty acids, the former preferring oleoyl over palmitoyl and the latter preferring palmitoyl over oleoyl groups. To study the remodeling of cardiolipin, we measured the reaction of trilinoleoyl-monolyso-cardiolipin with palmitoyl-oleoyl-PC and simulated it in a mathematical model. Simulations predicted and measurements confirmed a large number of bidirectional transacylations between the initial substrates, between substrates and products, and between different products. This led to a gradual diversification of the lipid composition from 2 to more than 15 species. Discrepancies between observed and simulated compositions demonstrated transacylation preference for oleoyl over palmitoyl groups. The data are consistent with a bidirectional ping-pong mechanism that operates through a single low-affinity binding site and suggest that transacylation specificity can at least in part be explained by selective loss of fatty acids through hydrolysis.

BACKGROUND:Although gliomas during pregnancy are rare, they present significant clinical and ethical challenges due to the potential effects of pregnancy on tumor behavior and the risks associated with the standard of care. Given the peak incidence of IDH-mutant glioma in the 3rd and 4th decades of life, clinicians face a challenge in balancing maternal oncological outcomes with fetal safety, while navigating the uncertainty surrounding the effects of standard treatment modalities on fetal development. OBSERVATIONS/METHODS:A 31-year-old woman at 23 weeks of gestation with a history of IDH-mutant glioma presented to the authors' institution with worsening neurological symptoms. MRI indicated tumor progression, and re-resection was performed via awake craniotomy with functional mapping. The maternal-fetal medicine team was consulted to guide the selection of anesthesia and optimize intraoperative positioning, ensuring the safety of both the patient and fetus. Postoperative recovery was uneventful, with stable maternal and fetal outcomes. Pathological analysis confirmed progression to a grade 4 astrocytoma. LESSONS/CONCLUSIONS:This case highlights the feasibility of awake craniotomy with functional mapping during pregnancy. Management of gliomas in pregnancy requires a multidisciplinary approach, balancing maternal health and fetal safety, with careful consideration of treatment timing and anesthetic strategies. https://thejns.org/doi/10.3171/CASE2696.

BACKGROUND:Fewer than 20% of donated lungs are transplanted. We examined the impacts of donor management and recovery at an in-hospital donor care unit (DCU) established in 2021 versus the donor hospital (DH). METHODS:(P/F ratio) were examined as a hypothesized effect modifier. We projected the national impact of improved utilization on lung transplant volume. RESULTS:After adjusting for donor differences, lung utilization was 88% higher (aRR: 1.88; 95% CI: 1.40, 2.53) in the DCU versus DH setting. Median P/F ratio increased from 275 to 348 mmHg (p<0.0001) in the DCU and explained approximately 38% of the improvement in lung utilization. Non-lung organ utilization was either improved or non-inferior in the DCU. Lung graft survival and pulmonary function were similar for recipients of DCU versus DH-managed donors. Nationally, an 88% improvement in lung utilization among donors not currently transferred to a DCU could theoretically result in ≥300 more lung transplants per year. CONCLUSIONS:Lung transplantation can be nearly doubled through lung-centric donor management in a DCU, without sacrificing recipient outcomes nor the utilization of other organs. Donor management practices to optimize lung utilization should be proliferated by establishing more DCUs and, where feasible, applying lung-centric protocols in donor hospitals.

BACKGROUND:Fast-track (FT) protocol is an established but not standardized approach in cardiac surgery. We aimed to describe our FT protocol and to compare outcomes before and after the protocol implementation (non-FT group and FT group, respectively). METHODS:Fast-track protocol was implemented in March 2021 in our institution. All patients who underwent median sternotomy from January 2018 to June 2024 were identified. Patient characteristics and outcomes were compared between the FT group and non-FT group, using propensity-score matching. RESULTS:A total of 456 patients, primarily aortic valve replacement, mitral valve repair or replacement, and root and ascending aortic surgery, were included. Of 456, 261 patients were the FT group and 195 patients were the non-FT group. In the FT group, 91.6% of patients were extubated in the OR (vs. 42.1% in the non-FT group, p < 0.001). In the FT group, 193 (73.9%) were discharged within 2 or 3 days after surgery. After propensity-score matching, the median hospital length of stays (LOS) was significantly shorter in the FT group (3 days vs. 4 days, p < 0.001). Baseline characteristics, operations, and perioperative outcomes were similar between the groups, including 30-day mortality (0.5% vs. 0.5%, p = 1.0), prolonged ventilation (1.1% vs. 1.1%, p = 1.0), discharge to home (1.6% vs. 2.2%, p = 0.72), and readmission (3.8% vs. 4.3%, p = 0.80). CONCLUSIONS:The FT protocol was associated with decreased hospital LOS. Additionally, this study suggested that discharge within 3 postoperative days is feasible after most valve surgeries.

Kidneys from donation after circulatory death (DCD) donors historically had lower recovery and utilization than kidneys from donation after brain death (DBD) donors. However, the organ shortage and advances in organ preservation have increased interest in DCD transplantation. We used OPTN data to study temporal changes in U.S. DCD kidney recovery and transplantation. The percent DCD among kidney donors increased from 21.0% (Era1: 2016-2019) to 30.6% (Era2: 2020-2022) and 42.4% (Era3: 2023-2025). By 2025Q2, more than half (50.4%) of kidney donors were DCDs. Wide variability persisted across eras in percent DCD by recovering OPO (Era1 range: 0%-38%, Era2: 0%-49%, Era3: 0.4%-60%) and by transplanting center (Era1 range: 0%-48%, Era2: 0%-58%, Era3: 0%-60%). Transplanted DCD kidneys in Era3 (vs Era1 & Era2) were more likely to have donor age >60, diabetes, hypertension, obesity, and death due to cardiovascular disease or stroke; 86.8% were pumped. Though the recovered DCD kidney nonuse rate rose from 20.8% (Era1) to 29.9% (Era2) and 35.4% (Era3), nonused DCD kidney donors were age and had more comorbidities in Era 3 compared to earlier eras. Given that half of kidney donors are now DCD, refinements in DCD donor selection and management are needed to optimize recovery and utilization.

BACKGROUND:Degenerative disc disease (DDD) with cartilaginous endplate degeneration and Modic type 1 or 2 changes is increasingly recognized as a source of chronic vertebrogenic and discogenic low back pain. Because the intervertebral disc and vertebral endplates function as a biological and biomechanical unit, regenerative strategies targeting both structures may better address the disc-endplate complex. CASE SERIES/METHODS:Thirteen consecutive patients with chronic refractory vertebrogenic and/or discogenic low back pain, MRI evidence of DDD with Modic type 1 or 2 changes, and failure of conservative management underwent combined intradiscal, peridiscal, and subchondral bone marrow aspirate concentrate (BMAC) injections under fluoroscopic guidance. Four patients had previously undergone basivertebral nerve radiofrequency ablation. The cohort included 6 men and 7 women with a mean age of 56.2 ± 17.5 years. Follow-up ranged from 4 to 15 months. Mean Visual Analog Scale scores decreased from 7.3 ± 2.0 at baseline to 2.1 ± 1.6 at latest follow-up, a mean reduction of 5.2 ± 1.8 points (72.7% ± 19.5%). All patients achieved at least 50% pain reduction and reported functional improvement. Twelve patients (92.3%) were satisfied or very satisfied, and all would recommend the procedure. No major procedure-related complications were observed. CONCLUSION/CONCLUSIONS:Combined intradiscal, peridiscal, and subchondral BMAC injections were associated with substantial pain reduction, functional improvement, high patient satisfaction, and no major complications in this small retrospective case series. Larger prospective controlled studies are needed to confirm these preliminary findings.

Interventional procedures that target the sympathetic nervous system and specific autonomic and sensory ganglia are widely used for refractory visceral, neuropathic, and cancer-related pain. They can provide substantial, often durable analgesia but carry a small yet clinically important risk of serious adverse events. This is the third part of our narrative-review series on the safety of interventional pain procedures, following Part 1 (spinal pain injections) and Part 2 (procedures for back pain), both published in the Journal of Pain Research. It is a structured but non-systematic narrative review (PubMed, Scopus, Embase, and the Cochrane Library; 1980-2026). We examine the complications of image-guided and neuroablative procedures directed at the trigeminal (Gasserian), sphenopalatine, stellate, thoracic sympathetic, celiac/splanchnic, lumbar sympathetic, superior and inferior hypogastric, and impar ganglia and plexuses; we outline the pharmacology of phenol and ethanol and compare them with conventional radiofrequency and cryoneurolysis. Most reported complications are mild, self-limiting, and physiologically predictable, such as hypotension, diarrhea, transient sensory change, and Horner syndrome. Serious events-paraplegia, spinal cord infarction, retropharyngeal hematoma, meningitis, visceral perforation, and anesthesia dolorosa-appear uncommon, but their true incidence remains uncertain and varies by procedure, and much of the evidence derives from isolated case reports. They reflect either anatomical proximity to critical neurovascular structures or unintended spread of the neurolytic agent. Across techniques, the determinants of safety comprise real-time image guidance, meticulous needle placement, incremental dosing, contrast confirmation, attention to anticoagulation status, and careful patient selection.

As interest in donation after circulatory death for heart transplantation (DCD-HT) grows, the need to standardize protocols and address ongoing controversies becomes increasingly apparent. However, efforts toward standardization are complicated by the fact that numerous organ procurement organizations, transplant centers, and academic societies have each posited their own protocols. While some degree of variability is inevitable and sometimes necessary, variability regarding end-of-life care, definitions for reported metrics, and standards for allograft assessment may lead to inefficiencies in scaled execution and worsen ethical controversies for donors at the end of life. This review analyzes key areas of variation in contemporary DCD-HT protocols, including donor selection, management during withdrawal of life-sustaining therapy, allograft ischemic parameters, and more, and examines ongoing controversies across preoperative, peri-withdrawal, and intraoperative phases. By synthesizing current practices and identifying critical gaps, we aim to support the development of more standardized, ethically robust, and clinically effective protocols for DCD-HT.