Clinical Focus

  • Neurosurgery

Professional Education

  • Fellowship: Stanford Health Care Pediatric Neurosurgery Fellowship (2023) CA
  • Residency: University of Vermont GME Programs (2022) VT
  • Residency: Ohio Health Doctor's Hospital Surgery Residency Program (2017) OH
  • Medical Education: Western University of Health Sciences College of Osteopathic Medicine of the Pacific - Northwest (2015) OR

All Publications

  • Neurological and clinical outcomes in infants and children with a fetal diagnosis of asymmetric ventriculomegaly, interhemispheric cyst, and dysgenesis of the corpus callosum. Journal of neurosurgery. Pediatrics Limoges, N., Ostrander, B., Kennedy, A., Woodward, P. J., Bollo, R. J. 2021: 1-5


    Advances in prenatal imaging have facilitated improvements in the fetal diagnosis of congenital anomalies. Asymmetric ventriculomegaly, interhemispheric cyst, and dysgenesis of the corpus callosum (AVID) is a constellation of congenital anomalies reported in fetal imaging. However, few data are available regarding postnatal outcomes of infants and children with a fetal diagnosis of AVID. The authors sought to report the neurodevelopmental outcomes of patients diagnosed with AVID before birth at a single institution.An institutional fetal imaging database was queried to identify cases with ventriculomegaly, interhemispheric cyst, and dysgenesis of the corpus callosum over a 10-year study period from 2000 to 2019. Overall, 41 maternal-infant dyads who met imaging criteria for AVID were identified; medical records were reviewed for prenatal variables including gestational age at birth, perinatal complications including fetal demise, and postnatal variables including demographics, mortality, hydrocephalus diagnosis and management, epilepsy, and neurodevelopmental outcomes at 2 years or the last follow-up.Among 41 patients, 25 (61%) were male. A slight majority of patients (55%) were born before 36 weeks of gestational age, and 27 patients (68%) were delivered via cesarean section because their head size precluded vaginal delivery. There were 8 incidences of fetal demise, 1 pregnancy was terminated, and 32 patients were born alive. Neonatal or early infant death occurred in 5 patients. Two children died during follow-up after the neonatal period (ages 7 months and 7 years). Twenty-six children survived to at least the 2-year follow-up, all of whom required treatment for hydrocephalus. Of those 26 children, 12 (46%) had a diagnosis of epilepsy, 14 (54%) could sit independently, 4 (16%) were in mainstream school, 16 (62%) had expressive language, and 7 (28%) had near-normal development without seizures.Among 41 maternal-fetal dyads with AVID, a majority of children survived to the 2-year follow-up, although all developed hydrocephalus. Many continued to have seizures, but expressive language use, attendance at mainstream school, and near-normal development without seizures were not infrequent. These data are critical for prenatal counseling and to establish the natural history of a diagnosis with limited outcome data.

    View details for DOI 10.3171/2021.9.PEDS21252

    View details for PubMedID 34798596

  • In Reply: Neurosurgery Resident Interviews: The Prevalence and Impact of Inappropriate and Potentially Illegal Questions. Neurosurgery Limoges, N., Zuckerman, S. L., Chambless, L. B., Benzil, D. L., Cruz, A., Durham, S. 2021; 89 (3): E196-E197

    View details for DOI 10.1093/neuros/nyab219

    View details for PubMedID 34171925

  • Neurosurgery Resident Interviews: The Prevalence and Impact of Inappropriate and Potentially Illegal Questions. Neurosurgery Limoges, N., Zuckerman, S. L., Chambless, L. B., Benzil, D. L., Cruz, A., Borden, J. H., Durham, S. 2021; 89 (1): 53-59


    The impact of workplace discrimination has gained recognition. Nearly two-thirds of all medical residency applicants reported being asked inappropriate or potentially illegal interview questions. The use of such questions during neurosurgery residency interviews has not yet been studied.To evaluate the prevalence of inappropriate or potentially illegal questions in residency interviews and the impact on applicants' rank lists.All 2018 to 2019 United States neurosurgery resident applicants were anonymously surveyed. The survey included 46 questions focused on demographics; if they were asked questions regarding rank list, age, gender, marital status, family planning, religion, sexual orientation, or disability and whether such questions affected their rank list formation.Of 265 surveyed United States applicants, 133 (50%) responded. Most respondents were male (78%), 24% were married, and 10% had children. During the formal interview, 94% were asked at least 1 inappropriate or potentially illegal question. About 78% reported being asked about marital status, 29% were asked about intent to have children. About 46% reported being counseled on their personal life, 30% were asked about their ethnic background, and 15% were asked about their religion. A total of 2 candidates reported questions about mental illness/disability, and 2 candidates reported being asked about sexual orientation. About 45% of applicants that were asked at least 1 of these questions ranked those programs lower.Nearly all (94%) neurosurgical residency applicants reported being asked at least 1 inappropriate or potentially illegal question during interviews. Our results indicate that inappropriate questions negatively affected program rankings.

    View details for DOI 10.1093/neuros/nyab059

    View details for PubMedID 33733664

  • Sinus Pericranii in Posterior Cranial Vault Distraction. The Journal of craniofacial surgery Tyrell, R., Limoges, N., Kestle, J., Gociman, B., Siddiqi, F. 2020; 31 (7): e715-e717


    Anomalous venous connections between the extracranial and intracranial systems are relatively rare. These connections are also known as sinus pericranii (SP) have been reported previously in the setting of various cranial malformations including craniosynostosis. Angiography may be useful in the diagnosis of SP also allowing for differentiation of the dominance of the venous systems. Several methods have been described in the treatment of SP. In isolated cases both endovascular and open approaches have been successful in the treatment of SP. In cases wherein there is synostosis present, both single- and multiple-staged operations have been described. In this article, we describe 2 cases of posterior cranial distraction in the setting of sinus peri cranii.

    View details for DOI 10.1097/SCS.0000000000006642

    View details for PubMedID 32649561

  • The neurosurgery residency interview: assessing applicant perspectives on question content, utility, and stress. Journal of neurosurgery Zuckerman, S. L., Limoges, N., Yengo-Kahn, A. M., Graffeo, C. S., Chambless, L. B., Chitale, R., Mocco, J., Durham, S. 2020; 134 (6): 1974-1982


    Residency interviews are integral to the recruitment process yet imperfect. Through surveys of neurosurgery residency applicants, the authors describe interview content and the perceived utility and stress of topics from the applicant's perspective.All 2018-2019 neurosurgery resident applicants applying to three particular programs were surveyed. Across 10 interview topics, survey questions assessed topic frequency and the applicant's opinion of the utility and stress of each topic (Likert scale 1-5). Analyses included descriptive statistics, Spearman's rank correlation, and logistic regression.One hundred thirty-three of 265 surveyed US residency applicants (50%) responded. Extracurricular activities, research, future career, non-medicine interests, and small talk were discussed in all interviews. The least frequent topics included neurosurgical knowledge assessment (79%) and manual dexterity tests (45%). The most useful topics according to respondents were future career objectives (4.78 ± 0.49) and prior research (4.76 ± 0.50); the least useful were neurosurgical knowledge assessment (2.67 ± 1.09) and manual dexterity tests (2.95 ± 1.05). The most stressful topics were neurosurgical knowledge assessment (3.66 ± 1.23) and ethical/behavioral scenarios (2.94 ± 1.28). The utility and stress of manual dexterity tests and neurosurgical knowledge assessments were inversely correlated (r = -0.40, p < 0.01; r = -0.36, p < 0.01), whereas no such correlation existed for ethical/behavioral questions (r = -0.12, p = 0.18), indicating that ethical/behavioral questions may have been stressful but were potentially useful topics. Respondents who attended ≥ 15 interviews were more likely to be asked about the three most stressful topics (each p < 0.05). Respondents with children were less likely to be asked about ethical/behavioral scenarios (OR 0.13, 95% CI 0.03-0.52, p < 0.01).Applicants found several of the most frequently discussed topics to be less useful, indicating a potential disconnect between applicant opinion and the faculty's preferred questions. Ethical/behavioral scenarios were rated as stressful but still useful, representing a potentially worthwhile type of question. These data provide several avenues for potential standardization and improvement of the interview process.

    View details for DOI 10.3171/2020.4.JNS2046

    View details for PubMedID 32679566

  • Pediatric neurosurgery training during residency in the United States: a program director survey. Journal of neurosurgery. Pediatrics Limoges, N. n., D'Agostino, E. n., Gelinne, A. n., Maher, C. O., Scott, R. M., Grant, G. n., Krieger, M. D., Limbrick, D. D., White, M. n., Durham, S. n. 2020: 1–7


    Pediatric neurosurgery is a core component of neurosurgical residency training. Pediatric case minimums are established by the Neurosurgery Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). Case minimums, by themselves, allow for great variability in training between programs. There are no prior data on how the residency programs meet these requirements. The authors' objective was to gather information on pediatric neurosurgical education among the ACGME-accredited neurosurgery training programs in order to shape further pediatric neurosurgical educational efforts.A 25-question survey about pediatric neurosurgical education was created by the Education Committee of the Section on Pediatric Neurological Surgery of the American Association of Neurological Surgeons/Congress of Neurological Surgeons and distributed to program directors of all 111 ACGME-accredited neurosurgery training programs.The response rate was 77% (86/111). In 55% of programs the residents are rotated to a responder-designated "freestanding" children's hospital, and 39% of programs rotate residents to a children's hospital within a larger adult hospital or a general hospital. There are 4 or fewer pediatric neurosurgical faculty in 91% of programs. In 12% of programs less than 100 cases are performed per year, and in 45% more than 500 are performed. In 31% of responding neurosurgery residency programs there is also a pediatric neurosurgery fellowship program supported by the same sponsoring institution. Seventy-seven percent of programs have at least one specific pediatric neurosurgery rotation, with 71% of those rotations occurring during postgraduate year 3 and 50% occurring during postgraduate year 4. The duration of pediatric rotation varies from no specific rotation to more than 1 year, with 48% of residents spending 4-6 months on a pediatric rotation and 12% spending 7-11 months. Last, 17% of programs send their residents to external sites sponsoring other residency programs for their pediatric rotation.There is great variety between neurosurgery training programs with regard to resident education in pediatric neurosurgery. This study's data will serve as a baseline for future studies, and the authors hope the findings will guide further efforts in pediatric neurosurgical education in residency training programs.

    View details for DOI 10.3171/2020.1.PEDS19662

    View details for PubMedID 32197250