Dr. Buch is a neurosurgeon with fellowship training in epilepsy, functional, and minimally invasive neurosurgery. He is a clinical assistant professor in the Department of Neurosurgery of Stanford University School of Medicine.
Dr. Buch focuses his expertise on the open and minimally invasive treatment of epilepsy, low grade brain tumors, movement and neuropsychiatric disorders, facial and body pain syndromes, and other complex neurological conditions. He uses advanced and innovative techniques to treat both adult and pediatric patients. For each patient, he develops a personalized care plan that is designed to be both comprehensive and compassionate.
Dr. Buch has conducted extensive research. His interests include restorative network engineering for intellectual and cognitive disability, personalized network-targeting for deep brain stimulation and MRI guided focused ultrasound, and focused ultrasound-mediated delivery mechanisms for gene, stem cell, and molecular therapies. He also is developing technological innovations such as the use of holographic mixed reality and artificial intelligence for visualization and guidance to improve minimally invasive neurosurgical procedures.
He has co-authored articles on his research discoveries in the Annals of Surgery, Frontiers in Neuroscience, Epilepsia, Stereotactic and Functional Neurosurgery, Surgical Innovation, Journal of Neurosurgery, and many other journals. Articles focus on developing novel network control theory applications to human brain functions and new techniques and technologies to enhance neurosurgical effectiveness and patient outcomes.
He is a contributor to the journals Surgical Innovation and Brain Sciences. He also has co-authored chapters in the books Neurosurgical Atlas, Operative Techniques in Epilepsy Surgery, Deep Brain Stimulation, and The Encyclopedia of Medical Robotics.
Dr. Buch has presented the findings of his research at the national conferences of numerous professional associations. Among them are the American Association of Neurological Surgeons, Society for Neuroscience, Congress of Neurological Surgeons, and Society for Imaging Informatics in Medicine. Topics include understanding network mechanisms of cognitive control and advances in the use of augmented reality technology to enhance neurosurgical approaches.
For his clinical, research, and academic achievements. Dr. Buch has earned many honors. He has won awards from the American Association of Neurological Surgeons, American Roentgen Ray Society, Congress of Neurological Surgeons, and National Institutes of Health.
Dr. Buch is a member of the American Association of Neurological Surgeons, Congress of Neurological Surgeons, World Society for Stereotactic and Functional Neurosurgery, American Association of Stereotactic and Functional Neurosurgery, and Alpha Omega Alpha Medical Honor Society.
He holds patents on artificial intelligence systems designed to help guide surgery and on neural control signals for behavioral modification therapy.
- Epilepsy Surgery
- Deep Brain Stimulation
- Laser Interstitial Thermal Therapy
- Focused Ultrasound
- Functional Mapping for Brain Tumors
- Awake Craniotomies
- Movement Disorders
- Facial Pain Syndromes
Honors & Awards
Nomination for TV Documentary Series, “New Frontiers in Neurosurgery”
Cover Article Selection, Epilepsia
Editor’s Choice, World Neurosurgery Best Papers
Pilot Award, Penn Health-Tech Medical Device Competition
“Rookie of the Year” Influencers of Healthcare Nomination, Philadelphia Inquirer
Invited Speaker, PennHealthX Medical Innovation Symposium
Nomination, STAT Wunderkinds
Resident Award, American Roentgen Ray Society
Podium Presentation Selections, American Association of Neurological Surgeons
Editor’s Choice: Best Papers, Journal of Neurosurgery Peds
Award, Who’s Who in America
National Innovation Pre-Accelerator Advancement Selection, FedTech
National Innovation Cohort Selection, Best Team, Lead Inventor, FedTech
Podium Presentation Selection Functional Scientific Session, American Association of Neurological Surgeons
Annual Meeting Best Oral Presentation, Pennsylvania Neurosurgical State Society
Alpha Omega Alpha Selection, Medical National Honor Society
Sigma Xi Research Award -- Most Outstanding Student Researcher in MD Class of 2013, The Warren Alpert Medical School of Brown University (2013)
Dr. Stanley M. Aronson Award -- Most Outstanding Student in Neurosciences in MD Class of 2013, The Warren Alpert Medical School of Brown University (2013)
National Institutes of Health Research Scholar Selection, Howard Hughes Medical Institute
2nd Place Overall Abstract Award, North American Neuromodulation Society
Podium Presentation Selection, American Society for Stereotactic and Functional Neurosurgery
Best Poster Award, Movement Disorders, American Society for Stereotactic and Functional Neurosurgery
New Investigator Award Finalist, Rhode Island Hospital Research Celebration
Presidential Scholar, United States Department of Education
Fellowship: Stanford University Dept of Neurosurgery (2021) CA
Fellowship: University of Pennsylvania Dept of Neurology PA
Instructor, Stanford University, Epilepsy, Restorative, and Functional Neurosurgery, Department of Neurosurgery (2021)
Fellowship, University of Pennsylvania, Epilepsy and Minimally Invasive Neurosurgery, Department of Neurosurgery (2020)
Residency: University of Pennsylvania Dept of GME (2020) PA
Medical Education: Warren Alpert Medical School Brown University (2013) RI
Research Scholar, Howard Hughes Medical Institute - National Institutes of Health, Complex Network Science (2012)
Long-term outcomes of mesial temporal laser interstitial thermal therapy for drug-resistant epilepsy and subsequent surgery for seizure recurrence: a multi-centre cohort study.
Journal of neurology, neurosurgery, and psychiatry
BACKGROUND: Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to surgical resection for drug-resistant mesial temporal lobe epilepsy (mTLE). Reported rates of seizure freedom are variable and long-term durability is largely unproven. Anterior temporal lobectomy (ATL) remains an option for patients with MRgLITT treatment failure. However, the safety and efficacy of this staged strategy is unknown.METHODS: This multicentre, retrospective cohort study included 268 patients consecutively treated with mesial temporal MRgLITT at 11 centres between 2012 and 2018. Seizure outcomes and complications of MRgLITT and any subsequent surgery are reported. Predictive value of preoperative variables for seizure outcome was assessed.RESULTS: Engel I seizure freedom was achieved in 55.8% (149/267) at 1year, 52.5% (126/240) at 2 years and 49.3% (132/268) at the last follow-up ≥1year (median 47 months). Engel I or II outcomes were achieved in 74.2% (198/267) at 1year, 75.0% (180/240) at 2 years and 66.0% (177/268) at the last follow-up. Preoperative focal to bilateral tonic-clonic seizures were independently associated with seizure recurrence. Among patients with seizure recurrence, 14/21 (66.7%) became seizure-free after subsequent ATL and 5/10 (50%) after repeat MRgLITT at last follow-up≥1year.CONCLUSIONS: MRgLITT is a viable treatment with durable outcomes for patients with drug-resistant mTLE evaluated at a comprehensive epilepsy centre. Although seizure freedom rates were lower than reported with ATL, this series represents the early experience of each centre and a heterogeneous cohort. ATL remains a safe and effective treatment for well-selected patients who fail MRgLITT.
View details for DOI 10.1136/jnnp-2022-330979
View details for PubMedID 37336643
Causal evidence for the processing of bodily self in the anterior precuneus.
To probe the causal importance of the human posteromedial cortex (PMC) in processing the sense of self, we studied a rare cohort of nine patients with electrodes implanted bilaterally in the precuneus, posterior cingulate, and retrosplenial regions with a combination of neuroimaging, intracranial recordings, and direct cortical stimulations. In all participants, the stimulation of specific sites within the anterior precuneus (aPCu) caused dissociative changes in physical and spatial domains. Using single-pulse electrical stimulations and neuroimaging, we present effective and resting-state connectivity of aPCu hot zone with the rest of the brain and show that they are located outside the boundaries of the default mode network (DMN) but connected reciprocally with it. We propose that the function of this subregion of the PMC is integral to a range of cognitive processes that require the self's physical point of reference, given its location within a spatial environment.
View details for DOI 10.1016/j.neuron.2023.05.013
View details for PubMedID 37295420
Multisite thalamic recordings to characterize seizure propagation in the human brain.
Brain : a journal of neurology
Neuromodulation of the anterior nuclei of the thalamus (ANT) has shown to be efficacious in a subset of patients with refractory focal epilepsy. One important uncertainty is to what extent thalamic subregions other than the ANT could be recruited more prominently in the propagation of focal onset seizures. We designed the current study to simultaneously monitor the engagement of the ANT, mediodorsal (MD) and pulvinar (PUL) nuclei during seizures in patients who could be candidates for thalamic neuromodulation. We studied 11 patients with clinical manifestations of presumed temporal lobe epilepsy (TLE) undergoing invasive stereo-encephalography (sEEG) monitoring to confirm the source of their seizures. We extended cortical electrodes to reach the ANT, MD and PUL nuclei of the thalamus. More than one thalamic subdivision was simultaneously interrogated in nine patients. We recorded seizures with implanted electrodes across various regions of the brain and documented seizure onset zones (SOZ) in each recorded seizure. We visually identified the first thalamic subregion to be involved in seizure propagation. Additionally, in eight patients, we applied repeated single pulse electrical stimulation in each SOZ and recorded the time and prominence of evoked responses across the implanted thalamic regions. Our approach for multisite thalamic sampling was safe and caused no adverse events. Intracranial EEG recordings confirmed SOZ in medial temporal lobe, insula, orbitofrontal and temporal neocortical sites, highlighting the importance of invasive monitoring for accurate localization of SOZs. In all patients, seizures with the same propagation network and originating from the same SOZ involved the same thalamic subregion, with a stereotyped thalamic EEG signature. Qualitative visual reviews of ictal EEGs were largely consistent with the quantitative analysis of the corticothalamic evoked potentials, and both documented that thalamic nuclei other than ANT could have the earliest participation in seizure propagation. Specifically, pulvinar nuclei were involved earlier and more prominently than ANT in more than half of the patients. However, which specific thalamic subregion first demonstrated ictal activity could not be reliably predicted based on clinical semiology or lobar localization of SOZs. Our findings document the feasibility and safety of bilateral multisite sampling from the human thalamus. This may allow more personalized thalamic targets to be identified for neuromodulation. Future studies are needed to determine if a personalized thalamic neuromodulation leads to greater improvements in clinical outcome.
View details for DOI 10.1093/brain/awad121
View details for PubMedID 37137813
Taking modern psychiatry into the metaverse: Integrating augmented, virtual, and mixed reality technologies into psychiatric care.
Frontiers in digital health
2023; 5: 1146806
The landscape of psychiatry is ever evolving and has recently begun to be influenced more heavily by new technologies. One novel technology which may have particular application to psychiatry is the metaverse, a three-dimensional digital social platform accessed via augmented, virtual, and mixed reality (AR/VR/MR). The metaverse allows the interaction of users in a virtual world which can be measured and manipulated, posing at once exciting new possibilities and significant potential challenges and risks. While the final form of the nascent metaverse is not yet clear, the immersive simulation and holographic mixed reality-based worlds made possible by the metaverse have the potential to redefine neuropsychiatric care for both patients and their providers. While a number of applications for this technology can be envisioned, this article will focus on leveraging the metaverse in three specific domains: medical education, brain stimulation, and biofeedback. Within medical education, the metaverse could allow for more precise feedback to students performing patient interviews as well as the ability to more easily disseminate highly specialized technical skills, such as those used in advanced neurostimulation paradigms. Examples of potential applications in brain stimulation and biofeedback range from using AR to improve precision targeting of non-invasive neuromodulation modalities to more innovative practices, such as using physiological and behavioral measures derived from interactions in VR environments to directly inform and personalize treatment parameters for patients. Along with promising future applications, we also discuss ethical implications and data security concerns that arise when considering the introduction of the metaverse and related AR/VR technologies to psychiatric research and care.
View details for DOI 10.3389/fdgth.2023.1146806
View details for PubMedID 37035477
View details for PubMedCentralID PMC10080019
Pilot study of responsive nucleus accumbens deep brain stimulation for loss-of-control eating.
Cravings that precede loss of control (LOC) over food consumption present an opportunity for intervention in patients with the binge eating disorder (BED). In this pilot study, we used responsive deep brain stimulation (DBS) to record nucleus accumbens (NAc) electrophysiology during food cravings preceding LOC eating in two patients with BED and severe obesity (trial registration no. NCT03868670). Increased NAc low-frequency oscillations, prominent during food cravings, were used to guide DBS delivery. Over 6 months, we observed improved self-control of food intake and weight loss. These findings provide early support for restoring inhibitory control with electrophysiologically-guided NAc DBS. Further work with increased sample sizes is required to determine the scalability of this approach.
View details for DOI 10.1038/s41591-022-01941-w
View details for PubMedID 36038628
Magnetic resonance imaging-guided laser interstitial thermal therapy for refractory focal epilepsy in a patient with a fully implanted RNS system: illustrative case.
Journal of neurosurgery. Case lessons
2022; 3 (21): CASE22117
BACKGROUND: The resective surgery plus responsive neurostimulation (RNS) system is an effective treatment for patients with refractory focal epilepsy. Furthermore, the long-term intracranial electroencephalography data provided by the system can inform a future resection or ablation procedure. RNS patients may undergo 1.5-T magnetic resonance imaging (MRI) under the conditions specified in the RNS system MRI guidelines; however, it was unknown if the MRI artifact would limit intraoperative laser interstitial thermal therapy (LITT) in a patient with a fully implanted RNS system.OBSERVATIONS: The authors were able to complete a successful awake LITT of epileptogenic tissue in a 1.5-T MRI scanner on the ipsilateral side to an implanted RNS system.LESSONS: If a future LITT procedure is probable, the neurostimulator should be placed contralateral to the side of the potential ablation. Using twist drill holes versus burr holes for depth lead placement may assist in future laser bone anchor seating. Before a LITT procedure in a patient with the neurostimulator ipsilateral to the ablation, 1.5-T MRI thermography scanning should be scheduled preoperatively to assess artifact in the proposed ablation zone. Per the RNS system MRI guidelines, the patient must be positioned supine and awake, with no more than 30 minutes of active scan time before a 30-minute pause.
View details for DOI 10.3171/CASE22117
View details for PubMedID 35734233
- Conversion to Hybrid Deep Brain Stimulation System to Enable Multi-Contact Fractionation Can be Therapeutic. Movement disorders : official journal of the Movement Disorder Society 2022
Network Brain-Computer Interface (nBCI): An Alternative Approach for Cognitive Prosthetics
FRONTIERS IN NEUROSCIENCE
2018; 12: 790
Brain computer interfaces (BCIs) have been applied to sensorimotor systems for many years. However, BCI technology has broad potential beyond sensorimotor systems. The emerging field of cognitive prosthetics, for example, promises to improve learning and memory for patients with cognitive impairment. Unfortunately, our understanding of the neural mechanisms underlying these cognitive processes remains limited in part due to the extensive individual variability in neural coding and circuit function. As a consequence, the development of methods to ascertain optimal control signals for cognitive decoding and restoration remains an active area of inquiry. To advance the field, robust tools are required to quantify time-varying and task-dependent brain states predictive of cognitive performance. Here, we suggest that network science is a natural language in which to formulate and apply such tools. In support of our argument, we offer a simple demonstration of the feasibility of a network approach to BCI control signals, which we refer to as network BCI (nBCI). Finally, in a single subject example, we show that nBCI can reliably predict online cognitive performance and is superior to certain common spectral approaches currently used in BCIs. Our review of the literature and preliminary findings support the notion that nBCI could provide a powerful approach for future applications in cognitive prosthetics.
View details for DOI 10.3389/fnins.2018.00790
View details for Web of Science ID 000449007900001
View details for PubMedID 30443203
View details for PubMedCentralID PMC6221897
Methods and Impact for Using Federated Learning to Collaborate on Clinical Research.
BACKGROUND: The development of accurate machine learning algorithms requires sufficient quantities of diverse data. This poses a challenge in health care because of the sensitive and siloed nature of biomedical information. Decentralized algorithms through federated learning (FL) avoid data aggregation by instead distributing algorithms to the data before centrally updating one global model.OBJECTIVE: To establish a multicenter collaboration and assess the feasibility of using FL to train machine learning models for intracranial hemorrhage (ICH) detection without sharing data between sites.METHODS: Five neurosurgery departments across the United States collaborated to establish a federated network and train a convolutional neural network to detect ICH on computed tomography scans. The global FL model was benchmarked against a standard, centrally trained model using a held-out data set and was compared against locally trained models using site data.RESULTS: A federated network of practicing neurosurgeon scientists was successfully initiated to train a model for predicting ICH. The FL model achieved an area under the ROC curve of 0.9487 (95% CI 0.9471-0.9503) when predicting all subtypes of ICH compared with a benchmark (non-FL) area under the ROC curve of 0.9753 (95% CI 0.9742-0.9764), although performance varied by subtype. The FL model consistently achieved top three performance when validated on any site's data, suggesting improved generalizability. A qualitative survey described the experience of participants in the federated network.CONCLUSION: This study demonstrates the feasibility of implementing a federated network for multi-institutional collaboration among clinicians and using FL to conduct machine learning research, thereby opening a new paradigm for neurosurgical collaboration.
View details for DOI 10.1227/neu.0000000000002198
View details for PubMedID 36399428
Do-It-Yourself Augmented Reality Heads-Up Display (DIY AR-HUD): A Technical Note.
International journal of spine surgery
We present a "Do-It-Yourself" method to build an affordable augmented reality heads-up display system (AR-HUD) capable of displaying intraoperative images. All components are commercially available products, which the surgeons may use in their own practice for educational and research purposes.Moverio BT 35-E smart glasses were connected to operating room imaging modalities (ie, fluoroscopy and 3D navigation platforms) via a high-definition multimedia interface (HDMI) converter, allowing for continuous high-definition video transmission. The addition of an HDMI transmitter-receiver makes the AR-HUD system wireless.We used our AR-HUD system in 3 patients undergoing instrumented spinal fusion. AR-HUD projected fluoroscopy images onto the surgical field, eliminating shift of surgeon focus and procedure interruption, with only a 40- to 100-ms delay in transmission, which was not clinically impactful.An affordable AR-HUD capable of displaying real-time information into the surgeon's view can be easily designed, built, and tested in surgical practice. As wearable heads-up display technology continues to evolve rapidly, individual components presented here may be substituted to improve its functionality and usability. Surgeons are in a unique position to conduct clinical testing in the operating room environment to optimize the augmented reality system for surgical use.
View details for DOI 10.14444/8106
View details for PubMedID 34266938
Theta Synchrony Is Increased near Neural Populations That Are Active When Initiating Instructed Movement
2021; 8 (1)
Theta oscillations (3-8 Hz) in the human brain have been linked to perception, cognitive control, and spatial memory, but their relation to the motor system is less clear. We tested the hypothesis that theta oscillations coordinate distributed behaviorally relevant neural representations during movement using intracranial electroencephalography (iEEG) recordings from nine patients (n = 490 electrodes) as they performed a simple instructed movement task. Using high frequency activity (HFA; 70-200 Hz) as a marker of local spiking activity, we identified electrodes that were positioned near neural populations that showed increased activity during instruction and movement. We found that theta synchrony was widespread throughout the brain but was increased near regions that showed movement-related increases in neural activity. These results support the view that theta oscillations represent a general property of brain activity that may also play a specific role in coordinating widespread neural activity when initiating voluntary movement.
View details for DOI 10.1523/ENEURO.0252-20.2020
View details for Web of Science ID 000641651800015
View details for PubMedID 33355232
View details for PubMedCentralID PMC7901148
Focused ultrasound for functional neurosurgery.
Journal of neuro-oncology
Brain lesioning is a fundamental technique in the functional neurosurgery world. It has been investigated for decades and presented promising results long before novel pharmacological agents were introduced to treat movement disorders, psychiatric disorders, pain, and epilepsy. Ablative procedures were replaced by effective drugs during the 1950s and by Deep Brain Stimulation (DBS) in the 1990s as a reversible neuromodulation technique. In the last decade, however, the popularity of brain lesioning has increased again with the introduction of magnetic resonance-guided focused ultrasound (MRgFUS).In this review, we will cover the current and emerging role of MRgFUS in functional neurosurgery.Literature review from PubMed and compilation.Investigated since 1930, MRgFUS is a technology enabling targeted energy delivery at the convergence of mechanical sound waves. Based on technological advancements in phased array ultrasound transducers, algorithms accounting for skull penetration by sound waves, and MR imaging for targeting and thermometry, MRgFUS is capable of brain lesioning with sub-millimeter precision and can be used in a variety of clinical indications.MRgFUS is a promising technology evolving as a dominant tool in different functional neurosurgery procedures in movement disorders, psychiatric disorders, epilepsy, among others.
View details for DOI 10.1007/s11060-021-03818-3
View details for PubMedID 34383232
Development of an Intraoperative Pipeline for Holographic Mixed Reality Visualization During Spinal Fusion Surgery
Objective. Holographic mixed reality (HMR) allows for the superimposition of computer-generated virtual objects onto the operator's view of the world. Innovative solutions can be developed to enable the use of this technology during surgery. The authors developed and iteratively optimized a pipeline to construct, visualize, and register intraoperative holographic models of patient landmarks during spinal fusion surgery. Methods. The study was carried out in two phases. In phase 1, the custom intraoperative pipeline to generate patient-specific holographic models was developed over 7 patients. In phase 2, registration accuracy was optimized iteratively for 6 patients in a real-time operative setting. Results. In phase 1, an intraoperative pipeline was successfully employed to generate and deploy patient-specific holographic models. In phase 2, the registration error with the native hand-gesture registration was 20.2 ± 10.8 mm (n = 7 test points). Custom controller-based registration significantly reduced the mean registration error to 4.18 ± 2.83 mm (n = 24 test points, P < .01). Accuracy improved over time (B = -.69, P < .0001) with the final patient achieving a registration error of 2.30 ± .58 mm. Across both phases, the average model generation time was 18.0 ± 6.1 minutes (n = 6) for isolated spinal hardware and 33.8 ± 8.6 minutes (n = 6) for spinal anatomy. Conclusions. A custom pipeline is described for the generation of intraoperative 3D holographic models during spine surgery. Registration accuracy dramatically improved with iterative optimization of the pipeline and technique. While significant improvements and advancements need to be made to enable clinical utility, HMR demonstrates significant potential as the next frontier of intraoperative visualization.
View details for DOI 10.1177/1553350620984339
View details for Web of Science ID 000621140400001
View details for PubMedID 33382008
View details for PubMedCentralID PMC8243385
Aventricular hemispherotomy: technical note
JOURNAL OF NEUROSURGERY-PEDIATRICS
2020; 26 (6): 642-647
Hemispheric disconnection in the form of hemispherectomy or hemispherotomy is the most effective way of treating intractable hemispheric epilepsy. Anatomical hemispherectomy approaches have largely been abandoned in most cases due to a higher risk of superficial hemosiderosis, intraoperative blood loss, hydrocephalus, prolonged hospital stay, and mortality compared to the variety of tissue-sparing hemispherotomy techniques. Disconnective hemispherotomy approaches utilize the lateral ventricle as a key component of the surgical corridor. Without a lateral ventricle, disconnective surgery becomes significantly challenging, typically leading to a hemispherectomy. The authors present the case of a patient with severe hemispheric dysplasia without a lateral ventricle on the pathologic side and detail a novel surgical technique for a prone, occipital interhemispheric, tissue-sparing, purely disconnective aventricular hemispherotomy with an excellent surgical outcome.
View details for DOI 10.3171/2020.5.PEDS20247
View details for Web of Science ID 000596398300006
View details for PubMedID 32858506
Policies Restricting Overlapping Surgeries Negatively Impact Access to Care, Clinical Efficiency and Hospital Revenue: A Forecasting Model for Surgical Scheduling.
Annals of surgery
To model the financial impact of policies governing the scheduling of overlapping surgeries, and to identify optimal solutions that maximize operating efficiency that satisfy the fiduciary duty to patients.Hospitals depend on procedural revenue to maintain financial health as the recent pandemic has revealed. Proposed policies governing the scheduling of overlapping surgeries may dramatically impact hospital revenue. To date, the potential financial impact has not been modeled.A linear forecasting model based on a logic matrix decision tree enabled an analysis of surgeon productivity annualized over a fiscal year. The model applies procedural and operational variables to policy constraints limiting surgical scheduling. Model outputs included case and financial metrics modeled over 1000-surgeon-year simulations. Case metrics included annual case volume, case mix, operating room (OR) utilization, surgeon utilization, idle time and staff overtime hours. Financial outputs included annual revenue, expenses and contribution margin.The model was validated against surgical data. Case and financial metrics decreased as a function of increasingly restrictive scheduling scenarios, with the greatest contribution margin loses ($1,650,000 per surgeon-year) realized with the introduction of policies mandating that a second patient could not enter the OR until the critical portion of the first surgery was completed. We identify an optimal scheduling scenario that maximizes surgeon efficiency, minimizes OR idle time and revenue loses, and satisfies ethical obligations to patients.Hospitals may expect significant financial loses with the introduction of policies restricting OR scheduling. We identify an optimal solution that maximizes efficiency while satisfying ethical duty to patients. This forecast is immediately relevant to any hospital system that depends upon procedural revenue.
View details for DOI 10.1097/SLA.0000000000004469
View details for PubMedID 33086323
Focused Ultrasound Thalamotomy with Dentato-Rubro-Thalamic Tractography in Patients with Spinal Cord Stimulators and Cardiac Pacemakers
STEREOTACTIC AND FUNCTIONAL NEUROSURGERY
2020; 98 (4): 263-269
Magnetic resonance image-guided high-intensity focused ultrasound (MRgFUS)-based thermal ablation of the ventral intermediate nucleus of the thalamus (VIM) is a minimally invasive treatment modality for essential tremor (ET). Dentato-rubro-thalamic tractography (DRTT) is becoming increasingly popular for direct targeting of the presumed VIM ablation focus. It is currently unclear if patients with implanted pulse generators (IPGs) can safely undergo MRgFUS ablation and reliably acquire DRTT suitable for direct targeting. We present an 80-year-old male with a spinal cord stimulator (SCS) and an 88-year-old male with a cardiac pacemaker who both underwent MRgFUS for medically refractory ET. Clinical outcomes were measured using the Clinical Rating Scale for Tremor (CRST). DRTT was successfully created and imaging parameter adjustments did not result in any delay in procedural time in either case. In the first case, 7 therapeutic sonications were delivered. The patient improved immediately and durably with a 90% CRST-disability improvement at 6-week follow-up. In our second case, 6 therapeutic sonications were delivered with durable, 75% CRST-disability improvement at 6 weeks. These are the first cases of MRgFUS thalamotomy in patients with IPGs. DRTT targeting and MRgFUS-based thermal ablation can be safely performed in these patients using a 1.5-T MRI.
View details for DOI 10.1159/000507031
View details for Web of Science ID 000605966100006
View details for PubMedID 32403106
Thalamic Deep Brain Stimulation for Essential Tremor: Relation of the Dentatorubrothalamic Tract with Stimulation Parameters
2020; 137: E89-E97
In deep brain stimulation (DBS) for essential tremor, the primary target ventrointermedius (VIM) nucleus cannot be clearly visualized with structural imaging. As such, there has been much interest in the dentatorubrothalamic tract (DRTT) for target localization, but evidence for the DRTT as a putative stimulation target in tremor suppression is lacking. We evaluated proximity of the DRTT in relation to DBS stimulation parameters.This is a retrospective analysis of 26 consecutive patients who underwent DBS with microelectrode recordings (46 leads). Fiber tracking was performed with a published deterministic technique. Clinically optimized stimulation parameters were obtained in all patients at the time of most recent follow-up (6.2 months). Volume of tissue activated (VTA) around contacts was calculated from a published model.Tremor severity was reduced in all treated hemispheres, with 70% improvement in the treated hand score of the Clinical Rating Scale for Tremor. At the level of the active contact (2.9 ± 2.0 mm superior to the commissural plane), the center of the DRTT was lateral to the contacts (5.1 ± 2.1 mm). The nearest fibers of the DRTT were 2.4 ± 1.7 mm from the contacts, whereas the radius of the VTA was 2.9 ± 0.7 mm. The VTA overlapped with the DRTT in 77% of active contacts. The distance from active contact to the DRTT was positively correlated with stimulation voltage requirements (Kendall τ = 0.33, P = 0.006), whereas distance to the atlas-based VIM coordinates was not.Active contacts in proximity to the DRTT had lower voltage requirements. Data from a large cohort provide support for the DRTT as an effective stimulation target for tremor control.
View details for Web of Science ID 000532762900003
View details for PubMedID 31954907
View details for PubMedCentralID PMC7584387
Detailed Analysis of Hydrocephalus and Hindbrain Herniation After Prenatal and Postnatal Myelomeningocele Closure: Report From a Single Institution
2020; 86 (5): 637-645
The Management of Myelomeningocele Study (MOMS) demonstrated that fetal myelomeningocele (fMMC) closure results in improved hydrocephalus and hindbrain herniation when compared to postnatal closure.To report on the outcomes of a single institution's experience in the post-MOMS era, with regard to hydrocephalus absence and hindbrain herniation resolution.A single-center retrospective study of a subset of post-MOMS patients who underwent fetal/postnatal myelomeningocele closure was performed. Primary outcomes included cerebrospinal fluid (CSF) diversion status and hindbrain herniation resolution. Families were contacted via telephone for outcome information if care was transitioned to outside institutions. Univariate/multivariable analyses were performed using several prenatal and postnatal variables.From January 2011 to May 2016, data were reviewed from families of 62 postnatal and 119 fMMC closure patients. In the postnatal group, 80.6% required CSF diversion compared to 38.7% fetal cases (P < .01). Hindbrain herniation resolution occurred in 81.5% fetal repairs compared to 32.6% postnatal (P < .01). In the fetal group, fetal/premature neonatal demise occurred in 6/119 (5.0%) patients. There was a 42.0% decrease (95% CI -55.2 to -28.8) and 48.9% increase (95% CI 33.7 to 64.1) in risk difference for CSF diversion and hindbrain herniation resolution, respectively, in the fetal group. On univariate analysis for both groups, prenatal atrial diameter, frontal-occipital horn ratio, and hindbrain herniation resolution were significantly associated with the absence of clinical hydrocephalus. The treatment of hydrocephalus was significantly delayed in the fetal group compared to the postnatal group (10 mo vs 13.8 d).This study demonstrates the benefits of fMMC closure with regard to CSF dynamics.
View details for DOI 10.1093/neuros/nyz302
View details for Web of Science ID 000537429900028
View details for PubMedID 31432079
Near-Infrared Fluorescence with Second-Window Indocyanine Green as an Adjunct to Localize the Pituitary Stalk During Skull Base Surgery
2020; 136: 326
A potential application of near-infrared (NIR) fluorescence imaging using second-window indocyanine green (SWIG) is demonstrated. We hypothesized that because the pituitary lacks a blood-brain barrier, we might visualize the pituitary stalk using SWIG. A 52-year-old, right-handed man presented to our clinic for evaluation of progressive loss of vision. Physical examination was significant for loss of right peripheral vision and near-complete loss of left field vision. Prolactin was high-normal at 16.2 mg/dL. Brain magnetic resonance imaging demonstrated a 36-mm sellar mass extending superiorly and laterally crossing the intracranial left internal carotid artery, consistent with a nonfunctional pituitary macroadenoma. We elected to pursue left pterional craniotomy for resection. The patient was eligible for our SWIG clinical trial and consented to the study. SWIG is a novel, investigational technique using Food and Drug Administration-approved indocyanine green to enhance visualization of neoplastic tissue intraoperatively.1-7 The patient received 2.5 mg/kg of indocyanine green intravenously approximately 24 hours preoperatively. Intraoperatively, under white-light microscopy, the tumor was easily identified and distinguished from the optic nerves and internal carotid artery. After debulking of the gross tumor, NIR visualization using a laser-equipped endoscope8 demonstrated strong NIR fluorescence in the pituitary stalk. Despite the distorted anatomy, this technique enabled us to confidently identify and preserve the pituitary stalk. Postoperatively, the patient had persistently high urine output that normalized in 24 hours without desmopressin (sodium 139-140 mmol/L); after uneventful recovery, he was discharged with mild improvement in visual function. This case demonstrated a potential use of our SWIG protocol. As the stalk demonstrates strong NIR fluorescence after high-dose indocyanine green administration, surgeons may be able to better localize and preserve the stalk even in complex skull base tumor cases where the anatomy may be significantly distorted.
View details for DOI 10.1016/j.wneu.2020.01.135
View details for Web of Science ID 000520838600135
View details for PubMedID 31996340
F-18-Fluciclovine PET to distinguish treatment-related effects from disease progression in recurrent glioblastoma: PET fusion with MRI guides neurosurgical sampling
2020; 7 (2): 152-157
Differentiation of true tumor progression from treatment-related effects remains a major unmet need in caring for patients with glioblastoma. Here, we report how the intraoperative combination of MRI with18F-fluciclovine PET guided surgical sampling in 2 patients with recurrent glioblastoma.18F-Fluciclovine PET is FDA approved for use in prostate cancer and carries an orphan drug designation in glioma. To investigate its utility in recurrent glioblastoma, we fused PET and MRI images using 2 different surgical navigation systems and performed targeted stereotactic biopsies from the areas of high ("hot") and low ("cold") radiotracer uptake. Concordant histopathologic and imaging findings suggest that a combined18F-fluciclovine PET-MRI-guided approach can guide neurosurgical resection of viable recurrent glioblastoma in the background of treatment-related effects, which can otherwise look similar on MRI.
View details for DOI 10.1093/nop/npz068
View details for Web of Science ID 000536505600004
View details for PubMedID 32206320
View details for PubMedCentralID PMC7081387
How technology is driving the landscape of epilepsy surgery
2020; 61 (5): 841-855
This article emphasizes the role of the technological progress in changing the landscape of epilepsy surgery and provides a critical appraisal of robotic applications, laser interstitial thermal therapy, intraoperative imaging, wireless recording, new neuromodulation techniques, and high-intensity focused ultrasound. Specifically, (a) it relativizes the current hype in using robots for stereo-electroencephalography (SEEG) to increase the accuracy of depth electrode placement and save operating time; (b) discusses the drawback of laser interstitial thermal therapy (LITT) when it comes to the need for adequate histopathologic specimen and the fact that the concept of stereotactic disconnection is not new; (c) addresses the ratio between the benefits and expenditure of using intraoperative magnetic resonance imaging (MRI), that is, the high technical and personnel expertise needed that might restrict its use to centers with a high case load, including those unrelated to epilepsy; (d) soberly reviews the advantages, disadvantages, and future potentials of neuromodulation techniques with special emphasis on the differences between closed and open-loop systems; and (e) provides a critical outlook on the clinical implications of focused ultrasound, wireless recording, and multipurpose electrodes that are already on the horizon. This outlook shows that although current ultrasonic systems do have some limitations in delivering the acoustic energy, further advance of this technique may lead to novel treatment paradigms. Furthermore, it highlights that new data streams from multipurpose electrodes and wireless transmission of intracranial recordings will become available soon once some critical developments will be achieved such as electrode fidelity, data processing and storage, heat conduction as well as rechargeable technology. A better understanding of modern epilepsy surgery will help to demystify epilepsy surgery for the patients and the treating physicians and thereby reduce the surgical treatment gap.
View details for DOI 10.1111/epi.16489
View details for Web of Science ID 000522059400001
View details for PubMedID 32227349
View details for PubMedCentralID PMC7317716
Second Window Indocyanine Green (SWIG) Near Infrared Fluorescent Transventricular Biopsy of Pineal Tumor
2020; 134: 196-200
Second Window Indocyanine Green (SWIG) is a novel technique for real-time, intraoperative tumor visualization using a high-dose infusion of indocyanine green (ICG) 24 hours before surgery. Due to pathologic diversity found in the pineal region, tissue diagnosis in patients with pineal region mass is essential to optimize further clinical management.We present the case of a 75-year-old woman with known pineal region mass for 18 years, who presented with progressive classic signs and symptoms of obstructive hydrocephalus over the past 6 months. Preoperative imaging confirmed a contrast-enhancing pineal region tumor, which appeared to be obstructing the aqueduct of Sylvius, causing proximal obstructive hydrocephalus. We delivered 5 mg/kg of ICG intravenously 24 hours before the surgery. The patient underwent an endoscopic third ventriculostomy and a biopsy of the pineal lesion. The tumor demonstrated clear near-infrared fluorescence, which was distinct from surrounding third ventricle floor and ependyma. The signal-to-background ratio was 2.9. The final pathology report revealed a World Health Organization grade I pineocytoma.We report on a novel application of near-infrared fluorescence for tumor identification of pineal region tumors, using the "SWIG technique."
View details for DOI 10.1016/j.wneu.2019.10.113
View details for Web of Science ID 000512878200170
View details for PubMedID 31669685
- Refocusing neurosurgical resident education amidst the COVID-19 crisis: A mental imagery-based transfer learning approach for virtual teaching of operative fundamentals. Annals of Surgical Education. 2020 3
Endoscopic endonasal resection versus open surgery for pediatric craniopharyngioma: comparison of outcomes and complications
JOURNAL OF NEUROSURGERY-PEDIATRICS
2019; 24 (3): 236-245
Craniopharyngioma represents up to 10% of pediatric brain tumors. Although these lesions are benign, attempts at gross-total resection (GTR) can lead to serious complications. More conservative approaches have emerged but require adjuvant radiation. Endoscopic endonasal surgery (EES) aimed at GTR has the potential to result in fewer complications, but there has been limited comparison to open surgery. The authors performed a review of these two approaches within their institution to elucidate potential benefits and complication differences.The authors performed a retrospective review of pediatric patients undergoing resection of craniopharyngioma at their institution between 2001 and 2017. Volumetric analysis of tumor size and postoperative ischemic injury was performed. Charts were reviewed for a number of outcome measures.A total of 43 patients with an average age of 8.2 years were identified. Open surgery was the initial intervention in 15 and EES in 28. EES was performed in patients 3-17 years of age. EES has been the only approach used since 2011. In the entire cohort, GTR was more common in the EES group (85.7% vs 53.3%, p = 0.03). Recurrence rate (40% vs 14.2%, p = 0.13) and need for adjuvant radiation (20.0% vs 10.7%, p = 0.71) were higher in the open surgical group, although not statistically significant. Pseudoaneurysm development was only observed in the open surgical group. Volumetric imaging analysis showed a trend toward larger preoperative tumor volumes in the open surgical group, so a matched cohort analysis was performed with the largest tumors from the EES group. This revealed no difference in residual tumor volume (p = 0.28), but the volume of postoperative ischemia was still significantly larger in the open group (p = 0.004). Postoperative weight gain was more common in the open surgical group, a statistically significant finding in the complete patient group that trended toward significance in the matched cohort groups. Body mass index at follow-up correlated with volume of ischemic injury in regression analysis of the complete patient cohort (p = 0.05).EES was associated with similar, if not better, extent of resection and significantly less ischemic injury than open surgery. Pseudoaneurysms were only seen in the open surgical group. Weight gain was also less prevalent in the EES cohort and appears be correlated with extent of ischemic injury at time of surgery.
View details for DOI 10.3171/2019.4.PEDS18612
View details for Web of Science ID 000484053700003
View details for PubMedID 31174192
Stereoelectroencephalography in Pediatric Epilepsy Surgery
JOURNAL OF KOREAN NEUROSURGICAL SOCIETY
2019; 62 (3): 302-312
Stereoelectroencephalography (SEEG) is an invasive technique used during the surgical management of medically refractory epilepsy. The utility of SEEG rests in its ability to survey the three-dimensional organization of the epileptogenic zone as well as nearby eloquent cortices. Once concentrated to specialized centers in Europe and Canada, the SEEG methodology has gained worldwide popularity due to its favorable morbidity profile, superior coverage of deep structures, and ability to perform multilobar explorations without the need for craniotomy. This rapid shift in practice represents both a challenge and an opportunity for pediatric neurosurgeons familiar with the subdural grid approach. The purpose of this review is to discuss the indications, technique, and safety of long-term SEEG monitoring in children. In addition to reviewing the conceptual and technical points of the diagnostic evaluation, attention will also be given to SEEG-based interventions (e.g., radiofrequency thermo-coagulation).
View details for DOI 10.3340/jkns.2019.0015
View details for Web of Science ID 000467678700006
View details for PubMedID 31085956
View details for PubMedCentralID PMC6514312
An estimation of global volume of surgically treatable epilepsy based on a systematic review and meta-analysis of epilepsy
JOURNAL OF NEUROSURGERY
2019; 130 (4): 1127-1141
OBJECTIVEEpilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation.METHODSThe authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence.RESULTSThis systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources.CONCLUSIONSUnderstanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.
View details for DOI 10.3171/2018.3.JNS171722
View details for Web of Science ID 000462866700009
View details for PubMedID 30215556
Factors Predicting Ventriculostomy Revision at a Large Academic Medical Center
2019; 123: E509-E514
Freehand bedside ventriculostomy placement can result in catheter malfunction requiring a revision procedure and cause significant patient morbidity. We performed a single-center retrospective review to assess factors related to this complication.Using an administrative database and chart review, we identified 101 first-time external ventricular drain placements performed at the bedside. We collected data regarding demographics, medical comorbidities, complications, and catheter tip location. We performed univariate and multivariate statistical analyses using MATLAB. We corrected for multiple comparisons using the false discovery rate (FDR) procedure.Multivariate regression analyses revealed that revision procedures were more likely to occur after drain blockage (odds ratio [OR] 17.9) and hemorrhage (OR 10.3, FDR-corrected P values < 0.01, 0.05, respectively). Drain blockage was less frequent after placement in an "optimal location" (ipsilateral ventricle or near foramen of Monroe; OR 0.09, P = 0.009, FDR-corrected P < 0.03) but was more likely to occur after placement in third ventricle (post-hoc P values < 0.015). Primary diagnoses included subarachnoid hemorrhage (n = 30, 29.7%), intraparenchymal hemorrhage with intraventricular extravasation (n = 24, 23.7%), tumor (n = 20, 19.8%), and trauma (n = 17, 16.8%). Most common complications included drain blockage (n = 12, 11.8%) and hemorrhage (n = 8, 7.9%). In total, 16 patients underwent at least 1 revision procedure (15.8%).Bedside external ventricular drain placement is associated with a 15% rate of revision, that typically occurred after drain blockage and postprocedure hemorrhage. Optimal placement within the ipsilateral frontal horn or foramen of Monroe was associated with a reduced rate of drain blockage.
View details for DOI 10.1016/j.wneu.2018.11.196
View details for Web of Science ID 000462958400059
View details for PubMedID 30503293
- Novel Inter-Trial Resting State Network Analysis can Reliably Predict Learning and Performance of a Cognitive Reaction Time Task JOURNAL OF NEUROSURGERY. 2019
- Increased dynamic modularity of the fronto-temporo-limbic network precedes enhanced task performance Journal of Neurosurgery 2018
Rotational vertebrobasilar insufficiency due to compression of a persistent first intersegmental vertebral artery variant: case report
JOURNAL OF NEUROSURGERY-SPINE
2017; 26 (2): 199-202
Rotational vertebrobasilar insufficiency, or bow hunter's syndrome, is a rare cause of posterior circulation ischemia, which, following rotation of the head, results in episodic vertigo, dizziness, nystagmus, or syncope. While typically caused by dynamic occlusion of the vertebral artery in its V2 and V3 segments, the authors here describe a patient with dynamic occlusion of the vertebral artery secondary to a persistent first intersegmental artery, a rare variant course of the vertebral artery. In this case the vertebral artery coursed under rather than over the posterior arch of the C-1. This patient was also found to have incomplete development of the posterior arch of C-1, as is often seen with this variant. The patient underwent dynamic digital subtraction angiography, which demonstrated occlusion at the variant vertebral artery with head turning. He was then taken for decompression of the vertebral artery through removal of the incomplete arch of C-1 that was causing the dynamic compression. After surgery the patient had a complete resolution of symptoms. In this report, the authors present the details of this case, describe the anatomical variants involved, and provide a discussion regarding the need for atlantoaxial fusion in these patients.
View details for DOI 10.3171/2016.7.SPINE163
View details for Web of Science ID 000393088900010
View details for PubMedID 27716015
Resident simulation training in endoscopic endonasal surgery utilizing haptic feedback technology
JOURNAL OF CLINICAL NEUROSCIENCE
2016; 34: 112-116
Simulated practice may improve resident performance in endoscopic endonasal surgery. Using the NeuroTouch haptic simulation platform, we evaluated resident performance and assessed the effect of simulation training on performance in the operating room. First- (N=3) and second- (N=3) year residents were assessed using six measures of proficiency. Using a visual analog scale, the senior author scored subjects. After the first session, subjects with lower scores were provided with simulation training. A second simulation served as a task-learning control. Residents were evaluated in the operating room over six months by the senior author-who was blinded to the trained/untrained identities-using the same parameters. A nonparametric bootstrap testing method was used for the analysis (Matlab v. 2014a). Simulation training was associated with an increase in performance scores in the operating room averaged over all measures (p=0.0045). This is the first study to evaluate the training utility of an endoscopic endonasal surgical task using a virtual reality haptic simulator. The data suggest that haptic simulation training in endoscopic neurosurgery may contribute to improvements in operative performance. Limitations include a small number of subjects and adjudication bias-although the trained/untrained identity of subjects was blinded. Further study using the proposed methods may better describe the relationship between simulated training and operative performance in endoscopic Neurosurgery.
View details for DOI 10.1016/j.jocn.2016.05.036
View details for Web of Science ID 000389093300023
View details for PubMedID 27473019
- Lumbar decompression for dorsiflexion palsy JOURNAL OF THE NEUROLOGICAL SCIENCES 2016; 362: 64-65
210 Human Sensorimotor Electrocorticography: Spectral Dynamics and Network Connectivity During a Simple Motor Task
2016; 63 (CN_suppl_1)
View details for DOI 10.1227/01.neu.0000489779.53428.e3
- Varicella zoster-induced magnetic resonance imaging abnormalities of the trigeminal nucleus JOURNAL OF THE NEUROLOGICAL SCIENCES 2015; 359 (1-2): 57-58