THE SOCIETY OF UNIVERSITY NEUROSURGEONSC h i n a

2 0 1 5A N N U A L M E E T I N GJ U LY 9 - J U LY 1 3 , 2 0 1 5

ELEKTASpineology

Surgical TheaterZeiss

Jointly Provided by the AANS

We are honored to welcome our SUN members and guests to Shanghai & Beijing.

Shanghai is Inspirational. It offers many spectacular views: ancient and modern; Eastern and Western; and high-speed and slow-paced. Truly, it is a city of cultural inclusiveness. The views on the Bund and Pudong are awe-inspiring. From any view, old or new, Shanghai is a world-class city and attractive destination.

Shanghai is High. It has long been China’s economic engine. The mighty Yangtze River empties into the Pacific at Shanghai, consolidating China’s economy into Shanghai. Currently, there are over 1,000 completed high-rise buildings in the city, and 165 high-rise buildings in the pipeline. It is a thrilling experience to witness all this panoramic view from either the Oriental Pearl TV Tower (468m / 1,538ft), Jinmao Tower (420.5m / 1,380ft), the Shanghai World Financial Center (492m / 1,614ft), or the future Shanghai Tower (632m / 2073feet).

Shanghai is Fast. Shanghai – A deep breath. That’s what a visitor has to take, after learning the city’s fast growth and development. The city is poised to pour billions of dollars into bio-pharmaceuticals, new energy, new materials, information technology and high-end manufacturing. Shanghai is to shift growth model from investment driven to innovation driven. And look at the city’s infrastructure: Shanghai boasts one of the world’s most extensive subway systems with a total length of 548 km of 15 metro lines. Shanghai is home to the world’s only commercially-operated maglev system. Passengers are transferred between the airport and downtown at speed of up to 431 km/h (268 mph).

Beijing is Historical. Many historical attractions leave guests’ deep impression. Temple of Heaven, the largest temple in the world, is highlighted by unique and intricate architectural designs dating back to the Ming dynasty. Tiananmen Square, situated in the heart of Beijing, is one of the largest city squares in the world. Beijing is also famous for Peking Duck. Almost all kinds of Chinese cuisines and international cuisines can be found in the city as well.

Huashan Hospital, one of the most well-known hospitals in China, is excited to host SUN China 2015. We look forward to meeting you in China in July, 2015!

Warm Regards,

Ying Mao, MD, PhD

Charles Y. Liu, MD, PhD

China 2015

Present OfficersPresident

Jacques Morcos

President-Elect Michael Levy

Vice President Nelson Oyesiku

Secretary/Treasurer Michael Wang

Member-at-largeRich Ellenbogen

HistorianKen Smith

Membership Committee Franco DeMonte

Arun AmarErol Veznedaroglu

Future Site Committee Charles Liu

Erol VeznedarogluNick Boulis

Ying Mao, MD, PhDMeeting Chair

Charles Liu, MD, PhDMeeting co-Chair

~~~~~~1965~~~~~~Montreal Neurological InstituteMontreal, QUE ~~~~~~1966~~~~~~Duke UniversityDurham, NC

~~~~~~1967~~~~~~University of Minnesota Minneapolis, MN

~~~~~~1968~~~~~~Upstate Medical CenterSyracuse, NY

~~~~~~1969~~~~~~Massachusetts General HospitalBoston, MA

~~~~~~1970~~~~~~Baptist Memorial HospitalMemphis, TN

~~~~~~1971~~~~~~Albert Einstein College of MedicineBronx, NY

~~~~~~1972~~~~~~University of British ColumbiaVancouver, BC

~~~~~~1973~~~~~~Emory UniversityAtlanta, GA

~~~~~~1974~~~~~~ University of Texas Medical School San Antonio, TX

~~~~~~1975~~~~~~Mayo ClinicRochester, MN

~~~~~~1976~~~~~~Jefferson Medical College Philadelphia, PA

~~~~~~1977~~~~~~Mayfield Neurological Institute Cincinnati, OH

~~~~~~1975~~~~~~Mayo ClinicRochester, MN

~~~~~~1976~~~~~~Jefferson Medical College Philadelphia, PA

~~~~~~1977~~~~~~Mayfield Neurological Institute Cincinnati, OH

~~~~~~1978~~~~~~Medical College of Georgia Augusta, GA

~~~~~~1979~~~~~~University of Guadalajara Guadalajara, MX

~~~~~~1980~~~~~~University of Florida Gainesville, FL

~~~~~~1981~~~~~~University of Western Ontario London, ONT

~~~~~~1982~~~~~~University of Mississippi Jackson, MS

~~~~~~1983~~~~~~Duke University/University of NC Durham/Chapel Hill, NC

~~~~~~1984~~~~~~University of Washington Seattle, WA ~~~~~~1985~~~~~~University of Colorado Denver/Vail, CO

~~~~~~1986~~~~~~University of Louisville Louisville, KY

~~~~~~1987~~~~~~Medical College of Virginia Richmond, VA

~~~~~~1988~~~~~~University of Tubingen Tubingen, FRG

~~~~~~1989~~~~~~University of Toronto Toronto, ONT

~~~~~~1990~~~~~~Louisiana State Univ. Medical Center New Orleans, LA

~~~~~~1991~~~~~Tufts New England Medical School Boston, MA ~~~~~~1992~~~~~~Dartmouth Medical School Woodstock, VT

~~~~~~1993~~~~~~St. Louis University Medical School St. Louis, MO

~~~~~~1994~~~~~~University of Lyon Lyon, France

~~~~~~1995~~~~~~Thomas Jefferson Medical School Philadelphia, PA

~~~~~~1996~~~~~~University of Southern California Los Angeles, CA

~~~~~~1997~~~~~~University of Michigan Ann Arbor, MI

~~~~~~1998~~~~~~University of Tennessee Memphis, TN

~~~~~~1999~~~~~~University of Melbourne Melbourne, Australia

~~~~~~2000~~~~~~Havard Medical School/Brigham & Women’sBoston, MA

~~~~~~2001~~~~~~Oregon Health Sciences UniversityPortland, OR ~~~~~~2002~~~~~~Northwestern University/ Chicago Evanston, IL

~~~~~~2003~~~~~~Columbia Presby. Med Center/NY Presby. Hospital New York, NY ~~~~~~2004~~~~~~Karolinska Institute Stockholm, Sweden

~~~~~~2005~~~~~~Wake Forest University School of Medicine Winston-Salem, NC

~~~~~~2006~~~~~~University of California – San DiegoDel Mar, CA

~~~~~~2007~~~~~~National Hospital for Neurology and NeurosurgeryLondon, England

~~~~~~2008~~~~~~University of California San Francisco, CA

~~~~~~2009~~~~~~Sapienza UniversityRome, Naples & Capri, Italy

~~~~~~2010~~~~~~University of MiamiMiami, Florida

~~~~~~2011~~~~~~Istanbul, Turkey

~~~~~~2012~~~~~~Emory UniversityAtlanta, Georgia ~~~~~~2013~~~~~~Carlos Haya UniversityMalaga, Spain

~~~~~~2014~~~~~~University of WashingtonSeattle, Washington

Previous Meetings

~~~~~~1965~~~~~~James T. Robertson, MD

~~~~~~1966~~~~~~George T. Tindall, MD

~~~~~~1967~~~~~~Robert G. Ojemann, MD

~~~~~~1968~~~~~~Charles L. Branch, MD

~~~~~~1969~~~~~~Jim Story, MD

~~~~~~1970~~~~~~Herbert Lourie, MD

~~~~~~1971~~~~~~Byron Pevehouse, MD

~~~~~~1972~~~~~~Kenneth Shulmann, MD

~~~~~~1973~~~~~~Darton Brown, MD

~~~~~~1974~~~~~~

Ellis Keener, MD

~~~~~~1975~~~~~~Robert Hardy, MD

~~~~~~1976~~~~~~Phanor Perot, MD

~~~~~~1977~~~~~~Gordon Thompson, MD

~~~~~~1978~~~~~~Lucien R. Hodges, MD

~~~~~~1979~~~~~~Robert White, MD

~~~~~~1980~~~~~~Robert Grossman, MD

~~~~~~1981~~~~~~Stewart Dunsker, MD

~~~~~~1982~~~~~~Marshall Allen, MD

~~~~~~1983~~~~~~Ian Turnbull, MD

~~~~~~1984~~~~~~Henry Garretson, MD

~~~~~~1985~~~~~~Harold F. Young, MD

~~~~~~1986~~~~~~Robert Smith, MD

~~~~~~1987~~~~~~Kenneth R. Smith, Jr. MD

~~~~~~1988~~~~~~Willis Brown, MD

~~~~~~1989~~~~~~Glenn W. Kindt, MD

~~~~~~1990~~~~~~

Salvador Gonzales-Cornejo, MD

~~~~~~1991~~~~~~Michael L.J. Apuzzo, MD

~~~~~~1992~~~~~~William A. Buchheit, MD

~~~~~~1993~~~~~~Alan R. Hudson, MD

~~~~~~1994~~~~~~Robert Maxwell, MD

~~~~~~1995~~~~~~Peter L. Black, MD

~~~~~~1996~~~~~~William Shucart, MD~~~~~~1997~~~~~~Ronald F. Young, MD

~~~~~~1998~~~~~~David W. Roberts, MD

~~~~~~1999~~~~~~Charles S. Hodge, Jr. MD

~~~~~~2000~~~~~~John E. McGillicuddy, MD

~~~~~~2001~~~~~~H. Hunt Batjer, MD

~~~~~~2002~~~~~~Philip Stieg, PhD, MD

~~~~~~2003~~~~~~Robert Rosenwasser, MD

~~~~~~2004~~~~~~Robert Breeze, MD

~~~~~~2005~~~~~~Kim Burchiel, MD

~~~~~~2006~~~~~~Jon Robertson, MD

~~~~~~2007~~~~~~Carl Heilman, MD

~~~~~~2008~~~~~~Robert Solomon, MD

~~~~~~2009~~~~~~Jeffrey Bruce, MD

~~~~~~2010~~~~~~

John Wilson, MD

~~~~~~2011~~~~~~Anil Nanda, MD

~~~~~~2012~~~~~~Thomas Origitano, MD

~~~~~~2013~~~~~~Neil Kitchen, MD

~~~~~~2014~~~~~~Sander Connolly, MD

Past Presidents

Acar, Feridun, MDAlbuquerque, Felipe, MD Amar, Arun, MD Anderson, Richard, MD Barrow, Daniel, MD Boulis, Nicholas, MD Brau, Ricardo, MD Bruce, Jeffrey, MD Choi, David, MD Connolly, E. Sander, MD Heilman, Carl, MD Kaiser, Michael, MD

Krishnamurthy, Satish, MD Lavine, Sean, MD Levy, Michael, MD Liu, Charles, MD Michael, Madison, MD Markert, James, MD McCutcheon, Ian, MD Morcos , Jacques, MD Nanda, Anil, MD Ogden, Fred, MD Oyesiku, Nelson, MD Pittman, Thomas, MD

Rosen, Charles, MD Sisti, Michael, MD Smith, Kenneth, MD Sin, Anthony, MD Solaroglu, Ihsan, MD Sorenson, Jeffrey, MD Tibbs, Philip, MD Veznedaroglu, Erol, MD Wang, Michael, MD

2015 Meeting Attendees

Murayama, YuichiPrabhu, SujitSelman, WarrenVajkoczy, Peter(Invited by Dr. Morcos)

Chin, Lawrence(Invited by Dr. Krishnamurthy)

Khalessi, Alexander (Invited by Dr. Amar)

Amin-Hanjani, SepidehAbou- Hamden, AmalBederson, JoshuaCharbel, FadyDufour, Henry Erkmen, KadirFroelich, Sebastien Farhat, Hamad Hasan, David Langer, DavidLiu, JamesMorita, Akio

SUN Members

Members’ Guests

Mcdonald, MatthewWu, Jau-Ching(Invited by Dr. Wang)

Smith, Donald(Invited by Dr. Sin)

Singer, Justin(Invited by Drs. Selman/Morcos)

Zhan, Rucai(Invited by Dr. Heilman)

Distinguished Service Award

Dr. Anil Nanda is the Professor and Chairman of the Department of Neurosurgery at LSU Health Sciences Center at Shreveport (LSUHSC-S). He earned his medical degree from JIPMER Madras University in India in 1982. Dr. Nanda completed his neurosurgery residency at the Hahnemann University School of Medicine in Philadelphia followed by fellowship training in microneurosurgery and cranial base surgery at the University of Pittsburgh in 1990. He has been at LSUHSC-S for 25 years and is responsible for creating the neurosurgery residency program at LSUHSC-S. The residency program has been in existence for over 15 years and is the largest in the state of Louisiana. In the spring of 2012, Dr. Nanda received his Master of Public Health degree from the Harvard School of Public Health. As part of his curriculum, Dr. Nanda helped pass the Louisiana Youth Concussion Law, requiring all schools, clubs, and other organizations that sponsor youth athletics to provide athletes and their parents with information about concussions and the potential long-term effects of playing after a head injury.

Committed to the expansion of higher education, Dr. Nanda has been the invited guest lecturer and visiting professor at over 130 national and international conferences and institutions. He has also published over 350 peer-reviewed journal articles, as well as two books including “Principles of Posterior Fossa Surgery.” He has received recognition as an Outstanding Leader of 2005 by The Times in Shreveport, induction into the Junior Achievement of North Louisiana 2011 Business Hall of Fame for leadership, determination, ethics, and giving back to the community, and inclusion among the Best Doctors in America consecutively from 1996 to 2014. Dr. Nanda has served as President of the North American Skull Base Society (2005-2006), Louisiana State Neurosurgical Society (2005-2007), Southern Neurosurgical Society (2006-2007), and Society of University Neurosurgeons (2010-2011). In 2013 he was elected to serve on the American Board of Neurological Surgery (ABNS) and the board of the American Association of Neurological Surgeons (AANS).

Dr. Nanda is married to attorney Laura Merkler Nanda and has three children, Alexander, Christopher, and Mary Catherine.

Professor and ChairmanLSU Health Sciences Center at Shreveport

Anil Nanda

One of China’s few first-class traditional artists who has embraced an international career, renowned Erhu virtuoso Ma Xiaohui speaks with the world through her Erhu (Chinese 2-string violin).

Ma Xiaohui graduated from the Shanghai Conservatory of Music, and served many years as Concert Master for the Shanghai Traditional Orchestra. She is artistic advisor for the Shanghai Grand Theatre, Culture Director for the Shanghai Overseas Exchange Association, and Director of the Shanghai Ma Xiaohui Art Center. Ma Xiaohui originated “Erhu Holding Hands with the World” in 2003 – a unique multicultural musical phenomenon that has thrilled audiences around the world. In 2008, she performed “Ehru Holding Hands” in Carnegie Weill Recital Hall – a performance that was “rapturously received” according to the local NYC media. Ma Xiaohui is the only Chinese artist who has performed and lectured thousands of times in

famous orchestras, concert halls, festivals and universities around the world.

Ma Xiaohui has served as Love Ambassador for the 2007 Special Olympics, Cultural Ambassador for 2010 Shanghai Expo. She has received many honors and awards, such as being selected to play for 21 presidents during the 2001 APEC in Shanghai, and receiving the Kennedy Center “Best Performance” award. She has twice received the “Shanghai Outstanding Artist” award.

Ma Xiaohui is perhaps best recognized for her famous duet with cellist Yo-Yo Ma on the Oscar-winning soundtrack for the film “Crouching Tiger, Hidden Dragon.” She has worked with well-known conductors and composers such as Zubin Mehta, Lorin Maazel, Tan Dun and Zuohaung Chen. Ma Xiaohui has performed in such venues as the Berlin Philharmonic Orchestra Ensemble, the French International Orchestra, the Bern Beethoven House, the Vienna Golden Hall, Columbia University and the Schleswig-Holstein Music Festival.

The Oxford Times Weekend wrote: “…Ma Xiaohui drew a kind of alto human voice bereft of words, but given song. It sounds so culture-free and universal, that Ma Xiaohui’s gift, and vibrant musicality, shone out on us like light...”

Ma Xiaohui says that her desire is to spread peace and harmony throughout the world through the spirit and beauty of her Erhu music – one soul at a time.

Chinese Erhu Virtuoso

Xiaohui, Ma

Meeting ScheduleThursday, July 9, 2015

Friday, July 10, 2015

5:00 - 7:00pm: Registration6:30 - 9:00pm: Welcome Reception at the Pudong Shangri-La, Jade on 36 restaurant East Shanghai (dress code smart casual)

7:00 - 11:00am: Registration6:30 - 10:30am: Breakfast at the Hotel Yi Café7:00-8:00am: Executive Meeting Horizon Club Meeting Room8:00 - 8:15am: Board shuttles at the Hotel to Huashan Hospital

9:00 - 11:30am: Visit Huashan Hospital

8:45 - 9:00 am: Welcome Speech for SUN Meeting Zhou, Liangfu 9:00 - 9:15am: Magnetic Resonance Therapy: Non-Invasive Liu, Charles Neuromodulation for Cognitive Neurorestoration

9:15 - 9:35am: History, Present and Future of Neurosurgical Mao, Ying Department of Huashan Hospital, Fudan University 9:35 - 9:55am: Precise Surgical Treatment for Glioma Patients in Wu, Jinsong Huashan Hospital 9:55-10:15am: “From-Bench-to-Bedside”: Basic and Clinical Research Zhao, Yao of Pituitary Adenoma

10:15-10:35am: Cerebral Vascular Diseases Surgery: Huashan Experience Gu, Yuxiang

10:35-10:55am: Stereotactic Surgery and Radiotherapy for Brain Tumors Pan, Li 10:55-11:10am: Discussion 11:30-11:45am: Board coaches for The Portman Ritz-Carlton, Shanghai for lunch

12:00-1:30pm: Lunch at the The Portman Ritz-Carlton, Shanghai The Shen Ballroom

1:30-1:45pm: Board coaches to Suzhou1:45-3:30pm: On the way from Shanghai to Suzhou3:30-4:30pm: Tour Suzhou Museum5:00-6:30pm: Visit Suzhou Silk Embroidery Museum7:00-9:00pm: Buffet dinner with folklore performance at Lingering Garden in Suzhou (dress code casual)

9:00-9:15pm: Board coaches back to the Hotel11:30pm: Arrival at the Hotel

Saturday, July 11, 2015

Accompanying Persons Program

9:00-11:30am: Shanghai Museum Tour

9:00 -9:15am: Depart at the Pudong Shangri-La, East Shanghai for the Shanghai Museum

9:45-11:30am: Visit the Shanghai Museum

11:30-11:45am: Board the coaches for lunch

12:00-1:30pm: Meet the members and lunch at the Portman Ritz-Carlton, Shanghai

1:30pm: Same as the Members’ Program

6:30 - 10:30 am: Breakfast at the Hotel (Guests and Spouses) Yi Café7:00-8:00am: Members Meeting Changan Room8:00-11:30am: Scientific Session I Pudong Shangri La Changan Room Moderators: Sander Connolly and Nelson Oyesiku

8:00 - 8:11 am: En bloc resection of primary spine tumours: trading Choi, David nerve roots for improved survival. 8:12 - 8:23 am: Arthroplasty for cervical spondylotic myelopathy: similar Wu, Jau-Ching results to patients with only radiculopathy at 3 years’ follow-up.

8:24 - 8:35 am: The importance of petrous origin in the treatment of Sisti, Michael cerebellopontine angle meningiomas

8:36 - 8:47 am: Endoscopic endonasal approach for the treatment of Froelich, Sebastien skull base chordomas: Lariboisière experience.

8:48 - 8:57 am: Discussion

8:58 - 9:09 am: Moyamoya Disease: Characterization and surgical Vajkoczy, Peter treatment of our European Caucasian population

9:10 - 9:21 am: Impact of Hemodynamics on Stroke Risk in Symptomatic Amin-Hanjani, Sepideh Vertebrobasilar Disease

9:22 - 9:33 am: Pressure Changes within the Sac of Human Cerebral Hasan, David Aneurysms in Response to Artificially Induced Transient Increases in Systemic Blood Pressure

9:34 - 9:45 am: Clinical application of CFD technology for treatment Murayama, Yuichi strategy of complex cerebral aneurysms

9:46 - 9:57 am: Management strategy and treatment outcomes of Morita, Akio unruptured intracranial aneurysms according to the natural course – implications from the UCAS Japan cohort

9:58 - 10:09 am: Bypass Selection for Aneurysm Surgery Charbel, Fady

10:10 - 10:21 am: Measuring Technical Proficiency in Neurosurgery Bederson, Joshua Residents through Intraoperative Video Evaluations

10:22 - 10:33 am: Discussion

10:34 - 10:45 am: Break

10:46 - 11:15am: Special cultural performance Xiaohui, Ma

11:16 - 11:18am: Distinguished Service Award Anil Nanda

11:19 - 11:22 am: Introduction of President Mike Wang

11:23 - 11:45am: Presidential Address Jacques Morcos Synchronicity: In life, at work and at play

11:45-12:00am: Board coaches at the Hotel for lunch

12:30-2:00pm: Lunch at the Lv Bo Lang Restaurant 2nd Floor

2:00-2:30pm: Tour Yuyuan Garden

2:30-3:00pm: Free time at Yuyuan Shopping Complex

3:00-3:15pm: Board coaches at the Yuyuan Shopping Complex for the Bund

3:30-4:00pm: Tour the Bund and free time at the Bund

4:00-4:15pm: Board coaches at the Bund for the Hotel

4:45pm: Arrival at the Hotel

5:30-5:45pm: Board the coaches at the Hotel for Gala dinner at Long Museum

6:30-7:00pm: Tour Long Museum

7:10-9:30pm: Gala Buffet dinner at the Long Museum (dress code black tie optional)

9:30-9:45pm: Board the coaches at the Long Museum for the Hotel

10:30pm: Arrival at the Hotel

6:30 - 10:30 am: Breakfast at the Hotel (Guests and Spouses) Yi Café

8:00-11:30am: Scientific Session I1 Pudong Shangri La Changan Room

Moderators: Carl Heilman and Ricardo Brau

8:00 - 8:11am: Preoperative 3D Modeling in Infants and Children with Levy, Michael Cerebral Aneurysmal Malformations 8:12 - 8:23am: Outcomes after suboccipital decompression without Anderson, Richard dural opening in children with Chiari I malformation 8:24 - 8:35am: Efficacy and Cost of Tranexamic Acid in Bristol, Ruth Craniosynostosis Surgery 8:36 - 8:47am: A practical outcome scale for paediatric neurosurgery Abou Hamden, Amal patients: The paediatric modified Rankin Scale

8:48 - 8:59am: Neurosurgical pediatric deformity experience at Sin, Anthony Shriners Hospital for Children – Shreveport and complication management: First three years. 9:00 - 9:09am: Discussion

9:10 - 9:21am: NEUROSURGERY: The Road Ahead Oyesiku, Nelson

9:22 - 9:33am: Idiopathic Intracranial Hypertension: Time for a Albuquerque, Felipe Randomized Trial Comparing Stenting to Shunting

9:34 - 9:45am: Tuberculum sella meningiomas: results of a personal Dufour, Henry prospective series of the contralateral approach to the worse optic nerve in 18 consecutive patients. Description of the “no touch nerve technique”

Sunday, July 12 , 2015

Accompanying Persons Program

10:00-12:30pm: Maglev Train Ride

10:00 -10:15am: Depart at the Pudong Shangri-La, East Shanghai for the Maglev Train Ride

10:15-11:45am: Maglev Train Ride

11:45-12:00pm: Board the coaches for lunch

12:30-2:00pm: Meet the members and lunch at the Lv Bo Lang Restaurant

2:00pm: Same as the Members’ Program

9:46-9:57am: Endoscopic sublabial Caldwell-Luc Approach: A useful Liu, James Adjunct when combined with endoscopic endonasal skull base approaches for multi-angle multi-corridor Surgery to the lateral infratemporal fossa

9:58-10:09am: Use of Hematopoietic Growth Factors in Traumatic Chin, Lawrence Brain Injury

10:10-10:21am: Altering endoplasmic reticulum stress in a model of Rosen, Charles blast-induced traumatic brain injury controls cellular fate and ameliorates neuropsychiatric symptoms

10:22-10:33am: Utility of the cephalic vein in the Imax-to-MCA bypass Langer, David

10:34-10:45am: 1860: A tale of two civil wars in China and the U.S. Nanda, Anil

10:46-10:55am: Discussion

10:56-11:45pm: Free time, check-out and lunch on your own at hotel

11:45-12:00pm: Board the coaches at the Hotel for the railway station for Beijing extension

1:30pm: Arrival at the Hongqiao Railway Station for the speed train to Beijing 2:00pm: Train (No. G4) departs for Beijing 6:48pm: Arrival at Beijing South Railway Station

7:15-7:30pm Board the coaches at the Beijing South Railway Station for the Ritz-Carlton Beijing, Financial Street

8:00pm: Arrival at the Hotel

8:15-10:00pm: Western dinner at the Hotel Temple of Heaven

Accompanying Persons Program

9:30-11:00am: Huangpu River Cruise

9:30 -9:45am: Depart from the Pudong Shangri-La, East Shanghai for the cruise

10:00-11:00am: Huangpu River Cruise

11:00-11:15am: Depart for the Hotel

11:30am: Arrival at the Hotel

11:30am: Free time, check-out and lunch on your own at hotel

Monday, July 13 , 20156:30 - 10:30 am: Breakfast at the Hotel (Guests and Spouses)

7:30-11:30am: Scientific Session I1I Ritz Changan Room Moderators: Erol Veznedaroglu and Russel Lonser

7:30-7:41 am: Welcome Zhao, Jizong 7:42 - 7:53 am: Mini-Open Pedicle Subtraction Osteotomy as a Wang, Michael treatment for severe adult spinal deformities: case series with initial clinical and radiographic outcomes 7:54 - 8:05 am: A modified Bi-Coranal cranial flap (U-Shape) for the Acar, Feridun insertion of deep brain stimulation electrodes. Is it really helpful

8:06 - 8:17 am: Impact of multimodality monitoring using direct Prabhu, Sujit electrical stimulation (DES) and corticospinal tract (CST) shift in iMRI

8:18 - 8:29am: Primary dural closure for retrosigmoid approaches: Michael, Madison Is it possible in all cases?

8:30 - 8:41am: Surgical Treatment of Tumors of the Fourth Ventricle: McCutcheon, Ian a Single-Institution Series

8:42 - 8:53am: Discussion

8:54 - 9:05am: The Penicillin Era for Ischemic Stroke Khalessi, Alexander

9:06 - 9:17am: GnRH Signalling: New Insights into the Pathogenesis of Solaroglu, Ihsan High Grade Gliomas

9:18 - 9:29am: Hyperosmolar intraventricular drug delivery in the Krishnamurthy, Satish management of metastatic breast cancer: An animal model

9:30 - 9:41am: Age and lesion-induced increases of GDNF transgene Tibbs, Phillip expression in brain following intracerebral injections of DNA nanoparticles

9:42 - 9:47am: Discussion

9:48 - 10:04am: Break

10:05-10:16am: A model for neurosurgical coverage in a Boulis, Nick resource-limited setting: Developing neurosurgical capacity at l’Hopital Universitaire de Mirebalais (Mirebalais, Haiti)

10:17-10:28am: Middle fossa encephalocele (MFE) with tegmen Erkmen, Kadir tympani defect (TTD)

10:29-10:40am: Virtual reality and Advanced Augmented Reality 3-D Selman, Warren Imaging is a valuable adjunct for preparation, planning and navigation for neurosurgical procedures.

10:41-10:52am: Strategic Management Simulations as a tool to assess Satish, Usha surgical resident competency

10:53-11:04am: Effect of resident handoffs on length of hospital and Markert, James ICU stay in a neurosurgical population: a cohort study

11:05-11:16am: Things that don’t belong near the carotid Amar, Arun

11:17-11:25am: Discussion

12:00-12:15pm: Board the coaches for lunch outside the Hotel

1:00-2:30pm: Lunch at a local restaurant

2:30-2:45pm: Board the coaches at the lunch restaurant for Tiananmen Rostrum

3:30-4:00pm: Tour the Tiananmen Rostrum

4:00-4:15pm: Board the coaches at the Tiananmen Square for Temple of Heaven

5:30-5:45pm: Board the coaches at the Temple of Heaven for the dinner restaurant

6:30-8:30pm: Dinner at a local restaurant

8:30-8:45pm: Board the coaches at the Restaurant for the Hotel

Accompanying Persons Program

9:30-12:30am: Hutong Tour

9:30 -9:45am: Depart from the Ritz-Carlton Beijing, Financial Street for the Hutong Tour

10:30-12:15pm: Hutong Tour

12:15-12:30pm: Board the coaches for lunch

1:00-2:30pm: Lunch at a local restaurant

2:30pm: Same as the Members’ Program

Upon completion of this CME activity, the participant should be able to:

•Discuss current practice patterns with regards to the symptomatology, diagnosis, treatment methods and complication avoidance with respect to the entire spectrum of neurosurgi cal conditions and allied specialties in the clinical and basic neurosciences.•Review real clinical cases and specific treat ment methods that are justified and explained by recognized world leaders in the field.• Describe the most recent and future trends in neurosurgery around the world.• Identify effective program innovations and models from experts around the world.

The material presented at the annual meeting of the Society of University Neurosurgeons (SUN) has been made available by the SUN and the AANS for educational purposes only. The material is not intended to represent the only, nor necessarily the best, method or procedure appropriate for the medical situations discussed, but rather it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. Neither the content (whether written or oral) of any course, seminar or other presentation in the program, nor the use of a specific product in conjunction therewith, nor the exhibition of any materials by any parties coincident with the program, should be construed as indicating endorsement or approval of the views presented, the products used, or the materials exhibited by the SUN and jointly provided by the AANS, or its Committees, Commissions, or Affiliates. Neither the AANS nor the SUN makes any statements, representations or warranties (whether written or oral) regarding the Food and Drug Administration (FDA) status of any product used or referred to in conjunction with any course, seminar or other presentation being made available as part of the annual meeting of the Society of University Neurosurgeons (SUN). Faculty members shall have sole responsibility to inform attendees of the FDA status of each product that is used in conjunction with any course, seminar or presentation and whether such use of the product is in compliance with FDA regulations.

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the AANS and the Society of University Neurosurgeons. The AANS is accredited by the ACCME to provide continuing medical education for physicians.

The AANS designates this live activity for a maximum of 9.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Didactic lectures, case presentations/discussions, panel discussions, and oral paper presentations

Learning Objectives

Educational Format

Joint Providership Disclaimer

Accreditation/Continuing Medical

Education (CME)

Disclosure InformationThe AANS and the Society of Univers i ty Neurosurgeons control the content and production of this CME activ i ty and attempt to ensure the presentat ion of balanced, object ive information. In accordance with the Standards for Commercial Support establ ished by the Accreditat ion Counci l for Continuing Medical Education (ACCME), faculty, abstract reviewers, paper presenters/authors, planning committee members, staff , and any others involved in planning the educational content and the s ignif icant others of those mentioned must disclose any relat ionship they or their co-authors have with commercial interests which may be related to their content. The ACCME def ines “relevant f inancial relat ionships” as f inancial relat ionships in any amount occurr ing within the past 12 months that create a conf l ict of interest.

Those who have disclosed a relat ionship* with commercial interests are l i s ted below:

Name Disclosure Type of Relat ionship*Acar, Fer idun, MD Pamukkale Grant Univers i ty, Turkey Amar, Arun, MD Covidien, Inc. Cl in ical Tr ial CommitteeAmin-Hanjani , Sepideh, MD NIH/NINDS Univers i ty Grants Vassol , Inc./GE NIH/NINDS Healthcare CNS Exe. Committee F iduciary Posit ionBoul is , Nicholas, MD ALS Associat ion Grant Neurostem, Consult ing Fee MRI Intervensions, Voyager, B iomedica, Regenx Boston Scient i f ic Stock or Shareholder Above and Employee Beyond, LLC SwitchBio F iduciary Posit ion Charbel, Fady, MD Transonic, Inc. Consultant Fee Vassol , Inc. Stock or ShareholderDavid, Choi, MD DePuy Synthe Grant

Khaless i , Alexander, MD St ryker, Consultant Fee Covidien, Microvention CNS, AHA/SAS F iduciary Posit ionHasan, David, MD NIH GrantLui , Charles, MD Integra L i fe Science Grant KLS Mart in GrantLui , James, MD B iomet, Honorar ium StrykerMarkert , James, MD Catherex, Inc NIH/DOD Catherex and acts as inst i tut ional PI for a Aett is var iety of cl in ical U Nebraska, t r ials NorthShore Hospital Wash U UAB/UABHSF Employee Catherex, Aett is Co-FounderMorcos, Jacques, MD Codman Consultant Fee

NameAbou-Hamden, Amal, MDAlbuquerque, Fel ipe, MDAnderson, Richard, MDBederson, Joshua, MDBristol , Ruth, MDChin, Lawrence, MDDufour, Henry, MDErkmen, Kadir, MDFroel ich, Sebast ien, MDHasan, David, MDKrishnamurthy, Sat ish, MDLanger, David, MD

Levy, Michael , MD, PhDMcCutcheon, Ian, MDMichael, Madison, MDMurayama, Yuichi , MDNanda, Ani l , MD Oyesiku, Nelson, MD, PhDPrabhu, Suj i t , MDSatish, Usha, MDSin, Anthony, MDSist i , Michael, MDT ibbs, Phi l l ip, MDVajkoczy, Peter, MDWu, Jau-Ching, MD

Those who have reported they do not have any relat ionships with commercial interests:

Kogent Stock or ShareholderMorita, Akio, MD Japanese Grant- in- Univers i ty Grant/Research Aid for Scient i f ic Support Research Nippon Medical School EmployeeRosen, Charles, MD NIH Univers i ty Grant MOSH Univers i ty Grant/Research Support Synthes Consultant FeeSelman, Warren, MD Surgical Theater, LLC, Stock or Shareholder Osteoplast ics, LLCSolaroglu, Ihsan, MD Koc Univers i ty, School Univers i ty Grant/Research Support of MedicineWang, Michael, MD Department of Univers i ty Grants/Research Defense Support Innovative Surgical Stock or Shareholder Devices Spinicity DePuy Spine Consultant Chi ldren Hospital of Los Angeles, Other F inancial or Mater ial DePuy Spine, Support

Abstracts

Magnetic Resonance Therapy: Non-Invasive Neuromodulation for Cognitive Neurorestoration

Charles Y. Liu, MD.University of Southern California, LA, CA, USA

The past decade has witnessed a tremendous escalation of interest in neurorestoration, where neurological deficits. Indeed, the most advanced groups in clinical neurosciences world-wide are combining neuroscience and neural engineering to develop methodologies to restore both upper and lower extremity motor function, as well as sensory function. However, despite the overwhelming burden of cognitive neurological dysfunction such as PTSD, autism, anxiety disorders, and Alzheimer’s Disease, there are very limited efforts to find solutions to these disorders that can be scalable to be relevant. The bulk of the treatment for these dysfunctions remains in the realm of psychopharmacology, which attempts to leverage the biochemical properties of the brain. Neuromodulation has been championed by neurosurgery as a potential alternative to neurotropic medication, aiming to find therapeutic effect via the biophysical properties of brain function. Despite promising results in certain cognitive disorders such as depression, the invasive nature of present strategies represents a formidable barrier to widespread application. Furthermore, present neuromodulation strategies are not informed by patient specific information. It would follow that essential features of the ideal strategy would be non-invasive, informed by recordings from individual patients, and have a wide spectrum of applications. In this paper, we discuss a new methodology for neuromodulation that is informed by quantitative analysis of EEG, followed by application of modulation via trans-cranial magnetic stimulation. This method is termed Magnetic Resonance Therapy and is being actively explored as a highly effective tool for cognitive neurorestoration.

En bloc resection of primary spine tumours: trading nerve roots for improved survival.

Choi, David, MD.The National Hospital for Neurology and Neurosurgery, Queen Square, London, UKIntroduction:Complete en bloc resection is the gold standard treatment for the majority of primary spine tumours. However, en bloc procedures are technically challenging with the potential for more complications than simple intralesional tumour excision, and sacrifice

of nerve roots is usually necessary to permit en bloc resection. Whether an en bloc resection is justified for an individual patient depends on the balance of the anticipated post-operative loss of function and the survival gain, and this will vary depending on the nature and extent of the tumour.

Methods:We reviewed the complication rates, in particular the neurological function after nerve root sacrifice, and recurrence-free survival in a single surgeon retrospective cohort of patients who underwent en bloc or near complete resection of primary bone tumours, with sacrifice of nerve root(s). We reviewed the neurological morbidity associated with loss of nerve root integrity, complications, disease free survival, and overall survival after surgery.

Results:25 patients underwent en bloc surgery for excision of primary spinal tumours (12 sarcomas, 9 aggressive haemangiomas, 2 chondrosarcomas, 1 chordoma, 1 paraganglioma). Procedures performed included 18 en bloc resections, 2 intralesional en bloc and 5 intralesional complete piecemeal excisions. After surgery, 2 patients were complicated by myelopathic leg weakness, 1 haemothorax, 1 pleural effusion requiring drainage, 1 CSF leak, 1 Superficial wound infection, 1 deep infection requiring wound lavage, 1 steroid-related acute psychosis. When a thoracic nerve root at T2 or below was divided there were no adverse neurological symptoms or signs. 6 patients underwent sacrifice of one or more brachial or lumbar plexus nerve roots, of whom 3 had no significant functional deficit, 2 had significant deficits which returned to near-normal by 6 months, and 1 had a permanent complete motor and sensory nerve root lesion. Of the patients who had complete en bloc resection there was no tumour recurrence (follow-up range 2 – 116 months).

Conclusion:The complete resection of primary bone tumours by en bloc spondylectomy is possible with acceptable morbidity and good recurrence free survival. For this goal, sacrifice of nerve roots produces less functional deficit than expected, but the increased morbidity of these challenging operations should be justified for an individual patient by improved survival, compared to alternative treatments.

Arthroplasty for cervical spondylotic myelopathy: similar results to patients with only radiculopathy at 3 years’ follow-up.

Wu, Jau-Ching, MD, PhDTaipei Veterans General HospitalTaipei, Taiwan

Introduction:Cervical arthroplasty has been accepted as a viable option for surgical management of cervical spondylosis or degenerative disc disease (DDD). The best candidates for cervical arthroplasty are young patients who have radiculopathy caused by herniated disc with competent facet joints. However, it remains uncertain whether arthroplasty is equally effective for patients who have cervical myelopathy caused by DDD. The aim of this study was to compare the outcomes of arthroplasty for patients with cervical spondylotic myelopathy (CSM) and patients with radiculopathy without CSM.

Methods:A total of 151 consecutive cases involving patients with CSM or radiculopathy caused by DDD and who underwent one- or two-levelcervical arthroplasty were included in this study. Clinical outcome evaluations and radiographic studies were reviewed. Clinical outcome measurements included the Visual Analog Scale (VAS) of neck and arm pain, Japanese Orthopaedic Association (JOA) scores, and the NeckDisability Index (NDI) in every patient. For patients with CSM, Nurick scores were recorded for evaluation of cervical myelopathy. Radiographic studies included lateral dynamic radiographs and CT for detection of the formation of heterotopic ossification.

Results:Of the 151 consecutive patients with cervical DDD, 125 (82.8%; 72 patients in the myelopathy group and 53 in the radiculopathy group) had at least 24 months of clinical and radiographic follow-up. The mean duration of follow-up in these patients was 36.4 months (range 24-56 months). There was no difference in sex distribution between the 2 groups. However, the mean age of the patients in the myelopathy group was approximately 6 years greater than that of the radiculopathy group (53.1 vs 47.2 years, p < 0.001). The mean operation time, mean estimated blood loss, and the percentage of patients prescribed perioperative analgesic agents were similar in both groups (p = 0.754, 0.652, and 0.113, respectively). There were significant improvements in VAS neck and arm pain, JOA scores, and NDI in both groups. Nurick scores in the myelopathy group also improved significantly after surgery. In radiographic evaluations, 92.5% of patients

in the radiculopathy group and 95.8% of those in the radiculopathy group retained spinal motion (no significant difference). Evaluation of CT scans showed heterotopic ossification in 34 patients (47.2%) in themyelopathy group and 25 patients (47.1%) in the radiculopathy group (p = 0.995). At a mean of over 3 years postoperatively, no secondary surgery was reported in either group.

Conclusion:The severity of myelopathy improves after cervical arthroplasty in patients with CSM caused by DDD. At 3-year follow-up, the clinical and radiographic outcomes of cervical arthroplasty in DDD patients with CSM are similar to those patients who have only cervicalradiculopathy. Therefore, cervical arthroplasty is a viable option for patients with CSM caused by DDD who require anterior surgery. However, comparison with the standard surgical treatment of anterior cervical discectomy and fusion is necessary to corroborate the outcomes of arthroplasty for CSM.

KEYWORDS: ACDF = anterior cervical discectomy and fusion; CSM = cervical spondylotic myelopathy; DDD = degenerative disc disease; cervical arthroplasty

The importance of petrous origin in the treatment cerebellopontine angle meningiomas

Sisti, Michael, MD.Columbia University, NY, NY, USA

Introduction:Resection of cerebellopontine angle (CPA) meningiomas can be challenging. Here, we propose a treatment approach combining facial nerve-sparing microsurgery and Gamma Knife radiosurgery (GKS) based on tumor size and petrous origin.

Methods: Seventy-nine patients treated by a single surgeon (MBS) for CPA meningiomas between 1998 and 2013 were included in this retrospective review. Each meningioma was assigned to one of 7 groups based on its petrous origin: (1) medial to the internal auditory canal (IAC) (2) medial and involving the IAC (3) posterior to the IAC (4) posterior and involving the IAC (5) both medial and posterior to the IAC (6) medial and posterior and involving the IAC (7) pure intra-IAC. Tumors <2 cm in greatest dimension were treated with GKS alone, while tumors >2 cm were treated either with a combination of subtotal resection and GKS or with surgical resection alone.

Endoscopic endonasal approach for the treatment of skull base chordomas: Lariboisière experience.

Froelich, Sebastien, MD. S. Froelich, D. Bresson, S. Bouazza, AL. Bernat, P. Herman*, B. George.

Department of Neurosurgery, Lariboisère Hospital, Paris-Diderot University, Assistance Publique-Hôpitaux de Paris, Paris, France*ENT department, Lariboisère Hospital, Paris-Diderot University, Assistance Publique-Hôpitaux de Paris, Paris

Introduction: Endoscopic endonasal approach (EEA) is a valuable tool for the management of ventral skull base tumors such as chordomas. Besides being a more logical corridor of access to this type of lesion, the EEA seems to allow a better gross total resection rate, which remains the best prognosis factor until now. However, this surgical modality exposes intrinsically to a higher rate of specific complications such as post-operative CSF leak and this morbidity must be weighed against the benefits in terms of resection.A retrospective analysis of patients with chordomas and treated with EEA was conducted. Material and Methods:60 consecutive patients were treated during a 9 years period. 28 were females and 32 males, undergoing a total of 67 endoscopic procedures. A two-stage surgery

Moyamoya Disease: Characterization and surgical treatment of our European Caucasian population

Vajkoczy, Peter, MD. Department of Neurosurgery, Charite Universitätsmedizin Berlin, Germany

“Moyamoya Vasculopathy” is a rare disease. Over the past years, we have treated 252 patients with MMV. 224 patients of those where European Caucasians allowing us to highlight the specific clinical features of this rare disease in this ethnic background. We analyzed demographic data, clinical symptoms, angiographic characteristics and functional hemodynamic studies. Furthermore, we reviewed the results of surgical therapy. MMD disease (n=153) presented with a female predominance of 2,9:1. 78% presented with a typical MMV, 17% with a unilateral MMV, and 5% with an atypical MMV. 16% of our patients belonged to the pediatric population. Overall, 81% and 9% of our cohort presented initially with ischemic and hemorrhagic

Results: Mean tumor size was 2.89 +/- 1.3 cm (0.1 – 6.5 cm) and most meningiomas originated medially from the IAC (50.6%). Tumor invaded the IAC in 39.2% of cases. Patients received the following treatment regimens: surgery only (50.6%); surgery combined with GKS (17.7%); or GKS only (31.6%). Post-operatively and/or post-GKS, facial nerve function was stable in 84.8% of patients, worsened in 12.7% and improved in 2.5%. Facial nerve function was more likely to be affected in tumors originating medially, or in tumors with mixed medial-posterior origin that also involved the IAC (p=0.043). Tumor size and IAC invasion did not independently correlate with facial nerve function.

Conclusion: In the surgical management of CPA meningiomas, the anatomical origin of the tumor, as it relates to the IAC, is one of the most powerful predictors of post-operative facial nerve function. In our experience, meningiomas with medial origin or tumors originating solely from the IAC were most amenable to GKS alone.

was performed in 7 cases. Thirty-nine patients (65%) had a previous surgery in another institution: one in 32 patients (53%), two or more in 7 patients (12%). The epicenter of the lesion was the clivus (37%), the sellae (27%), the CCJ (21%) or the sphenoid (15%). The mean tumor volume was 24,1 cm3 (median: 18cm3, range- 0,4-88 cm3).

Results: Partial resection was achieved in 43%, subtotal in 20% and total in 37%. The newly diagnosed chordomas had a 62% rate of resection versus 23% for those who had been previously operated. Post-operative mortality (J0-J30) concerned 3 patients (5%) due to an intraventricular hemorrhage and two carotid artery injury (one intraoperative rupture and one delayed). Post-operative CSF leakage occurred in 15 patients (25%) and 16 patients had a postoperative meningitis (26,7%). Fifty-eight percent of per operative leaks were not controlled despite skull base reconstruction. A new cranial nerve deficit, mainly abducens nerve palsy, occurred in 5 patients (8,3%).

Conclusion: The EEA of skull base chordomas requires a long and gradual learning curve. If the resection rate seems to be better in our experience for EEA versus traditional approach, it remains a highly complex surgical procedure. Previously operated and/or radiated patient have a higher morbidity rate that should be taken into account in the decision making for surgery.

Impact of Hemodynamics on Stroke Risk in Symptomatic Vertebrobasilar Disease

Sepideh Amin-Hanjani, MD University of Illinois in Chicago, Chicago, IL, USA

Introduction: Atherosclerotic vertebrobasilar disease (VBD) is a significant etiology of posterior circulation stroke, with regional hypoperfusion as an important potential contributor to stroke risk. To examine the role of hemodynamic compromise in VBD, a prospective observational study, Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS), was conducted.

Methods: Patients with recent vertebrobasilar (VB) TIA or stroke and ≥50% atherosclerotic stenosis or occlusion in vertebral and/or basilar arteries were enrolled at 5 centers. Large vessel flow in the VB territory was assessed using quantitative MRA, and patients were designated as low flow or normal flow based on distal territory regional flow, incorporating collateral capacity. Patients underwent standard medical management and blinded follow-up assessment, with primary outcome of VB territory stroke.

manifestation, respectively. The rate of hemorrhagic manifestation of MMV among the pediatric group was slightly higher (12%). Angiographic analysis revealed steno-occlusive involvement of the posterior circulation in 34% with a higher involvement in pediatric patients (64%) compared to adults (26,5%). Patients with MMS (n=60) presented with a large variety of co-morbidties. Among those Trisomy21 and hematological disorders were the most frequent ones. MMS presented with a female predominance of 2,7:1. 80% presented with a typical MMV, 14% with a unilateral MMV, and 6% with an atypical MMV. 31% of our patients belonged to the pediatric population. 82% and 8% of our cohort presented initially with ischemic and hemorrhagic manifestation, respectively. Our general surgical strategy is to revascularize both affected hemispheres in a staged fashion. In adults, STA-MCA bypass alone or in combination with EDS is our favorite strategy, in pediatric patients, we tend to apply more extensive strategies such as STA-MCA bypass plus EMS/EDAS. In summary, the characterization of a homogenous European Caucasian cohort reveals several significant differences when compared to Asian cohorts. In contrast, MMV presents similarly among European and North American cohorts, suggesting that non-Asian MMV is characterized by distinct clinical features.

Results: The cohort (n=72, 44% female) had a mean age of 66 (range 40 to 90) years; two thirds presented with ischemic stroke. Ten VB strokes occurred during the median follow-up of 23 months. Distal flow status was found to be a significant predictor of subsequent VB stroke (p=0.039), with a 12 and 24 month event free survival of 78 % and 70% respectively in the low flow group versus 96 % and 87 % in the normal flow group. On multivariate analysis adjusting for age and stroke risk factors the hazard ratio for the low flow group was 11.5 (95% CI 1.9 to 71.0, p =0.008). Medical risk factor management at 6 month intervals was similar between low and normal flow patients. Distal flow

Conclusion: Distal flow status in the posterior circulation determined using a noninvasive and practical imaging tool is a robust predictor of subsequent VB stroke risk. Identification of high risk patients has important implications for future investigation of interventional therapies.

Pressure Changes within the Sac of Human Cerebral Aneurysms in Response to Artificially Induced Transient Increases in Systemic Blood Pressure

Hasan, David, MD. Bradley J. Hindman, M.D., Michael M. Todd, M.D.Iowa University, Iowa City, IA, USA

Formation and rupture of cerebral aneurysms have been associated with chronic hypertension. The effect of transient increase in blood pressure and its effect on intra-aneurysmal hemodynamics have not been studied. We examined the effects of controlled increases in blood pressure on different pressure parameters inside the sac of human cerebral aneurysms and corresponding parent arteries using invasive technology. Twelve patients (10 female, 2 male, age 54 ± 15 years) with unruptured cerebral aneurysms undergoing endovascular coiling were recruited. Dual-sensor microwires with the capacity to simultaneously measure flow velocity and pressure were used to measure systolic, diastolic, and mean pressure inside the aneurysm sac, and to measure both pressures and flow velocities in the feeder vessel just outside the aneurysm. These pressures were recorded simultaneously with pressures from a radial arterial catheter. Measurements were taken at baseline and then during a gradual increase in systemic SBP to a target value of ≈25 mmHg above baseline, using a phenylephrine infusion. The dose needed to achieve the required increase in radial arterial SBP was 0.8 ± 0.2 mcg/kg/min. There was a clear linear relationship

Clinical application of CFD technology for treatment strategy of complex cerebral aneurysms

Murayama, Yuichi, MD. Hiroyuki Takao, MD. Ph.D., Ichiro Yuki, MD, Toshihiro Ishibashi, MD., Takashi Suzuki, Ph.D.Department of NeurosurgeryJikei University School of Medicine, Japan

Abstract: Aim: Computational fluid dynamics analysis of cerebral aneurysm has been mainly studied for risk of rupture or growth mechanism. We applied CFD for treatment simulation for complex intracranial unruptured aneurysms (UIAs).

Methods: Between 2007 and 2014, 20 complex shaped UIAs were analyzed before embolization. Average size was 11mm and location was basilar bifurcation (n=7), Basilar trunk (n=2), ICA (n=6), MCA (n=2), and ACA (n=3). Geometry of the UIAs and blood vessels was extracted from DSA images and analyzed using a mathematical formula for fluid flow under pulsatile blood flow conditions. CFD analysis was conducted to identify high pressure area, wall shear stress (WSS) and stream line to plan target embolization.

Results: All 20 UIAs were successfully treated using multiple catheter technique (n=15) or multiple catheter catheter

between changes in radial and aneurysmal pressures with substantial patient-by-patient variation in the slopes of those relationships. The overall increases in systolic and mean pressures in both radial artery and in the aneurysms were similar. Pressures in the aneurysm and in the parent vessels were similar. Peak and mean flow velocities in the parent arteries did not change significantly with phenylephrine infusion, nor did vessel diameters as measured angiographically. In summary, the hemodynamic changes within the sac of human cerebral aneurysm in response to transient increase in systemic blood pressure is variable and independent of aneurysm size.

Kew words: pulse pressure, peak flow velocity, means flow velocity, Volcano microwire systolic blood pressure, and diastolic blood pressure.

technique with stent assisted technique (n=5).Microcathter was positioned under guidance of stream line and target dense packing was achieved the area of high pressure. At the area of low WSS, loose packing was intentionally done to avoid branch occlusion which arising from the dome. 3 UIA showed mild recanalization and only 1 UIAs required retreatment.

Conclusion: Although it requires time and skilled scientists, CFD technology can be used to clinical practice for treatment planning of complex UIAs.

Management strategy and treatment outcomes of unruptured intracranial aneurysms according to the natural course – implications from the UCAS Japan cohort

Morita, Akio, MD. Nippon Med. Sch./NeurosurgerySendagi/Bunkyo-kuTokyo, Japan

Background: Management strategy of the unruptured intracranial aneurysms (UIA) should be made by balancing rupture risk and management risk of aneurysms as well as patient’s physical and mental conditions. Rupture risks and its prediction models of UCA have been recently reported, but management risks need to be further clarified. We now report the treatment data from a Japanese cohort and created risk prediction model.

Methods: Out of the total cohort of 6,413 patients, 2,627 underwent repair (2,311 by open craniotomy) in 215 institutions. Morbidity was defined as decline of modified Rankin scale to the level of two or below at one month after treatment. Factors with p value less than 0.10 by multivariate cox regression model were considered important and included in the prediction model. Prediction scores were derived from multivariate hazard ratio.

Results: Overall morbidity was recorded in 79 cases (3.0%). Important risk factors were as follows; Size≧10mm, Basilar Location, not associated with daughter sac, Age≧70, Hypertension, Diabetes Mellitus, initial modified Rankin scale and multiple aneurysm treatment at one cession. Neither hospital treatment volume nor method of treatment affected treatment morbidity. We created risk prediction model for morbidity to be balanced with rupture prediction score. For the summed score less than 3, predicted management morbidity is less than 1%.

Conclusion: Risks associated with management of UIA can be stratified with several factors. Risk prediction model of management as shown here should support decision making on UIA management in conjoined with rupture risk prediction model.

Bypass Selection for Aneurysm Surgery

Charbel, Fady, MD. University of Illinois in Chicago, Chicago, IL, USA

Introduction: There can be much debate concerning the optimal strategy in bypass for aneurysm reconstruction. Yet, donor selection can be optimized via an algorithm based on the concept of a flow replacement bypass which aims to compensate for loss of flow in the efferent vessels of the aneurysm. We present the methodology and quantitative follow-up for native donors selected in this manner.

Methods: A strategy matching graft flow to demand was implemented and patients with bypass for anterior circulation intracranial aneurysms using only a native donor (superficial temporal artery, STA) selected based on a flow algorithm over a ten year period were retrospectively studied. Intracranial hemispheric and bypass flows (mL/min) were assessed intra-operatively with an ultrasonic flow probe, as well as preoperatively and postoperatively when available using quantitative MRA.

Results: 22 patients with flow data were included (median aneurysm size 22 mm). The intraoperative flow offer (cut flow) of the STA was sufficient in these cases relative to the flow demand in the sacrificed vessel (59 vs. 28 ml/min) to warrant its use. Bypass flow averaged 81 mL/min postoperatively (n=19). Bypass flows were highest in the immediate postoperative period but remained stable on intermediate and final follow-up (40 vs. 52, p=0.39, n=8). In patients with both pre and postoperative flows available, mean ipsilateral hemisphere flows were maintained post bypass (299 vs. 335, n=7); for those with follow-up imaging, hemispheric flows remained stable over intermediate, and long term follow-up (333 vs. 282, n=7; and 363 vs. 286, n=6). Ipsilateral flows remained similar to contralateral flows at all time-points.

Conclusion: Direct measurement of flow deficit in aneurysm surgery requiring parent vessel sacrifice can guide

the choice of flow replacement graft and confirm the subsequent adequacy of bypass flow. Native donors can carry sufficient flow for territory demand when an intraoperative flow based algorithm is used for donor selection.

Preoperative 3D Modeling in Infants and Children with Cerebral Aneurysmal Malformations

Levy, Michael, MD. Clinical Professor of Surgery, UCSD School of Medicine,San Diego, CA, USA

There are numerous pitfalls that can result in an excessive morbidity /mortality in treating infants with complex cerebral aneurysmal malformations. Diminished blood volume in addition to estimated blood loss and Sustainable loss our primary concerns. Duration of the operative invention is a significant variable in children as is the anatomic variation and vascularity of the skull, peer cranium, and dura. Blood Volume, EBL and Loss

We reviewed our series of children less than 36 months of age who presented with complex aneurysmal vascular malformations over the past 20 years. There were 22 patient’s identified (15 males, 7 females). Mean Age was 12.2 Months (+ 13.3 months).

8 presented with acute subarachnoid hemorrhage, of which bled greater than 3 days prior to admission. Cranial nerve abnormalities were present in 6, hydrocephalus in 2, an intracerebral hemorrhage in 2. 19 aneurysms were spontaneous, 2 traumatic, and 1 infectious in nature.

Measuring Technical Proficiency in Neurosurgery Residents through Intraoperative Video Evaluations

Bederson, Joshua, MD Mount Sinai HospitalNY, NY, USA

Background: Although technical skills are fundamental in neurosurgery, there is little agreement on how to describe, measure, or compare skills among surgeons. Objective: The primary goal of this study was to develop a quantitative grading scale for technical surgical performance that distinguishes operator skill when graded by domain experts (residents, attendings, and non-surgeons). Scores provided by raters should be highly reliable with respect to scores from other observers.

Methods: Neurosurgery residents were fitted with a head-mounted video camera while performing craniotomies under attending supervision. Seven total videos, one from each PGY level (1-7), were anonymized and scored by 16 attendings, 8 residents, and 7 non-surgeons using a grading scale. Seven skills were assessed; these were incision, efficiency of instrument use, cauterization, tissue handling, drilling/craniotomy, confidence, and training level.

Results:A strong correlation was found between skills score and PGY year (p<0.0001, ANOVA). Junior residents (PGY 1-3) had significantly lower scores than senior residents (PGY 4-7, p<0.0001,t-test). Significant variation among junior residents was observed, while senior residents’ scores were not significantly different from one another. Inter-rater reliability, measured against other observers, was high (r= 0.581 ± 0.245,Spearman) as was assessment of resident training level (r= 0.583 ± 0.278,Spearman). Both variables were strongly correlated (r = 0.90,Pearson). Attendings, residents, and non-surgeons did not score differently (p=0.46, ANOVA).

Conclusion: Technical skills of neurosurgery residents recorded during craniotomy can be measured with high inter-

rater reliability. Surgeons and non-surgeons alike readily distinguish different skill levels. This type of assessment could be used to coach residents, to track performance over time, and potentially to compare skill levels. Developing an objective tool to evaluate surgical performance would be useful in several areas of neurosurgery education.Keywords: neurosurgery simulation; intraoperative evaluations; surgical skills; video-based resident training

10 aneurysms were defined as giant including 1 bihemispheric anomaly. 7 involved the posterior circulation whereas 14 involved the anterior circulation.

1 patient with a bihemispheric anomaly was treated non operatively. 3 underwent coiling and/or embolization alone, 3 underwent embolization with resection, 7 underwent trapping with excision, 5 underwent classic clip ligation, 2 underwent clip ligation in the setting of cardiac arrest, and 2 underwent classic clipping in combination with wrapping. We will discuss the presentation and outcomes in all patients in addition to addressing 4 cases addressed with a 3 dimensional modeling to assist in facilitating the surgical approach.We found that preoperative planning diminished surgical duration in our 4 cases. It additionally increased the anatomic recognition and decreased the time until proximal control was obtained

Giant 9/22Basilar 1ICA Bifurcation 5Pericallosal 3MCA 6PICA 2P2 4Diffuse 1 Bihemispheric

Outcomes after suboccipital decompression without dural opening in children with Chiari I malformation

Anderson, Richard, MD. Benjamin C Kennedy, Neil A FeldsteinNeurological Institute Columbia University,NY, NY, USA

Introduction: Symptomatic pediatric Chiari Malformation Type I (CM-I) is most often treated with posterior fossa decompression (PFD), but controversy exists over whether the dura needs to be opened during PFD. While dural opening as a part of PFD has been suggested to result in a higher rate of resolution of Chiari symptoms, it has also been shown to lead to more frequent complications. In this paper, we present the largest reported series of outcomes after PFD without dural opening surgery, as well as identify risk factors for recurrence.

Methods: A retrospective review of 156 consecutive pediatric patients undergoing PFD without dural opening by the senior authors from 2003-2013 was performed. Patient demographics, clinical symptoms and signs,

Efficacy and Cost of Tranex

Bristol, Ruth, MD.Pflibsen L, Hooft N, Singh DJ, Beals SP, Joganic E, Maneri C Barrow Neurological Institute, Phoenix, AZ, USA

Craniosynostosis surgery is associated with significant blood loss. Tranexamic acid (TXA) has been used to reduce blood loss and transfusion requirements in patients undergoing calvarial vault reconstruction. This has been reported by several centers and appears to be a robust effect.

We retrospectively reviewed 79 patients with craniosynostosis who underwent either anterior or posterior vault remodeling before institution of a TXA administration protocol (non-TXA group) and 35 patients after institution of the TXA protocol (TXA group) to evaluate the effect of TXA at our institution. In the TXA group, a loading dose of 10mg/kg was followed by a 24 hr infusion of 5/mg/kg/hr. Clinical and cost analysis was carried out between the two groups.

The TXA group required significantly less total blood transfusion during their operation; 278cc TXA group vs 387 cc non-TXA (p=0.0146), and no transfusions

radiographic findings, intraoperative ultrasound, and neuromonitoring findings were reviewed. Univariate and multivariate regression modeling were performed to determine risk factors for recurrence of symptoms and the need for reoperation.

Results: Over 90% of patients had a good clinical outcome with improvement or resolution of their symptoms at last follow-up (mean 32 months). There were no major complications. The mean length of stay was 2.0 days. In a multivariate regression model, partial C2 laminectomy was an independent risk factor associated with reoperation (p=0.037). Motor weakness on presentation was also associated with reoperation but with only trend level significance (p=0.075). No patient with less than 8mm of tonsillar herniation required reoperation.

Conclusion: The vast majority (>90%) of children with symptomatic Chiari I malformation will have improvement or resolution of symptoms after a PFD without dural opening. A non-dural opening approach avoids major complications. While no patient with tonsillar herniation < 8 mm required reoperation, children with tonsillar herniation at or below C2 have a higher risk for failure with this approach.

Neurosurgical pediatric deformity experience at Shriners Hospital for Children – Shreveport and complication management: First three years.

Sin, Anthony, MD.Department of NeurosurgeryLSUHSC, Shreveport, LA, USA

Introduction: Pediatric spinal deformity service at Shriners Hospital has been traditionally provided by an orthopedic surgeon until late 2011. A neurosurgery spinal surgeon took over the practice and has been the primary surgeon for past four years.

Methods: The patients’ charts and radiological studies have been retrospectively reviewed for basic demographic information with emphasis on perioperative complications and subsequent management.

Results: 153 surgical procedures were performed in 142 patients between January 2012 and January 2015. There were more females than males (92:50) with average age of 11 years (range 3 to 22 years-old). A variety of pediatric spinal pathologies were treated including coccyx resection in 3 year-old girl for debilitating pain due to prominent elongated coccyx: AIS 82, JIS 11, EOS 7/growing rods 2, NM scoliosis 24, Scheuerman’s kyphosis 12, Spondylolisthesis 2, previous deformity surgery 13. An average of 9 levels was fused with intent

A Practical Outcome Scale for Paediatric Neurosurgery Patients: The Paediatric Modified Rankin Scale

Abou-Hamden, Amal, MD.Senior Consultant Neurosurgeon: The Royal Adelaide Hospital and The Women’s &Children’s Hospital Senior Clinical LecturerThe University of Adelaide, Adelaide, Australia

Introduction:The “modified Rankin Scale” (mRS) is a commonly used outcome for measuring how well patients with neurological disorders are doing. It is quick and easy for clinicians to apply the mRS in a clinic. Unfortunately the scale is reliable and valid only in adult patients. There is no published reliability and validity information regarding its usage in children. We, therefore, conducted a prospective study to determine the reliability, validity; and responsiveness of the mRS in a sample of paediatric neurosurgery patients. Method: We developed a revised version of the mRS for use in paediatric neurosurgery patients. Neurosurgery consultants, registrars and one clinical research assistant independently scored the mRS. Reliability was determined using kappa statistics(k).Validity was determined by correlating the mRS to the other established valid measuresat 4-week post-discharge. Spearman’s rank coefficient (r) was used to demonstrate the validity. For responsiveness we analysed the correlation of the scores at three intervals: 4 week versus 3 months, 4 weeks versus 6 months, and 3 versus

6 months. Repeated measures analysis was used to determine the change in the mRS in relation to change in clinical status over time. Results:mRS has excellent inter-rater (k= 0.84; kw =0.89) and intra-rater reliability (k=0.79; kw =0.86). School-age group demonstrated higher reliabilitythan the non-school-age group.Validity of the mRS is supported by a strong correlation with the GOSE-Peds(r=0.700) and the PSOM(r=0.703).Responsiveness of the mRS is demonstrated by a strong correlation of the score at both 4 weeks, 3 and 6 months with the GOSE-Peds and the PSOM .There was a change in the mRS in relation to change in the clinical status. ConclusionOur findings support the use of the paediatric mRSas a valid and reliable clinical outcome assessment measure in paediatric neurosurgical disorders.

postoperatively, compared to the non-TXA group who received an average of 77cc postoperatively (p<0.001). EBL was lower in the TXA group: 195 cc in the TXA group vs 290cc non-TXA (p=0.0009). All underwent transfusion intraoperatively, as per our institutional preference. The cost of TXA is $43.40 per 100mg vial. Non-irradiated packed red blood cells cost $0.92 per mL. The overall cost for the TXA patients was 50% higher (p<0.001), at $893.97 per person vs. nonTXA at $419.22 per person. Length of stay was not significantly different.

Intraoperative TXA administration reduced blood lost and transfused, in patients undergoing craniosynostosis surgery. There were no adverse events related to TXA administration. The TXA 24 hour infusion increases cost, but avoids exposure to a second unit of blood. The use of post-operative drains has also declined sharply with TXA. Future efforts will focus on decreased infusion time and incorporation of other blood preservation protocols.

NEUROSURGERY: The road ahead

Nelson M. Oyesiku, MD, PhDEmory University School of Medicine

Biomedical publishing is undergoing rapid change in content delivery, operating paradigms and content generation.The Editor-in-Chief will examine these issues from the standpoint of NEUROSURGERY and provide perspectives and plans for the evolution of the next generation tf the journal.

Idiopathic Intracranial Hypertension: Time for a Randomized Trial Comparing Stenting to Shunting

Albuquerque, Felipe, MD.Michael Levitt, MDBarrow Neurological Institute, Phoenix, AZ, USA

Objective: Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure, headache, and if severe, vision loss. Retrospective series have suggested that in patients with IIH in whom there is stenosis of one or more dural venous sinuses, venous stenting may improve objective symptoms such as visual loss and papilledema and subjective symptoms such as headache. We have design a prospective, randomized trial to compare the efficacy of these 2 treatments in ameliorating moderate to severe visual loss.

Methods: The Operative Procedures versus Endovascular Neurosurgery for Untreated Pseudotumor (OPEN-UP) trial will be a randomized, open-label trial to determine whether dural venous sinus stenting is as safe and effective as CSF shunting in halting or improving moderate-to-severe visual loss in IIH patients. The study population includes patients with IIH (as defined by the 2013 International Classification of Headache Disorders) with at least moderate visual loss (perimetric mean deviation (PMD) at least -8 dB but better than -30 dB) in at least one eye (the study eye).

Results: We anticipate first-stage enrollment of 98 patients (equally randomized to dural sinus stenting and CSF shunting). All patients diagnosed with IIH will undergo cerebral venography with pressure measurements under local anesthesia. Since a pressure gradient of ≥ 8 mmHg has been shown to correlate with treatment success after stenting for IIH, this value will be used as a threshold above which patients will be randomized to one of the two treatment arms.

Conclusion: Primary outcome will be assessed via changes in the patients’ PMD, which was chosen as a primary outcome at 6 months due to its generalizability, test-retest reliability and standardization across centers. Secondary outcomes will include the number of IIH-related surgeries at 1 year as well as resolution of venous pressure gradient and changes in quality of life measures at 6 months.

to instrument every level using pedicle screws (range 2 – 16 levels). Two wound infections required washout in NM cases – one within two weeks and the other after one year. Two patients had symptomatic radiculopathy from pedicle screws, and subsequently surgically removed even though intraoperative EMG was normal. Four patients had neurological deficits immediately post-operative. Three required reexploration, and all but one regained all the function at the last follow-up visit.

Conclusion: A wide scope of deformity pathologies can be seen in pediatric population and some require surgical intervention. Complications can occur and surgeons should be able to optimize and manage them.

Endoscopic sublabial Caldwell-Luc Approach: A useful Adjunct when combined with endoscopic endonasal skull base approaches for multi-angle multi-corridor Surgery to the lateral infratemporal fossa

Liu, James, MD.Jean Anderson Eloy, MDDepartments of Neurological Surgery and Otolaryngology-Head and Neck Surgery, Center for Skull Base and Pituitary Surgery, Rutgers New Jersey Medical School, Neurological Institute of New Jersey, Newark, New Jersey, USA

Background: Skull base lesions involving the pterygopalatine and infratemporal fossa can be challenging to remove because of their deep location and proximity to critical neurovascular structures. Traditional approaches include pre-auricular orbitozygomatic subtemporal and anterior transfacial transmaxillary approaches, which involve cranial/facial incisions, craniotomy, and facial osteotomies. A purely endoscopic endonasal approach can be considered as an alternative minimal-access approach. However, access to the far lateral skull base is limited by the nasolacrimal duct. The addition of an endoscopic sublabial transmaxillary approach (Caldwell-Luc) provides direct anterior access to the lateral

was lareralized in 89% (n=16) and median in 11% (n=2). A unilateral extension of the meningioma to the distal optic canal was noticed in 89% of cases (all cases of lateral insertion). Visual improvement or normalisation occur in 17 patients and worsen in one case. 15% cases of hyposmia and 15% cases of anosmia occur after surgery.

Discussion / Conclusion: Unilateral compressive neuropathy is the most common symptoms for TSM. This compression is constantly from medial to lateral, pushing and/or elevating the optic nerve who is stretched beetwem the meningioma, the falciform ligament and the lateral wall of the optic canal. Removing this compressive part of the tumor via an homolateral approach lead to unavoidable manipulation of the nerve and blind maneuvers, possibly responsible of post-operative worsening. Removing the meningioma and controlling the more agressive part of the tumor through a controlateral approach permit a safe decompression without any manipulation of the optic nerve (« no touche nerve technique »). Visula outcome is very good with this technique. The drawback of this contyrolateral subfrontal approach is the rate of olfactory trouble.

Idiopathic Intracranial Hypertension: Time for a Randomized Trial Comparing Stenting to Shunting

Dufour, Henry, MD.Professor of Neurosurgery, Chairman of NeurosurgeryUniversity hospital of Marseilles, la TimoneUniversité de la MéditéranéeMarseilles, France

Title: Tuberculum sellae meningiomas : results of a personnal prospective serie of the controlateral approach to the worse optic nerve in 18 consecutive patients. Description of the « no touch nerve technique »

Introduction: Tuberculum sellae meningiomas (TSM) are mostly discovered because of bilateral or unilateral visual impairement. Visual outcome is the main challenge of this surgery. Numerous approaches had been described : subfrontal bilateral, interhemispheric, subfrontal unilateral, orbito-frontal, fronto-lateral, fronto-pterional, minipterional, or extended endoscopic endonasal approach. During the last twenty years, the time delay of tuberculum sellae meningioma has shortened because of a better availability of efficient MRI and best methods of diagnosis for compressive optic neuropathy, frequently showing unilateral forms of optic compression.

Methods: Beetween January 2010 and January 2015, all patients diagnosed with visual impairement due to tuberculum sellae meningioma were included in a prospective data base. Preoperative visual status (visual acuity and visual field – Fahlbusch’s score), MRI T1 and T2 sequences, intraoperative datas, surgical follow-up including visual outcome, olfaction, MRI, and cosmetic result were analyzed. All patients were operated trough an orbito-frontal approach, controlateral to the compressed optic nerve in case of unilateral compression, or controlateral to the optic nerve the more compressed by the meningioma in case of bilateral compression.

Results: 18 patients (17 W, 1 M) meet the above criteria. Mean time delay before diagnosis was 9 months. All patients had compressive optic neuropathy, always asymetrical. Visual deficit was always correlated with the lateralisation of the insertion and/or the dominant encasement of distal optic canal. The surgical approach was a limited fronto-orbital rim bone flap (3 cm X 3 cm) through a fronto-temporal incision. The insertion

Use of Hematopoietic Growth Factors in Traumatic Brain Injury

Chin, Lawrence, MD.SUNY Upstate Medical UniversitySyracuse, New York, USA

Introduction: SCF and G-CSF (S+G) are hematopoietic growth factors that regulate bone marrow stem cell survival and regeneration. Receptors for SCF and G-CSF are expressed in neurons and cerebral endothelial cells and also pass through the blood-brain barrier. Studies from our lab have shown that S+G reduces infarct size and forms the basis for these studies in TBI. Cognitive function was assessed using the water maze test, which measures how long it takes mice to learn platform locations.

Methods: A controlled cortical impact (CCI) model in C57BL mice

infratemporal fossa via an anterior maxillotomy without violation of the nasolacrimal duct.

Methods: We present our technique of combined endoscopic endonasal and endoscopic sublabial Caldwell-Luc approaches for complex tumors involving the lateral infratemporal fossa. Tumors treated included 2 juvenile nasopharyngeal angiofibromas, 2 schwannomas, 1 meningioma, and 1 plasma cell granuloma. The surgical technique and operative nuances are described.

Results: Gross to near-total resection was achieved in all cases. The additional endoscopic Caldwell-Luc approach allowed for multi-corridor multi-portal exposure, thereby providing unrestricted access and surgical freedom to perform resection of these difficult lesions. The use of angled endoscopes and curved instrumentation also improved visualization and access to the tumor. There was one postoperative CSF leak in 1 patient who had a combined orbitozygomatic and endoscopic endonasal approach which was successfully repaired with a nasoseptal flap.

Conclusion: The endoscopic sublabial transmaxillary (Caldwell-Luc) approach is a useful adjunct when used in combination with the endoscopic endonasal approach to remove extensive ventral skull base lesions that extend laterally into the infratemporal fossa and middle fossa. This combined approach highlights the utility of multi-portal multi-corridor endoscopic skull base surgery.

Altering endoplasmic reticulum stress in a model of blast-induced traumatic brain injury controls cellular fate and ameliorates neuropsychiatric symptoms

Rosen, Charles, MD.Professor and ChairDepartment of NeurosurgeryWest Virginia University School of MedicineMorgantown, West Virginia, USA

Neuronal injury following blast-induced traumatic brain injury (bTBI) increases the risk for neuropsychiatric disorders, yet the pathophysiology remains poorly understood. Blood-brain-barrier (BBB) disruption, endoplasmic reticulum (ER) stress, and apoptosis have all been implicated in bTBI. Microvessel compromise is a primary effect of bTBI and is postulated to cause subcellular secondary effects such as ER stress. What remains unclear is how these secondary effects progress to personality disorders in humans exposed to head trauma. To investigate this we exposed male rats to a clinically relevant bTBI model we have recently developed. The study examined initial BBB disruption using Evan’s blue (EB), ER stress mechanisms, apoptosis and impulsive-like behavior measured with elevated plus maze (EPM). Large BBB openings were observed immediately following bTBI, and persisted for at least 6 h. Data showed increased mRNA abundance of stress response genes at 3 h, with subsequent increases in the ER stress markers C/EBP homologous protein (CHOP) and growth arrest and DNA damage-inducible protein 34 (GADD34) at 24 h. Caspase-12 and Caspase-3 were both cleaved at 24 h following bTBI. The ER stress

was used to create a right hemisphere brain injury. After TBI mice were divided into vehicle control (n=11) and S+G treatment (n=12). In addition a sham group was tested that did not undergo TBI. Three weeks after TBI the mice underwent one week of treatment followed two weeks and six weeks later with water maze testing.

Results:Water maze data showed that S+G treatment significantly improved learning compared to vehicle control. In addition, treated mice were found to have increased bone marrow-derived monocytes (BMDM), which enhances neurite outgrowth and neuronal network formation.

Conclusion- Hematopoietic stem cell factors given in the chronic phase of traumatic brain injury improve functional recovery related to learning. The mechanism may be related to direct effects on neurons or indirect effects of (BMDM)

1860: A tale of two civil wars in China and the U.S.

Nanda, Anil, MD.Professor and ChairLouisiana State University Health Sciences at Shreveport, Shreveport, LA, USA

The Civil War in the United States was the defining cornerstone of American history, with over 600,000 casualties in a four-year-war shepherded by the leadership of the likes of Abraham Lincoln and Ulysses Grant. The Chinese Civil War from 1850 to 1865 was an even more devastating war with several millions killed. It was called the Holy Taiping Uprising, complete with a self-proclaimed Messiah. Hong Xiuquan believed he was Jesus Christ’s younger brother and was called to establish a holy kingdom, the Taiping Heavenly Kingdom, to replace the Manchu Qing dynasty. It took almost 14 years of widespread violence to depress the rebellion, losing some of the war’s more capable leaders in the process. Much like the American Civil War, there were racial overtones concerning the Manchu people, an ethnic minority of the Manchuria region, and the Hong majority. Aptly, when Ulysses Grant visited Chinese General Zeng Guofan, Guofan said, “The two of us have suppressed the largest rebellion ever recorded in history.” A timeline and the controversies with surgical vignettes of this era will be presented.

Mini-Open Pedicle Subtraction Osteotomy as a treatment for severe adult spinal deformities: case series with initial clinical and radiographic outcomes

Michael Y. Wang MD*, FACS Gerd Bordon, MD, PhD±University of Miami, Miami, FL, USA

The Civil War in the United States was the defining cornerstone of American history, with over 600,000 casualties in a four-year-war shepherded by the leadership of the likes of Abraham Lincoln and Ulysses Grant. The Chinese Civil War from 1850 to 1865 was an even more devastating war with several millions killed. It was called the Holy Taiping Uprising, complete with a self-proclaimed Messiah. Hong Xiuquan believed he was Jesus Christ’s younger brother and was called to establish a holy kingdom, the Taiping Heavenly Kingdom, to replace the Manchu Qing dynasty. It took almost 14 years of widespread violence to depress the rebellion, losing some of the war’s more capable leaders in the

Utility of the cephalic vein in the Imax-to-MCA bypass

Langer, David, MD. Lenox Hill Hospital, Northshore, NY, NY, USA

Background: The cervical carotid system had been routinely used as a source of donor vessels for radial artery or saphenous vein grafts in cerebral bypass. Recently the Internal Maxillary Artery (IMAX) in the subcranial fossa has been described as an alternative donor source with significant reduction of graft length potentially correlating with improved patency. We describe our experience using the forearm cephalic vein grafts for short segment IMax-to-MCA bypasses.

Methods: All vein grafts were harvested from the volar forearm between the proximal antecubital fossa where the median antecubital vein is confluent with the cephalic vein, and the distal wrist.Results: Six patients were treated with IMax-to-MCA bypass. In four of them the cephalic vein was utilized. Post-operative angiography demonstrated good filling of the graft with robust distal flow. None of the patients developed vascular complication in the upper arm. All but one patient tolerated the procedure well. There was one case of mortality. Follow up imaging (6 -12 month) demonstrated patent graft vessel.

Conclusion: The IMax-to-MCA “middle” flow bypass allows for shorter graft length with both the proximal and distal anastomoses within the same surgical field. These unique variable flow grafts represent an ideal indication for the use of the cephalic vein of the forearm which is more easily harvested than the wider SVG, has good match size to the required M2/M3 segments of the MCA, supple vessel walls that facilitate handling during anastomosis and lower morbidity potential than the

use of the Radial artery. Going forward, the cephalic vein will be our preferred choice for EC-IC transplanted conduit bypass.

inhibitor, salubrinal (SAL), was administered (1 mg/kg i.p.) to investigate its effects on neuronal injury and impulsive-like behavior associated with bTBI. SAL reduced CHOP protein expression, and diminished Caspase-3 cleavage, suggesting apoptosis attenuation. Interestingly, SAL also ameliorated impulsive-like behavior indicative of head trauma. These results suggest SAL plays a role in apoptosis regulation and the pathology of chronic disease. These observations provide evidence that bTBI involves ER stress and that the unfolded protein response (UPR) is a promising molecular target for the attenuation of neuronal injury.

A modified Bi-Coranal cranial flap (U-Shape) for the insertion of deep brain stimulation electrodes. Is it really helpful?

Acar, Feridun, MD.Pamukkale University, Denizli, Turkey

Background: Hardware-related infection after deep brain stimulation (DBS) as well as skin erosion are the most serious complications and may need additional interventions. The use of traditional c-shape bilateral incision showed not to be helpful.

Objectives: To present our new modified bi-frontal incision for the insertion of the electrodes and the implication of new incision in infections and erosion of skin.

Methods: In our department 170 patients underwent DBS for the treatment of a variety of movement disorder disorders between 2008 and April 2015. These operations were performed by only one experienced in field neurosurgeon. Since March 2014 we follow the new incision in 38 patients. An approximately 20cm C-shape skin incision was designed as a modified bifrontal skin flap. With this modified skin incision the supratroclear, supraorbital, superficial temporalis, and posterior auricular artery branches are avoided and they are not damaged

Results: The overall infection rate was 5.2% (2 in 38 patients). It is smaller than the previous infection rate, which was 8.32%. However, with the new incision we found no erosion at the scalp because of the electrodes and the electrode stabilizer. The healing of wound though was superior to the previous old bilateral c-shape incision.

Conclusions: Although our team tried to change the incision for better results in infection rate and erosion of the skin, still the percentage of the infections stayed slightly high but still lower than the previous incision. It is probably then not only to the style of the incision but

is multifactorial. On the other hand the healing of the wound and the avoidance of skin erosion was superior. Demonstrating that is normal because we do avoid the pressure on the skin and also we keep intact all the feeding arteries of the scalp.

Impact of multimodality monitoring using direct electrical stimulation (DES) and corticospinal tract (CST) shift in iMRI

Prabhu, Sujit, MD.MD Anderson Cancer Ctr/NeurosurgeryHouston, TX, USA

Objective: The role combining DES and CST shift in the iMRI has not been previously studied.

Methods: 53 cases underwent resection of tumors adjacent to the motor gyrus and the underlying CST in the iMRI (BranSuite-1.5 T). All patients had pre and postoperative DTI mapping including cortical and subcortical DES. There were 40 HGG (76%), 4 LGG (8%) and 9 (17%) metastases. Eighteen patients (34%) had a re-resection after the first intraoperative scan.

Results: In the immediate postoperative period 55% had a new neurological deficit. At 3 months only 6 (11%) had worsening of their neurological condition compared to their preoperative state. A GTR was achieved in a majority (77%) of patients. We divided the patient tumors into 4 groups. Group 1 (32%) include patients whose tumors were 0-5 mm from the CST based on preoperative scans, group 2 (28%) 6-10 mm, group 3 (13%) 11-15 mm and group 4 (26%) 16-20 mm respectively. At 1 and 3 months patients in group 4 had fewer neurological deficits compared to the other groups (P=0.001 and P=0.007 respectively). There was however no difference in the EOR between the groups (P=0.61). Among the patients who had a re-resection (n=18) the mean EOR increased from 84% to 95% (P=0.002). A regression equation showed the probe to CST (mm) =1.10+0.83 of the Prass probe current (mA), indicating a very close relationship between these two parameters. In patients who had a re-resection we looked specifically at the shift in CST and how this impacted extent of resection and neurological outcome. In 7 cases the CST was shifted towards the cavity, in 8 cases away from the cavity, in 3 no shift was noted. The shift recorded was 4.4±3.2 mm for the group. In seven of the 18 cases where the CST shift was towards the cavity no worsening deficits were seen and no new deficits were

process. Much like the American Civil War, there were racial overtones concerning the Manchu people, an ethnic minority of the Manchuria region, and the Hong majority. Aptly, when Ulysses Grant visited Chinese General Zeng Guofan, Guofan said, “The two of us have suppressed the largest rebellion ever recorded in history.” A timeline and the controversies with surgical vignettes of this era will be presented.

Surgical Treatment of Tumors of the Fourth Ventricle: a Single-Institution Series

McCutcheon, Ian, MD. The University of Texas M. D. Anderson Cancer CenterHouston, TX, USA

Background:Surgical series of fourth ventricular tumors typically focus on one pathology, or on pediatric populations. We investigated surgical outcome after fourth ventricular tumor resection in a diverse patient population, the largest cohort of such tumors described to date.

Methods:We retrospectively reviewed (1993-2009) patients (n=55) undergoing surgery for tumors of the fourth ventricle. Data included patient demographics, pathological and radiographic tumor characteristics, and surgical factors (approach, surgical adjuncts, extent of resection). Complications were recorded after surgery and at 30 and 90 days to determine patient recovery. All factors were analyzed to determine those most associated with post-operative neurological complications.

Results: There were no post-operative deaths. Complete resection was achieved in 75% of patients, but 45% experienced at least one major neurological complication; 31% had minor complications only. New or worsening gait/focal motor disturbance (56%), speech/swallow deficits (38%), and cranial neuropathy (31%) were the most common new deficits after surgery. Of these, cranial nerve deficits were least likely to resolve at 30 or 90 days. In multivariate analysis patients undergoing a transvermian approach had more post-operative cranial nerve deficits, gait disturbance, and speech/swallow deficits, than those treated with a telovelar approach. Surgical adjuncts (imaging, neurophysiological monitoring) did not significantly affect neurological outcome. 22% of patients required shunting after resection. Patients who required intra-operative ventriculostomy, those undergoing a transvermian approach, and patients <18 years old were more likely to require shunting. 20% of patients suffered at least one medical complication after resection: most were respiratory in nature.

Conclusions:Complications after fourth ventricular tumor surgery are not rare. Neurological complications occurred in a majority of patients. Post-operative cranial nerve deficits were the least likely to resolve at 30- and 90-day follow-up. Of the variables analyzed, surgical approach

Primary dural closure for retrosigmoid approaches: Is it possible in all cases?

Michael, Madison, MD. Semmes-MurphyUniversity of Tennessee, Memphis, TN, USA

Background: Postoperative cerebrospinal fluid leaks continue to represent one of the potential complications of a retrosigmoid approach. The authors describe a simple technique, which allows for primary closure of the dura following retrosigmoid approaches. The incidence of cerebrospinal fluid leaks using this method is reported.

Methods: A retrospective chart review was conducted on all cases (n=83) of retrosigmoid craniotomies performed by the senior surgeon from February 2009 to February 2015. The dura was opened along the posterior aspect of the venous sinuses, and stay sutures were placed on the anterior side to enhance exposure. The posterior fossa dura maintained its’ position on the moist surface of the cerebellum, and a wet cottonoid was placed on the top of the dura. Upon closure, the dura was re-approximated primarily using interrupted sutures. Any visualized mastoid air cells were sealed with bone paste. A dry piece of Gelfoam was placed within the epidural space, and contoured titanium mesh was used to reconstitute the bony defect. No fat, lumbar drain, or head dressing was used. The incidence of postoperative cerebrospinal fluid leak and pseudomeningoceles was investigated.

Results: There were no patients that developed postoperative cerebrospinal fluid leaks or pseudomeningoceles.

Conclusions: Primary dural closure is possible in retrosigmoid approaches. Careful attention to the handling of the dura is necessary to achieve this. This obviates the need for autologous fat or postoperative lumbar drain.

observed in the 2 patients in whom no CST was noted.

Conclusions: In tumors operated in the iMRI adjacent to the CST, multimodality monitoring using DES and CST shift enhances EOR while preserving neurological function.

The Penicillin Era for Ischemic StrokeKhalessi, Alexander, MDUCSD Medical Ctr.San Diego, CA, USA

Among the 750,000 strokes annually in the United States, large vessel occlusion (LVO) produces profound disability, mortality, and direct economic costs. Research and therapeutic efforts in stroke involve both neuroprotective and revascularization strategies.

Beginning with the Merci device, endovascular therapy offered the promise of interrupting the pathogenesis of LVO and preventing irreversible damage to the brain. Despite technical advancements and improved systems of care, endovascular therapy was long frustrated by an absence of established clinical benefit in randomized trials. Lessons from these initial negative clinical trials and their bearing on current clinical practice will be discussed.In the past eight months, multiple randomized trials have now established the clinical benefit of mechanical thrombectomy for large vessel occlusion. The following presentation will provide a review of the MR CLEAN, ESCAPE, EXTEND IA, and SWIFT PRIME trials. Inclusion criteria and clinical results will be emphasized.

These trials prompted an Endovascular Therapy update to the American Heart Association and American Stroke Association (AHA/ASA) Guidelines on the Early Treatment of Acute Ischemic Stroke. Guidelines regarding clinical and imaging criteria for patient selection, system targets for time points in acute patient presentation, and clinical scenarios needing further research will be reviewed.Finally, with renewed emphasis on pre-procedural arterial imaging to confirm LVO and the increased use of stent retriever technology, implications for systems of care and research on the biology of these thrombectomy procedures will be introduced.

had the most significant impact on neurological morbidity; the telovelar approach carried the lowest morbidity.

GnRH Signalling: New Insights into the Pathogenesis of High Grade Gliomas

Ihsan Solaroglu, MD,1, 2

1Koç University, School of Medicine, Department of Neurosurgery, Istanbul, Turkey2Loma Linda University, Department of Basic Sciences, Loma Linda, CA, US

Glioblastoma multiforme (GBM) is the most common and lethal malignant primary brain tumor. Despite

decades of research efforts, the mean survival of GBM patients has not notably improved. A better understanding of the biology of this tumor is an urgent task in order to develop new treatment strategies. Gonadotropin hormone-releasing hormone (GnRH), a hypothalamic hormone, regulates gonadotropin secretion through the activation of its specific receptors. Receptors for GnRH have also been reported to be present on a variety of human tumors including breast, prostate, ovarian, endometrial cancers and GBM. Recent studies showed that activation of these receptors by means of GnRH agonists is linked to a strong antitumor (antiproliferative, antimetastatic, antiangiogenic) activity. In the present study, we investigated the role of Leuprorelin, a GnRH agonist, in GBM survival and migration.

GBM and ovary tissue samples were obtained from patients of American Hospital (Istanbul, Turkey). GBM cell lines were purchased from American Tissue Type Culture Collection (Virginia, USA). Immunofluorescence staining (IF) and immunohistochemistry (IHC) were used to show expression of GnRH-R in GBM tissue and cell lines. RNA was extracted by Qiagen RNAeasy Mini Kit and RNA concentration was measured using Nanodrop. Cell viability was determined via Cell Titer-Glo® (CTG) Luminescent Cell Viability Assay (Promega, USA).

IF, IHC and qRT-PCR showed the GnRH-R expression in GBM cell lines and human GBM tissue. Treatment of GBM cells with Leuprorelin inhibited the proliferation of GBM cells in vitro. The present results suggest that GnRH analogs may be a promising drug in the treatment of GBM patients. approaches. Careful attention to the handling of the dura is necessary to achieve this. This obviates the need for autologous fat or postoperative lumbar drain.

Hyperosmolar intraventricular drug delivery in the management of metastatic breast cancer:An animal model:

Satish, KrishnamurthyState University of New YorkSyracuse, NY, USA

Introduction:Brain metastases from breast cancer occur in 30,000 cancer patients each year in the US2. The prognosis is poor, with 80% mortality within one year of diagnosis. Chemotherapy has rarely been used due to the significant obstacle posed by the blood brain-barrier for delivery of drugs to the brain.We have shown that hyperosmolar dextrans injected

A model for neurosurgical coverage in a resource-limited setting: Developing neurosurgical capacity at l’Hopital Universitaire de Mirebalais (Mirebalais, Haiti)

Boulis, Nick, MD.Emory University, Atlanta, GA, USAIntroduction/Background: Haiti is among the poorest and most pathologically burdened countries in the Western Hemisphere. We estimate that Haiti has 2-4 practicing neurosurgeons for ~10 million individuals. Following years of discussion with nonprofit Partners In Health, we completed a fact finding mission at Hopital Universitaire de Mirebalais (HUM) in June 2014, identifying this as a suitable location to trial a collaborative model of neurosurgical capacity development.

Methods: A pilot trip was completed in February 2015 (Feb 2-26). This trip was designed to assess the feasibility of a resident rotation-based model of neurosurgical coverage at HUM. Week one emphasized pre-operative assessment. Week two focused on completing indicated operations in the presence of a US attending. Week three focused on post-operative care. A longitudinal emphasis was placed on inpatient/outpatient consultations as well as didactic instruction for HUM

Age and lesion-induced increases of GDNF transgene expression in brain following intracerebral injections of DNA nanoparticles

Tibbs, Phillip, MD.University of Kentucky, Lexington, KY, USA

In previous studies that used compacted DNA nanoparticles (DNP) to transfect cells in the brain, we observed higher transgene expression in the denervated striatum when compared to transgene expression in the intact striatum. We also observed that long-term transgene expression occurred in astrocytes as well as neurons. Based on these findings, we hypothesized that the higher transgene expression observed in the denervated striatum may be a function of increased gliosis. Several aging studies have also reported an increase of gliosis as a function of normal aging. In

into the ventricular CSF are distributed widely in the brain parenchyma especially in perivascular areas. We hypothesized that hyperosmolar drug injected into the ventricular CSF would be effective in metastatic tumors given their vascularity. We used DV1, a novel synthetic inhibitor of CXCR4 which inhibits breast cancer metastasis in vitro.

Material and Methods:Two groups of athymic mice were used: 1) control group (n=17) 2) DV1 group (n=17). Breast cancer cell line used was MDA-MB231-luciferase. Tumor was implanted in three spots in the right hemisphere. Alzet pump pre-loaded with either saline or DV1 solution was implanted with the tip of catheter in the left lateral ventricle. IVIS imaging was done 9 days post implantation and pump was removed on the same day. IVIS imaging was repeated 9 days after pump removal to investigate the continued effect of DV1. T test was used for statistical comparisons between the groups.

Results:Hyperosmolar DV1 was distributed widely in the brain, including in the tumor tissue, following CSF infusion. DV1 was more densely distributed in the tumor than in the brain parenchyma without the tumor. Tumor was less dense in the DV1 experimental group compared to saline control group. Cessation of infusion of DV1 increased the tumor density compared to the saline control group. These findings suggest that infusion of DV1 inhibits tumor growth.

Conclusions:Intraventricular hyperosmolar drug delivery can be an effective strategy for metastatic breast cancer management.

this study we used DNPs that encoded for human glial cell line-derived neurotrophic factor (hGDNF) and either a non-specific human polyubiquitin C (UbC) or an astrocyte-specific human glial fibrillary acidic protein (GFAP) promoter. The DNPs were injected intracerebrally into the denervated or intact striatum of young, middle-aged or aged rats, and glial cell line-derived neurotrophic factor (GDNF) transgene expression was subsequently quantified in brain tissue samples. The results of our studies confirmed our earlier finding that transgene expression was higher in the denervated striatum when compared to intact striatum for DNPs incorporating either promoter. In addition, we observed significantly higher transgene expression in the denervated striatum of old rats when compared to young rats following injections of both types of DNPs. Stereological analysis of GFAP+ cells in the striatum confirmed an increase of GFAP+ cells in the denervated striatum when compared to the intact striatum and also an age-related increase; importantly, increases in GFAP+ cells closely matched the increases in GDNF transgene levels. Thus neurodegeneration and aging may lay a foundation that is actually beneficial for this particular type of gene therapy while other gene therapy techniques that target neurons are actually targeting cells that are decreasing as the disease progresses.

Middle fossa encephalocele (MFE) with tegmen tympani defect (TTD)

Erkmen, Kadir, MD.Temple University, Philadelphia, PA, USA

Introduction:Middle fossa encephalocele (MFE) with tegmen tympani defect (TTD) often requires middle fossa craniotomy for repair. Moderate temporal lobe retraction may be required to visualize the skull base defect. We describe an endoscopic approach to the middle fossa skull base for repair of this lesion.

Methods:Endoscopic MFE/TTD repair was performed in 6 patients. All patients presented with CSF otorrhea and were diagnosed with MFE/TD on MRI and CT imaging. There were variable degrees of pre-operative hearing loss. The endoscope was used for visualization during skull base exploration and tegmen typani repair through an expanded burr hole exposure along the floor of the middle fossa. Zero, thirty, and seventy-degree endoscopes were used for visualization. Defects were repaired using a bony buttress along the floor, and a small vascularized temporalis muscle flap rotated under the temporal lobe through the exposure.

Virtual reality and Advanced Augmented Reality 3-D Imaging is a valuable adjunct for preparation, planning and navigation for neurosurgical procedures.

Selman, Warren, MD.Justin Singer MDDepartment of Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, USA

Neurosurgical practice is a highly imaging dependent specialty with significant reliance on 2-dimensional (2-D), multi-planar imaging review platforms and 2-D computer assisted navigation systems, which are now ubiquitous in modern neurosurgical practice. Computer processing and advances in imaging have provided the ability to produce high quality 3-dimensional (3-D) image reconstructions, augmented reality and virtual reality environments. Many areas of medicine including cardiology, cardiothoracic surgery, vascular surgery and radiology have embraced these imaging advances and to a great extent volume rendered 3-D images created via multi-detector CT-angiography have transformed medical diagnosis and procedural planning1. Despite sufficient advances in radiology to produce 3-D vascular images, neurosurgical practice, however, has been

surgical staff (e.g. patient assessment, operative techniques, bedside procedure completion).

Results: Sixty patients received neurosurgical evaluation (23 cranial, 35 spinal, 2 other). 44% of spinal pathology and 39% of cranial pathology was traumatic. Ten patients (2d-78yrs) received thirteen operations. These included 9 de novo spine operations and 2 wound revisions. One patient with a shunt malfunction/infection received a planned externalization and delayed re-internalization. Six patients were stabilized with spinal instrumentation. Post-operative follow-up (t=3-3.5mo) has shown stable to improved neurologic function in 10/11 patients with no evidence of hardware complication. One patient (age 78) died in the peri-operative period related to pre-existing multisystem trauma.

Conclusions: This data supports a need for ongoing neurosurgical support and training, the presence of an infrastructure for provision of operative and peri-operative care, and a robust system for longitudinal follow-up. This experience demonstrated the feasibility of providing neurosurgical coverage at HUM and may serve as a template for an international elective rotation-based model of coverage and neurosurgical capacity building.

Results:The endoscopic technique was successful in repairing the tegmen tympani defect in all 6 patients. Incision size and craniotomy size were significantly smaller than the standard middle fossa craniotomy approach. Significantly less temporal lobe retraction was required to perform the repair. All 6 patients had adequate repair of the MFE/TTD. Direct suturing of the dural defect was not possible due to the small working angle, however rotation of a vascularized temporalis muscle flap was possible through the keyhole craniotomy. There were no patients with recurrent CSF leak or hearing loss after repair in the series.

Conclusion:This endoscopic technique is safe and effective for MFE/TTD repair without compromise of repair integrity. The repair can be performed with a targeted keyhole craniotomy, minimizing incision size, muscle dissection, and bone work. Increased viewing angles on the endoscope resulted in reduced amount of temporal lobe retraction, while allowing close examination of the bony TTD, visual inspection of the inner ear, and identification of the dural defect. While direct repair of the dura is difficult with the small working angle, the use of vascularized temporalis muscle rotational flap provides a robust repair.

Strategic Management Simulations as a tool to assess surgical resident competency

Satish, Usha, MD.State University of New YorkSyracuse, NY, USA

Assessment of resident competency is a primary requisite to ensure physicians are trained to function optimally in real life with all its challenges. In surgical disciplines, structured tests (for example American Board of Surgery In-Training Examination) as well as ongoing evaluation by the faculty are used for evaluating resident competency. Although structured tests evaluate the content knowledge, faculty ratings obtained over several years of familiarity with the resident are a better measure of how residents actually perform. We present the use of Strategic Management Simulations (SMS) to assess cognitive competence in surgical residents.

SMS technology is an evaluation methodology that has high levels of reliability and validity and is an established predictor of real world functioning along several integral competencies required for physician competence. The real world atmosphere of the task and setting, involving multiple potentially interactive components of task demands as well as multiple and interactive options to engage in various aspects of behavior allows for a more realistic (ecologically relevant) assessment of competency. Measurement via SMS provides both numeric and graphic information on competence across a range of responses to task demands.

somewhat slower at incorporating these advances to enhance current practice 2, 3. A US Army Medical Research, Telemedicine and Advanced Technology Research Center (TATRC) study compared surgeons’ performance when they utilized virtual reality simulation for their training versus standard training.4 This study demonstrated that the “virtual reality” training group made six times fewer intraoperative errors than the standard training group. Other studies have documented the benefits of augmented reality in decreasing the likelihood of error and facilitating both recall and attention.5, 6 In light of the reliance of neurosurgical practice on advanced imaging, we believe that similar benefits would accrue to neurosurgical procedures, with the incorporation of patient specific, interactive, 3-D imaging reconstructions for virtual reality into the workflow for case preparation. Surgical Theater LLC, has developed the FDA 510K certified Surgical Navigation Advance Platform (SNAP) which utilizes CT and MRI data to create interactive, patient-specific, 3-D images. These interactive images can be used for case preparation, and in conjunction with conventional navigation platforms, provide real-time augmented reality, 3-D navigation during procedures. At our institution, case preparation and navigation with the SNAP has been incorporated into our workflow for complex cranial procedures. Prior to the surgery we review and interact with the 3-D image reconstructions. With the Oculus Rift (Menlo Park, CA) interface, we can virtually explore and interact with the patient’s anatomy and pathology prior to performing a procedure. Once in the operating room, we then use navigation for the procedure with the same 3-D images used for case preparation. We believe that virtual reality and augmented reality case preparation and navigation platforms will prove to be a valuable part of the neurosurgical armamentarium.

References: 1. Rubin GD, Leipsic J, Joseph Schoepf U, Fleischmann D, Napel S. CT angiography after 20 years: a transformation in cardiovascular disease characterization continues to advance. Radiology. 2014 Jun;271(3):633-52

2. Vieco PT, Shuman WP, Alsofrom GF, Gross CE. Detection of circle of Willis aneurysms in patients with acute subarachnoid hemorrhage: a comparison of CT angiography and digital subtraction angiography. AJR Am J Roentgenol 1995; 165(2):425–430.

3. Rubin GD, Shiau MC, Leung AN, Kee ST, Logan LJ, Sofilos MC. Aorta and iliac arteries: single versus multiple detector-row helical CT angiography. Radiology 2000; 215(3):670–676.

4. Gallagher A. Importance of validation in simulation. Presentation. Telemedicine and Advanced Technology Research Center (TATRC), US Army Medical Research and Material Command, July 30 2004.

5. Macchiarella ND, Liu D, Gangadharan SN, Vincenzi DA, Majoros AE. Augmented Reality as a Training Medium for Aviation/Aerospace Application. Thousand Oaks, CA: SAGE Publications; 2005:2174-2178.

6. Neumann U, Majoros A. Cognitive, performance, and systems issues for augmented reality applications in manufacturing and maintenance. Proc. IEEE Virtual Reality Annual International Symp. (VRAIS 98). Los Alamitos, CA: IEEE. CS Press, 1998:4-11

Effect of resident handoffs on length of hospital and ICU stay in a neurosurgical population: a cohort study

Markert, James, MD.Elizabeth N. Kuhn, M.D.1, Matthew C. Davis, M.D.1, Bonita S. Agee, Ph.D., M.P.H.1, Robert A. Oster, Ph.D.2, and James M. Markert, M.D., M.P.H.1

university of Alabama, Birmingham, AL, USA

Background: Handoffs and services changes are potentially modifiable sources of medical error and delays in transition of care. In this cohort study, we assess the relationship between resident service handoffs and length of stay for neurosurgical patients.

Methods: All patients admitted to the University of Alabama at Birmingham neurosurgical service from July 1, 2012 through July 1, 2014 were retrospectively identified. A service handoff was defined as any point when a resident handed off coverage of a service for longer than a weekend. A conditional probability distribution was constructed to adjust length of stay for the increasing probability of a random handoff. Student’s t-test and analysis of covariance (ANCOVA) were used to assess relationships between resident service handoffs and length of hospital stay, adjusted for potential confounders.

Things that don’t belong near the carotid

Amar, Arun, MD.Alex Khalessi, MDUniversity of Southern California, LA, CA, USA

Objective: Blunt and penetrating injuries to the carotid artery may result from intentionally inflicted wounds or from iatrogenic mishaps during surgery. Endovascular approaches are being increasingly applied in their treatment. A series of cases is presented in order to elucidate the management principles of carotid artery injury in the neck and skull base.

Methods: elected cases of violent attacks and surgical complications resulting in dissection, pseudoaneurysm, and other types of carotid artery damage are reviewed. The pathogenesis, clinical presentation, and endovascular repair are discussed.

Results: Goals of treatment include prevention of bleeding and thromboembolic sequelae. Endovascular options include deliberate parent vessel sacrifice, stent-assisted coil embolization, placement of covered stent graft, and others. Selection among these options depends on the presence or absence of active bleeding, collateral flow to the brain, anatomic characteristics of the lesion, and other patient-specific factors.

Conclusions: Suspected or confirmed breaches to the integrity of the carotid artery require vigilant clinical and radiographic surveillance. Endovascular strategies permit customized repair, tailored to patient-specific variables.

Results: 3038 patients were included in the statistical analyses. Adjusted length of stay (5.32 vs 3.53 adjusted days) and ICU stay (4.38 vs 2.96 adjusted days) were both longer for patients who experienced a service handoff, with no difference in mortality. In the ANCOVA model, resident service handoff remained predictive of both length of stay (p<0.001) and length of ICU stay (p<0.001).

Conclusions: Occurrence of a resident service handoff is an independent predictor of length of hospital and ICU stay in neurosurgical patients. This finding is novel in the neurosurgical literature. Future research might identify mechanisms for improving continuity of care and mitigating the effect of resident handoffs on patient outcomes.

Assessed performance attributes on several validated performance indicators include “simpler” measures of competency (activity and timeliness of response), intermediate categories (information orientation, information utilization and emergency management) to complex measures (initiative, breadth of approach, planning and strategy). Surgical residents from different institutions across the US have participated. The task requirements enable the assessment of decision making under both crisis and non-crisis situations along several parameters of thinking.

Standard testing of cognitive parameters are usually performed individually and the interaction of various parameters are extrapolated to real life subsequently. SMS simultaneously evaluates multiple cognitive parameters simultaneously in a “real life” like situation.

The SMS technique provides an accurate measure of real world performance and provides objective validation of faculty ratings. Details of technology, output graphs and results will be presented.

BYLAWSOF

THE SOCIETY OF UNIVERSITY NEUROSURGEONS, INC

ARTICLE 1

NAME AND OBJECT

Section 1. This organization shall be known as “The Society of University Neurosurgeons, Incorporated.”

Section 2.

The objectives of this Society shall be: to promote scientific and social discourse among its members, to encourage inves-tigative work in the neurological sciences, to improve teaching methods and techniques in neurological surgery, and to inspire its members to acquire humanistic ideals and to achieve clinical excellence in the practice of medicine.”

To:

“Vision:

To enhance academic neurosurgeons throughout the world and improve the state of clinical and laboratory neuroscience globally

Mission Statements:

a) To improve the exchange of new ideas and scientific disclosures

b) To enhance comprehension of global activities, university settings, and specific regional challenges in the aca-demic sector

To mentor and direct emerging academic neurosurgeons during the midcareer period

Section 3. No part of the income or property of this Society shall inure to the

benefit of any individual.

ARTICLE II

MEMBERSHIP QUALIFICATIONS

Section 1. The membership of the Society shall be divided into five classifications.

(a) Active

(b) Senior

(d) Honorary

(e) Inactive

A member shall be elected as provided in Article V- CANDIDATES FOR

MEMBERSHIP

Section 2. Classification of Membership

(a) ACTIVE. Active members shall be neurological surgeons who have been certified by the American Board of Neurological Surgery, Inc., or are certificants of The Royal College of Physicians and Surgeons (Neurosurgery) of Canada and who are engaged in the practice of Neurological Surgery.

(b) SENIOR. An Active member may, upon request to and approval of the Executive Council, transfer to Senior membership upon attaining the age of sixty (60) years or upon retirement from practice of neurological surgery. Senior members may not vote or hold office but may serve on Committees; and are not required to pay dues or regularly attend annual meetings.

(d) HONORARY. Honorary members shall be chosen as recognized leaders in the field of neurological sciences. They shall not exceed five in number. They shall not be required to pay dues or attend annual meetings. They shall not vote or hold office but may serve on committees.

(e) INACTIVE. Inactive members shall be former Active members who by virtue of illness or other reasons can no longer maintain Active membership and are not eligible for any other classification of membership. An Active member may, upon request to and approval of the Executive Council, transfer to Inactive status. An Inactive member may be restored to Active status by request to and approval of the Executive Council. Inactive members shall not vote, hold office or serve on Committees. They shall not be required to pay dues or attend annual meetings.

Section 3. Qualifications for Membership.

The Membership Committee shall be cognizant of the objectives of the Society and shall

recommend for membership individuals who are affiliated with a medical school or outstanding clinic. If an Active member ceases to comply with the membership requirements as provided in Section 2(a), he/she must resign from the Society or be transferred to a different membership classification. Individual exception to this rule requires recommendation by the Executive Council and approval by majority vote of the Active membership.

Section 4. Limitation of Membership:

The number of Active members in the Society may be limited upon recommendation of The Executive Council and approval by a majority vote of the Active membership. Honorary members shall not exceed five in number at any time.

ARTICLE III

OFFICERS

Section 1. The officers of the Society shall be President, President Elect, Vice-President, and

Secretary/Treasurer. The Executive Council shall be composed of the officers, one Active Member-at-Large appointed by the President, and the Immediate Past-President of the Society.

Section 2. The Nominating Committee shall present a slate of proposed officers to be elected for the succeeding year at each annual meeting. Active members present at the meeting may

make additional nominations. Election of officers shall be by ballot; the member receiving the largest number of votes cast for that office shall be elected. Officers so elected shall take office at the close of that annual meeting.

Section 3. Vacancy of an office shall be filled by an appointee of the Executive Council.

Section 4. The President shall serve for a term of one (1) year. He/She shall preside at all meetings and decide all questions of order,appoint committees and cast the deciding vote in ties.

Section 5. The President Elect shall be elected at each annual meeting. He/She shall become

President of the Society at the close of the subsequent annual meeting.

Section 6. The Vice-President shall assist the President. He/She shall preside at functions and

meetings in the absence of the President.

Section 7. The Secretary/Treasurer shall serve for a term of three (3) years. The Executive Council shall determine at which year the election for Secretary/Treasurer will be held. He/She shall keep records of attendance and minutes of each meeting, read all correspondence to the Society, handle all notices and correspondence of the Society. He/She shall account for the finances of the Society, collect dues and notify members of delinquent standing. He/She shall receive all applications for membership or guest attendance and forward this information to the Membership Committee at least one month prior to the annual meeting.

Section 8: The Executive Council shall be the governing body of the Society and have charge of activities of the Society not otherwise provided in these Bylaws. The Executive Council shall work in close coordination with the Membership Committee concerning the proposal of candidates for membership in the Society.

Section 9: The Historian of the Society shall maintain and update the Society of University yearbooks, which should document the scientific and social programs of the yearly meeting.

ARTICLE IV

MEETINGS

Section 1. The Society shall meet annually in the Spring or Early Summer at a site determined by the Future Sites Committee

Section 2. The annual meeting shall be a three day scientific program preceded or followed by a weekend as determined by the Program Committee. The scientific presentations shall be

balanced between clinical and investigative topics. Section 3. The Chairman of the Program Committee shall serve as Host for the annual meeting, assisted by his/her Committee and will be responsible for arrangements of both social and scientific activities during the meeting.

Section 4. Robert’s Rules of Order (Revised) shall govern the conduct of the business meetings of the Society and the duties of its officers. The order of business shall consist of a roll call, reading of minutes, reading of correspondences, old business, new business, election of new members, reports of committees, the Secretary/Treasurer’s report, election of officers, appointment of committees, and adjournment.

Section 5. Members of any class shall be assessed a pro rata share of the expenses of the annual meetings which they attend.

ARTICLE V

CANDIDATES FOR MEMBERSHIP

Section 1. Candidates for membership shall have the qualifications as provided in Articles 1,2, & 3.

Section 2. No candidate shall be elected to Active membership who has not attended at least one annual meeting as a guest.

Section 3. Each candidate shall be nominated in writing to the Secretary/Treasurer at least two (2) months prior to the next annual meeting. The nomination shall include the candidate’s curriculum vitae and a statement of his/her present academic and professional status. The

completed proposal for membership shall be forwarded to the Membership Committee

for consideration. The Membership Committee shall present to the Executive Council their recommendations for new members. On approval of the Executive Council, candidates shall be proposed to the Active Membership for written secret ballot at the annual meeting of the Society. Election of a member requires affirmative vote of three fourths (3/4) of the Active members present and voting at the annual meeting.

Section 4. The Membership Committee shall present no more than five (5) candidates for active

membership each year with no requirement of a minimal number to be presented.

Section 5. The Secretary/Treasurer shall notify each candidate elected to membership not earlier than two (2) weeks following the date of his/her election and collect a membership initiation and certificate fee, the amount to be determined each year by the Executive Council.

Section 6. A candidate who has failed to be elected may be reconsidered at subsequent annual

meeting upon written request of three (3) Active members to the Executive Council.

ARTICLE VI

DUES

Section 1. All Active members of the Society shall be assessed annual dues, the amount to be

determined each year by the Executive Council.

Section 2. Dues are payable in advance for the succeeding year at the time of or immediately

following the annual meeting, at the discretion of the Secretary/Treasurer.

ARTICLE VII

STATUS OF MEMBERS

Section 1. All members shall be in good standing when abiding by the Bylaws of the Society.

Section 2. An Active member shall be suspended when dues or assessments have not been paid for the previous two (2) years. If he/she fails to attend two (2) consecutive annual meetings

and does not present an excuse acceptable to the Executive Council, a warning letter will be sent. If an active member fails to attend three consecutive meetings, then his/her membership will be terminated.

Section 3. A member may be suspended or dropped from any class of membership in the Society by an affirmative vote of three-fourths (3/4) of the Active membership.

ARTICLE VIII

COMMITTEES

Section 1. The Society may have standing and ad hoc committees as determined by the President and the Executive Council. There shall be at least four standing committees:

Membership Committee. Nominating Committee, Future Sites Committee and Program

Committee.

Section 2. The Membership Committee shall be composed of three (3) members, one to be elected at large each year to serve a term of three (3) years. The senior member of the

Committee shall serve as Chairman. This Committee shall review nominations for new

members and present the applications of the most worthy and desirable candidates to the

Executive Council. The names of the candidates approved by the Executive Council shall be submitted to a vote by the Active membership at the next annual meeting of the Society.

Section 3. The Executive Council shall serve as the Nominating Committee, with the Immediate

Past-President of the Society as Chairman.

Section 4. The President taking office at the close of the annual meeting shall appoint the Program Committee each year. The Chairman of the Committee shall be the Host for the next

annual meeting. The Program Committee may invite guests to complement the scientific

program of the meeting

Section 5. The Future Sites Committee shall be composed of three (3) members, one to be elected at large each year to serve a term of three (3) years. The senior member of the Committee shall serve as Chairman. This Committee shall recommend the site of future meetings, at least three years in advance.

Section 6. The Bylaws Committee shall make recommendations to the Executive Committee by proposing amendments to the bylaws, rules, and regulations. The Bylaws Committee will be composed of three (3) to six (6) members, each serving a term of up to three (3) years. Recommendations so approved will then be voted upon by the Membership via email ballot or at the Annual Meeting.

Section 7. The Senior Advisory Committee shall make recommendations to the Executive Committee for maintaining the Vision and Mission of the Organization. Senior Advisory Committee members will be able to attend Executive Committee meetings. This Committee will be composed of three (3) to six (6) members, each serving a term of up to three (3) years

ARTICLE IX

GUESTS

Section 1. The Society shall encourage the presence of guests at its annual meeting.

Section 2. Certain invited guests of the Society shall not pay a registration fee or be charged for a share of the group expenses of the meeting. Such guests shall include individuals approved by the Executive Council.

Section 3. “Individual guests to the annual meeting may be invited by members. The member shall notify the Secretary/

Treasurer of the name and address of his/her proposed guest, and the

Secretary/Treasurer shall officially invite the guest to the meeting.

ARTICLE X

AMENDMENTS

Section 1. Amendments to these Bylaws may be made by a proposal in writing from a member of the Executive Council at any time. The amendment shall be voted on at the subsequent

annual meeting. The Secretary/Treasurer shall notify all Active members in writing of the proposed amendment prior to the annual meeting, and such amendment shall require for adoption an affirmative vote of three fourths (3/4) of the Active members present and voting.

Section 2. Amendments to the Bylaws and voting procedures may also be conducted by email. The Secretary will notify members by email of the need to vote on an Amendment to the Bylaws, permitting 14 days for voting. Such proposed amendments shall require for adoption an affirmative vote of three quarters (3/4) of the Active Members responding. Amendments to the Bylaws and voting procedures may also be conducted by email. The Secretary will notify members by email of the need to vote on an Amendment to the Bylaws, permitting 14 days for voting. Such proposed amendments shall require for adoption an affirmative vote of three quarters (3/4) of the Active Members responding

RULES AND REGULATIONS

Of

THE SOCIETY OF UNIVERSITY NEUROSURGEONS, INC.

SUBJECT 1

MEMBERSHIP

Section 1. Candidate Profile

(a) Candidates should be less than 48 years of age

(b) Candidates should be committed to an academic career

(c) Candidates should have sufficient publications that the quality of their academic activity can be evaluated

(d) Candidates should have attended a SUN meeting, presented a paper before the Society, and expressed an interest in the Society.

(e) Candidates should have potential for hosting a future SUN meeting.

Section 2. Membership Process

(a) Candidates must have attended at least one SUN meeting and presented at least one paper to the Society before being recommended for membership

(b) No voting for membership will occur at the meeting where the candidate is a guest and presents a paper to the Society

(c) The membership process would be initiated by obtaining the membership application form from the Secretary of the Society

(d) Upon completion the form would be returned to the Secretary who, following documentation of its completeness, would forward it to the Chair of the

Membership Committee

(e) The candidate is proposed for membership to the Membership Committee and a recommendation is made to the Executive Committee based on the candidate’s profile

(f) At the next regular meeting, the candidate is brought forward for membership during the first business session

(g) If elected by the membership, the candidate will be invited to membership and upon joining the Society, is then eligible to attend the next regular meeting

S h a n g h a i

C h i n a

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