Table of Contents
Program-At-A-Glance …………………………………………………………………..Page 2
Social Events Calendar………………………………………………………………….Page 3
Full Program…………………………………………………………………………….…..Page 4
Special Speakers and Invited Guests………………………………………….….Page 9
CME Information……………………………………………………………………….….Page 12
Abstracts……………………………………………………………………………………...Page 14
2019 Save the Date……………………………………………………………………….Page 45
Membership Directory………………………………………………………………….Page 46
ASPN Officers and Committees……………………………………………………..Page 70
ASPN Past Meetings………………………………………………………………………Page 72
ASPN Past Presidents…………………………………………………………………….Page 73
ASPN Past Lecturers………………………………………………………………………Page 74
ASPN History and Purpose…………………………………………………………….Page 75
ASPN Founding Members………………………………………………………………Page 76
ASPN Deceased Members……………………………………………………………..Page 77
ASPN Constitution and Bylaws………………………………………………………Page 78
Program At-A-Glance
Sunday, January 28, 2018
5:00 – 7:00 pm Welcome Reception East Beach
Monday, January 29, 2018 Grand Ballroom Patio
Grand Ballroom
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests Grand Ballroom
8:00 am – 8:10 am Welcome Remarks Grand Ballroom Patio
Grand Ballroom
8:10 am – 9:10 am General Session I: The History and Future of ASPN Grand Ballroom
9:10 am – 9:30 am Refreshment Break Grand Ballroom Patio
Grand Ballroom
9:30 am – 10:00 am General Session II: Abstracts
Grand Ballroom Patio
10:30 am – 12:00 pm General Session III: Overlapping Surgeries Grand Ballroom
Grand Ballroom
12:00 pm – 12:15 pm Refreshment Break
Grand Ballroom Patio
12:15 pm – 12:30 pm Update ABNS/ABPNS Grand Ballroom
Tuesday, January 30, 2018 Grand Ballroom Patio
Grand Ballroom
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests Hotel Lobby
8:00 am – 8:20 am General Session IV: Abstracts Grand Ballroom Patio
Grand Ballroom Patio
8:20 am – 9:30 am General Session V: Hoffman Lecturer
Grand Ballroom
9:30 am – 10:00 am Refreshment Break Grand Ballroom
Grand Ballroom Patio
10:00 am – 11:00 am General Session VI: ASPN Advocacy
Duval Street
11:00 am – 11:15 am Refreshment Break
Grand Ballroom Patio
11:15 am – 12:00 pm Presidential Address Grand Ballroom
Grand Ballroom
1:00 pm – 1:15 pm Fishing Tournament Shuttle Departures
Grand Ballroom Patio
2:00 pm – 6:00 pm Fishing Tournament Grand Ballroom
Flagler Beach
Wednesday, January 31, 2018
Grand Ballroom Patio
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests Grand Ballroom
Grand Ballroom
7:15 am – 8:00 am Fellowship Director’s Meeting
Grand Ballroom Patio
8:00 am – 8:30 am General Session VII: Abstracts Grand Ballroom
8:30 am – 12:15 pm General Session VII: Neuro-Oncology Updates/The Next Epoch
10:00 am - 10:15 am Refreshment Break
8:00 pm KW Poker Pub Crawl
Thursday, February 1, 2018
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests
8:00 am – 8:30 am General Session IX: Abstracts
8:30 am – 12:00 pm General Session X: Pediatric and Spine Trauma
9:30 am – 10:00 am Refreshment Break
11:15 am – 12:20 pm General Session XI: Concussion
6:30 pm – 9:30 pm ASPN Dinner
Friday, February 2, 2018
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests
8:00 am – 8:30 am General Session XII: Abstracts
8:30 am – 10:30 am General Session XIII: Pediatric Neurosurgery Trials
9:30 am – 9:45 am Refreshment Break
10:30 am – 10:40 am Closing Comments
Social Program East Beach
Sunday, January 28, 2018 Grand Ballroom Patio
5:00 pm – 7:00 pm Welcome Reception
Grand Ballroom Patio
Monday, January 29, 2018 Hotel Lobby
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests
Grand Ballroom Patio
Tuesday, January 30, 2018 Big Pine
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests
1:00 pm – 1:15 pm Fishing Tournament Shuttle Departures Duval Street
2:00 pm – 6:00 pm Fishing Tournament
Grand Ballroom Patio
Wednesday, January 31, 2018 Flagler Beach
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests Grand Ballroom Patio
9:30 am – 11:30 am ASPN Book Club with Hemingway Guest Speaker
8:00 pm KW Poker Pub Crawl
Thursday, February 1, 2018
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests
6:30 pm – 9:30 pm ASPN Dinner featuring The Caribbean Chillers
Friday, February 2, 2018
7:15 am – 9:15 am Breakfast for Physicians and Registered Guests
Final Program
Sunday, January 28th
5:00 pm -7:00 pm Welcome Reception East Beach
Monday, January 29th
7:15 am – 9:15 am Breakfast for Registered Physicians and Registered Guests Grand Ballroom Patio
8:00 am – 8:10 am Welcoming Remarks and Introduction ASPN 2018
Rich Ellenbogen, M.D.; Sam Browd, M.D.
General Session I: The History and Future of ASPN Grand Ballroom
History of ASPN: Mike Scott, M.D.
8:10 am – 9:10 am Future of ASPN: Rich Ellenbogen, M.D.
9:10 am – 9:30 am Beverage Break Grand Ballroom Patio
General Session II: Abstracts Grand Ballroom
Abstract #1: Toba Niazi, M.D.
9:30 am – 9:35 am Abstract #2: Jeffrey Raskin, M.D.
9:35 am – 9:40 am Abstract #3: Shaun Rodgers, M.D.
9:40 am – 9:45 am Abstract #4: Christina Notarianni, M.D.
9:45 am – 9:50 am Abstract #5: Jonathan Pindrik, M.D.
9:50 am – 9:55 am Abstract #6: Alexandra Beier, DO
9:55 am – 10:00 am Abstract #7: Renee Reynolds, M.D.
10:00 am – 10:05 am
10:05 am – 10:30 am Beverage Break Grand Ballroom Patio
General Session III: Overlapping Surgeries Grand Ballroom
Overlapping Surgeries: Rich Ellenbogen, M.D.
10:30 am – 11:30 am ASPN Position Statement: Rick Boop, M.D.
11:30 am -12:00 pm Update ABNS/ABPNS: Rich Ellenbogen, M.D.; Rick Boop, M.D. & John Ragheb, M.D.
Tuesday, January 30th, 2018
7:15 am – 9:15 am Breakfast for Registered Physicians and Registered Guests Grand Ballroom Patio
General Session IV: Abstracts Grand Ballroom
Abstract #8: Jennifer Strahle, M.D.
8:00 am – 8:05 am Abstract #9: Rabia Qaiser, M.D.
8:05 am – 8:10 am Abstract #10: Mike DeCuypere, M.D.
8:10 am – 8:15 am Abstract #11: Christian Kaufman, M.D.
8:15 am – 8:20 am Abstract #12: Scellig Stone, M.D.
8:20 am – 8:25 am Abstract #13: Neena Maripudi, M.D.
8:25 am – 8:30 am
8:35 am – 8:40 am General Session V: Hoffman Lecturer, ASPN Advocacy and Presidential Address Grand Ballroom
8:40 am – 9:40 am Introduction of Hoffman Lecturer: Rich Ellenbogen, M.D.
Harold and JoAnn Hoffman Lectureship: General Peter Chiarelli, US Army (Retired)
9:40 am – 10:00 am Beverage Break Grand Ballroom Patio
10:00 am – 11:00 am ASPN Advocacy
Moderator: Jonathan Martin, M.D. & Katie Orrico, J.D.
Firearm Injury Prevention: Jonathan Martin, M.D.
Sports Health & Safety: Alex Powers, M.D.
International Medicine: Sandi Lam, M.D.
US Trauma Systems: Susan Durham, M.D.
Transitional Care: Brendan Roque, M.D.
11:00 am – 11:15 am Beverage Break Grand Ballroom Patio
11:15 am – 11:25 am Presidential Roast: Gerry Grant, M.D. & Al Cohen, M.D.
11:25 am – 12:15 pm Presidential Address: Richard Ellenbogen, M.D.
1:00 pm Shuttles depart for Fishing Tournament Hotel Lobby
Wednesday, January 31st, 2018
7:15 am – 8:00 am Fellowship Director’s Meeting Grand Ballroom Patio
7:15 am – 9:15 am Breakfast for Registered Physicians and Registered Guests Grand Ballroom Patio
8:00 am – 8:05 am General Session VI: Abstracts Grand Ballroom
8:05 am – 8:10 am Abstract #14: Jeffrey Leonard, M.D.
8:10 am – 8:15 am Abstract #15: Amanda Saratsis, M.D. Grand Ballroom
8;15 am – 8:20 am Abstract #16: Eric Thompson, M.D. Grand Ballroom Patio
8:20 am – 8:25 am Abstract #17: John Myseros, M.D.
8:25 am – 8:30 am Abstract #18: Ian Heger, M.D. Grand Ballroom Patio
8:30 am – 8:35 am Abstract #19: Jean-Pierre Farmer, M.D.
Abstract #20: Amy Lee, M.D.
8:35 am – 9:35am General Session VII: Neurooncology Update:
9:35 am – 10:00 am Examples of Evolving Care and The Next Epoch
Neurooncology Update: Examples of Evolving Care
Moderator: Rick Boop, M.D.
Ian Pollack, M.D.; Jeffery Wisoff, M.D.
Beverage Break
10:00 am – 11:00 am The Next Epoch: The Horizon
Moderator: Gerry Grant, M.D.
Vaccine Therapy: Corey Raffel, M.D.
Convection Enhanced Delivery: Mark Souweidance, M.D.
MRgFUS: Jim Rutka, M.D.
11:00 am – 11:15 am Beverage Break
11:15 am – 12:00 pm Oncology Technology Update: Moderator: Herb Fuchs, M.D.
Genetic Modeling: David Daniels, M.D.
Molecular Biology: Sam Cheshier, M.D.
Advance Imaging: Mark Krieger, M.D.
8:00 pm Key West Poker Pub Crawl with Dr. John Ragheb
Thursday, February 1st, 2018
7:15 am – 9:15 am Breakfast for Registered Physicians and Registered Guests Grand Ballroom Patio
Grand Ballroom Patio
8:00 am – 9:00 am The State of Sports Concussion: Legitimate Concern vs. Paranoia?
Kevin Guskiewicz, Ph.D. Grand Ballroom
Grand Ballroom
9:00 am – 9:15 am Beverage Break Grand Ballroom Patio
9:15 am – 10:00 am General Session VIII: Spine Trauma Flagler Beach
Spine Trauma: Doug Brockmeyer, M.D.; Richard Anderson, M.D.
10:00 am – 10:05 am General Session IX: Abstracts
10:05 am – 10:10 am Abstract #21: Nathan Renalli, M.D.
10:10 am – 10:15 am Abstract #22: Scott Wait, M.D.
10:15 am – 10:20 am Abstract #23: Stephanie Greene, M.D>
Abstract #24: Tong Yang, M.D.
10:20 am – 10:45 am Beverage Break
10:45 am – 11:45 am General Session X: Pediatric Trauma & Injury Prevention
Pediatric Trauma Update: Moderator: David Adelson, M.D.
Guidelines: Gerry Grant, M.D.
Monitoring: David Adelson, M.D.
Surgical Management: Nate Selden, M.D.
11:45 am – 12:05 pm Injury Prevention Advocacy: Mark Proctor, M.D.
6:30 pm – 9:30 pm ASPN Dinner
Friday, February 2nd, 2018
7:15 am – 9:15 am Breakfast for Registered Physicians and Registered Guests Grand Ballroom Patio
Grand Ballroom
8:00 am – 8:05 am General Session XI: Abstracts Grand Ballroom
8:05 am – 8:10 am Abstract #25: Marcus Bookland, M.D.
8:10 am – 8:15 am Abstract #26: Ian Mutchnick, M.D. Grand Ballroom Patio
8:15 am – 8:20 am Abstract #27: Libby Kosnik Infinger, M.D.
8:20 am – 8:25 am Abstract #28: William Loudon, M.D.
Abstract #29: Erin Kienha, M.D.
8:25 am - 9:30 am General Session XII: Pediatric Neurosurgery Trials
Open Clinca: Report on Pediatric Neurosurgery Trials
Moderator: Ab Kuklarni, M.D.
HCRN: John Kestle, M.D.
Park Reeves: Dave Limbrick, M.D.
Guidelines: Kathy Mazzola, M.D.
ETV/CPC: Ab Kulkarni, M.D.
Myelo Closure: Jay Wellons, M.D.
Myelo Delivery: Stephanie Greene, M.D.
9:30 am – 9:45 am Beverage Break
9:45 am – 10:30 am Panel: Large Trials in Pediatric Neurosurgery
10:30 am – 10:40 am Closing Comments: Rich Ellenbogen, M.D.
10:40 am Adjourn
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
The 2018 Harold and JoAnn Hoffman Lecturer:
General Peter Chiarelli, United States Army (Ret.)
General Peter Chiarelli, USA (Ret.) was appointed the Chief
Executive Officer of ONE MIND in 2012. He is a retired General with
almost 40 years of experience.
As the 32nd Vice Chief of Staff in the Army, Chiarelli was
responsible for the day-to-day operations of the Army and its
1.1 million active and reserve soldiers. This included the
oversight of many of the Army’s R&D programs, and the
implementation of recommendations related to its
behavioral health programs, specifically its Health
Promotion, Risk Reduction and Suicide Prevention Program.
As commander of the Multi-National Corps-Iraq, Chiarelli
coordinated the actions of all four military services and was
responsible for the day-to-day combat operations of more than 147,000 U.S. and Coalition troops.
He was also the Senior Military Assistant to the Secretary of Defense Robert Gates from March 2007
to August 2008. Chiarelli pioneered efforts to restore government, economic stability and essential
services during two tours in Iraq; exercised command and control of combat operations; and
trained, prepared and mobilized reserve forces for critical response operations. He retired from the
Army in 2012.
In 2013, Chiarelli received the Patriot Award, the Congressional Medal of Honor Society’s highest
honor for his dedication and ongoing efforts to help soldiers, civilians and families suffering from
the invisible wounds of war.
As the CEO of ONE MIND, Chiarelli continues his advocacy to benefit all affected by brain disease and
injury through eliminating the stigma and fostering fundamental changes that will radically accelerate
the development and implementation of improved diagnostics, treatments, and cures. ONE MIND is
an independent, 501(c)(3) non-profit organization that believes in Open Science Principles and
creates global public-private partnerships between health care providers, researchers, academics
and the health care industry, while supporting groundbreaking new research.
Chiarelli holds a Bachelor of Science in Political Science from Seattle University, a Master of Public
Administration from the Daniel J. Evans School of Public Affairs at the University of Washington, and
a Master of Arts in National Security and Strategy from Salve Regina University. He is also a
graduate of the College of Naval Command and Staff, and the National War College.
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
INVITED ATTENDING GUESTS
Beier, DO Alexandra Kosnik Infinger, MD, MPH Libby
UF Health Medical University of South Carolina
836 Prudential Drive Suite 1205 96 Jonathan Lucas St
Jacksonville, FL 32207 CSB 301, MSC 606
Ph: 904-633-0992 Charleston, SC 29425
Email: [email protected] Ph: 843-798-4858
Email: [email protected]
Bookland, MD Markus
Connecticut Children's Medical Center Lee, MD Amy
282 Washington St. Seattle Childrens
Hartford, CT 06106 4800 Sand Point Way NE OA.9.220
Ph: 860-545-8373 Seattle, WA 98105
Email: [email protected] Ph: 206-987-4240
Email: [email protected]
Daniels, MD, PhD David
Mayo Clinic Loudon, MD, PhD William
200 First Street SW Children's Hospital of Orange Coutny
Rochester, MN 55905 4020 Calle Marlena
Ph: 507-284-2376 San Clemente, CA 92672
Email: [email protected] Ph: 714-509-7020
Email: [email protected]
DeCuypere, MD, PhD Michael
University of Tennessee Department of Marupudi, MD, MS Neena
Neurosurgery Children's Hospital of Michigan, Wayne State
6325 Humphreys Blvd School of Medicine
Memphis, TN 38103 11810 Hunters Park Court
Ph: 9015227700 Livonia, MI 48150
Email: [email protected] Ph: 3138334490
Email: [email protected]
Kaufman, MD Christian
Children's Mercy Kansas City Mutchnick, MD MS Ian
2401 Gillham Rd Norton Heathcare / Norton Children's Hospital
Kansas City, MO 64108 1246 Everett Ave
Ph: 816-302-3581 Louisville, KY 40204
Email: [email protected] Ph: 5023225714
Email: [email protected]
Kiehna, MD Erin
Novant Health - Hemby Children’s Hospital Niazi, MD Toba
1440 Harding Place Nicklaus Children's Hospital
Apt 627 3100 SW 62nd Ave, 3109
Charlotte, NC 28204 Miami, FL 33155
Ph: 3232290439 Ph: 305-662-8386
Email: [email protected] Email: [email protected]
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
INVITED ATTENDING GUESTS
Notarianni, MD Christina Rodgers, MD Shaun
LA State University Health Sciences Center Cohen Children's Medical Center of New York
1501 Kings Hwy. 410 Lakeville road, suite 204
Shreveport, LA 71103 New Hyde Park, NY 11042
Ph: 318-675-6404 Ph: 5163543401
Email: [email protected] Email: [email protected]
Pindrik, MD Jonathan Saratsis, MD Amanda
Nationwide Childrens Hospital Ann & Robert H. Lurie Children’s Hospital of
250 Brodbelt Lane, Suite 403 Chicago
Columbus, OH 43215 225 East Chicago Avenue
Ph: 614-722-4679 Box 28
[email protected] Chicago, IL 60611
Ph: 3122274220
Powers, MD Alex Email: [email protected]
Wake Forest Baptist Health
Medical Center Blvd Stone, MD, PhD Scellig
Winston-Salem, NC 27157-1029 Boston Children's Hospital
Ph: 336-716-6053 300 Longwood Ave
Email: [email protected] Hunnewell 2
Boston, MA 02115
Qaiser, MD Rabia Ph: 617-355-1485
West Virginia University Email: [email protected]
1 Medical Center Drive, PO Box 9183
Morgantown, WV 26506 Strahle, MD Jennifer
Ph: 304-293-5041 Washington University School of Medicine
Email: [email protected] 1 Children's Place
Suite 4s20
Raskin, MD Jeffrey St. Louis, MO 63110
Riley Children's Hospital/Goodman Campbell Ph: 314-454-4630
Brain and Spine Email: [email protected]
705 Riley Hospital Drive #1134
Indianapolis, IN 46202 Thompson, MD Eric
Ph: 317.396.1401 Duke University
Email: [email protected] DUMC
Box 3272
Reynolds, MD Renee Durham, NC 27710
University at Buffalo Neurosurgery Ph: 919-684-5013
1001 Main Street Email: [email protected]
Buffalo, NY 14203
Ph: 716-218-1040 Yang, MD, PhD Tong
Email: [email protected] Sanford Brain and Spine Center
700 1st Ave. S
Fargo, ND 58103
Ph: 701-234-4255
Email: [email protected]
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
CME CREDITS
In order to receive your CME credits, please complete the evaluation and attendance verification form
via this link https://www.surveymonkey.com/r/2018ASPNEVAL. Your certificate will be emailed to
you approximately 4 weeks after the course.
DESIGNATION STATEMENT
The AANS designates this live activity for a maximum of 15.75 AMA PRA Category 1 Credits™. Physicians
should claim only the credit commensurate with the extent of their participation in the activity.
LEARNING OBJECTIVES
Upon completion of this program participants should be able to:
1. Discuss the path to expertise of pediatric neurosurgery with focus on head trauma, neuro-oncology,
and advocacy.
2. Recognize the latest treatment strategies, protocols and technology for how to best
manage difficult cases in pediatric neurosurgery.
3. Indicate various levels of leadership from practice development to faculty growth,
support and advancement.
METHOD OF INSTRUCTION
This will be a live presentation, with interactive discussion, case studies, lectures, panel discussions, and
abstract presentations.
WHO ATTENDS
This annual meeting is open to ASPN members and guest physician of members. Please note that
members may recommend guest physicians to attend the meeting, but the final selection of all guest
physicians is decided by the ASPN Executive Committee.
PLANNERS
The following person planned or contributed to the planning of this CME activity:
Samuel Browd, M.D., ASPN Scientific Program Chair
Richard Ellenbogen, M.D., ASPN President
Christy Gill, ASPN Meeting Planner
The ASPN Annual Meeting is jointly provided by the AANS.
JOINT PROVIDERSHIP ACCREDITATION STATEMENT
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 American Society of Pediatric Neurosurgeons. The AANS is accredited
by the ACCME to provide continuing medical education for physicians.
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
JOINT PROVIDERSHIP DISCLAIMER
The material presented at the 41st Annual Meeting of the American Society of Pediatric Neurosurgeons
(ASPN) has been made available by the ASPN 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 ASPN and jointly provided
by the AANS, or its Committees, Commissions, or Affiliates.
Neither the AANS nor the ASPN 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 38th
Annual Meeting of the American Society of Pediatric Neurosurgeons. 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.
DISCLOSURES
The AANS and ASPN control the content and production of this CME activity and attempt to ensure the
presentation of balanced, objective information. In accordance with the Standards for Commercial
Support established by the Accreditation Council 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 significant others of those mentioned must
disclose any relationship they or their co-authors have with commercial interests which may be related
to their content. The ACCME defines "relevant financial relationships" as financial relationships in any
amount occurring within the past 12 months that create a conflict of interest.
FACULTY DISCLOSURES Disclosure Type of Relationship
Faculty Name
Sam Browd Aqueduct Critical Care, Inc. Industry/Grant Support
Navisonics, Inc. Vicis, Inc. eLoupes, Stock or Shareholder
Inc. Therma Neurosciences, Inc. Other Financial Support
Aqueduct Critical Care, Inc.
Navisonics, Inc. Vicis, Inc. eLoupes,
Inc.
ABNS
Richard Ellenbogen NIH/NCI Paul Allen Foundation University Grants/Research
Support
VICIS AQUEDUCT Honorarium
ABNS
Other Financial Support
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
Gerald Grant Child Health Research Institute University Grants/Research
(Stanford) Support
Johnson & Johnson (Global Health) Industry Grant Support
Integra Life Sciences Employee
David Limbrick PCORI, NIH Industry Grant Support
Medtronic, Inc. Stock or Shareholder
Mark Souweidane Thank University Grants/Research
Aesculap Support/ Industry Grant
Support
Consultant Fee and Honorarium
Scott Wait Codman/Integra Consultant Fee
Speakers, their paper presenters/authors, and staff (and the significant others of those mentioned)
who have reported they do not have any relationships with commercial companies:
Richard Anderson Erin Kiehna Rabia Qaiser
Alexandra Beier Mark Krieger Corey Raffel
Marcus Bookland Abhaya Kulkarni
Frederick Boop Sandi Lam John Ragheb
Rocque Brandon Amy Lee Nathan Ranalli
Doug Brockmeyer Jeffrey Leonard Jeffrey Raskin
Samuel Cheshier William Loudon Renee Reynolds
Peter Chiarelli Jonathan Martin
David Daniels Neena Marupudi Brandon Rocque
Michael DeCuypere Catherine Mazzola Shaun Rodgers
Susan Durham Karin Muraszko James Rutka
Ian Mutchnick Amanda Saratsis
Jean-Pierre Farmer John Myseros
Herbert Fuchs Toba Niazi R Michael Scott
Stephanie Greene Christina Notarianni Nathan Selden
Kevin Guskiewicz Katie Orrico Scellig Stone
Jonathan Pindrik Jennifer Strahle
Ian Heger Ian Pollack Eric Thompson
Alex Powers John Wellons
Libby Infinger Mark Proctor Jeffrey Wisoff
Christian Kaufman Tong Yang
John Kestle
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
Introducing standard work tools for dynamic stereoelectroencephalography electrodes: naming
convention and perioperative planning
Jeffrey S. Raskin MS MD,1,2 Kathryn Wagner MD,1 Dylan Adams BS,1 JoWinsyl Montojo RN, 1 Howard L.
Weiner MD, 1 Sandi Lam MD MBA, 1 Daniel J. Curry MD1
1Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor
College of Medicine, Houston, Texas, USA
2Section of Pediatric Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine
Department of Neurosurgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
Introduction: Stereoelectroencephalography (sEEG) has evolved since the original grid-based depth
electrodes (DE) by Talairach and Bancaud. Although subdural grids (SDGs) became more commonly used
in the United States, recent advances in imaging and technology have made sEEG a safe and effective
minimally invasive surgical option for a wide spectrum of diagnoses, including localization related
epilepsy. Despite publications highlighting techniques and indications, standard work for Phase 1
targeted DE has not been defined. In this manuscript, we propose the term dynamic sEEG, and define
some standard work tools to promote uniformity in the field. A short efficiency study is also presented.
Methods: An interdisciplinary approach between operating room personnel and neurosurgeons from
July to August 2016 resulted in the production of standard work for sEEG. Iterative procedural
refinement resulted in the production of a 34-page illustrated manual, a naming convention for DE
trajectories, a reusable portable perioperative planning board for clear documentation, and a planning
form to capture Phase 1 data used for trajectories. A retrospective review of sEEG cases between March
2015-June 2016 and July 2016-April 2017 were compared for efficiency in DE placement.
Results: The process for dynamic sEEG at Texas Children’s Hospital was formally reviewed including
anesthesia, positioning, nursing guidelines, surgical steps and post-operative care for the workflow using
cranial fixation and ROSATM-guided placement. There was 40% improvement in time per electrode from
44.7+/- 9.0 mins to 26.9+/- 6.5 mins (p=0.0007) following the development and use of the manual, the
naming convention, and the reusable portable perioperative planning and documentation board.
Conclusions: We propose the term dynamic sEEG for DE trajectories placed according to Phase 1 data.
This workflow can be optimized by using standard work tools presented above. The naming convention
encodes critical data and allows portability among providers. Use of a planning form optimizes research,
and global adoption will facilitate multicenter studies correlating Phase 1 modality and seizure onset
zone identification.
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
Outcomes Following Endoscopic Endonasal Resection of Sellar and Suprasellar Lesions in Pediatric
Patients
Shaun Rodgers Abstract ASPN 2018
Shaun D. Rodgers, MD; Christoforos Koumas, BS; Anya Laibangyang, BS; Shanna L. Baron, FPN; Todd
Schaeffer, MD; Mark Shikowtiz, MD; Mark A. Mittler, MD; Steven J. Schneider, MD
Objective: The endoscopic endonasal approach (EEA) is emerging as a credible surgical alternative for
resection of sellar and suprasellar lesions such as pituitary adenomas, craniopharyngiomas, and Rathke
cleft cysts. However, the application of this surgical approach to pediatric patients poses several unique
challenges that have not yet been well evaluated. The authors evaluated the safety, efficacy, and
outcomes associated with the use of the endoscopic endonasal approach for treatment of these
pathologic entities in pediatrics patients. Additionally, we examined our use of the endonasal flap in our
EEA cases.
Materials-Methods: We performed a retrospective review of 30 pediatric patients who underwent EEA
and recorded surgical endocrine and ophthalmological outcomes, as well as complications. We
reviewed the use of 14 endonasal flap in 13 patients.
Results: Of The 30 pediatric patients, 9 had pituitary adenomas, 12 had craniopharyngiomas, and 9 had
Rathke cleft cysts. Twenty-three (77%) patients had gross-total resection determined by 3 month
postoperative MRI and 22(73%) remain disease free to date. Eleven (37%) patients experienced
improvements in their vision and 11 (37%) experienced improvements in anterior pituitary
function. Complications included new endocrinopathy in 6 (20%) patients, new permanent diabetes
insipidus in 5 (17%) patients, headaches in 5 (20%) patients, vasospasm/stroke in 3 (10%) patients, and
CSF leak in one patient (3%) without and endonasal flap. The peri-operative mortality rate was 0% and
the mean follow up period was 37 months. Of the 14 endonasal flaps used, no CSF leaks were found.
Conclusion: This study highlights the endoscopic endonasal approach as a safe, effective, and less
morbid surgical alternative for the management of sellar and suprasellar pathologies in pediatric
populations with excellent otucomes and minimal complications. When the endonasal flap is used, the
risk of csf leak is greatly reduced.
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
Dysembryoplastic neuroepithelial tumor (DNET) of the septum pellucidum
Rimal Dossani, MD and Christina Notarianni, MD
Louisiana State University Health Sciences Center, Shreveport
Dysembryoplastic neuroepithelial tumors (DNETs) of the septum pellucidum are a rare location for
DNETs, which are most commonly located in the temporal cortex. A 5 year old boy with a history of
absence seizures, controlled with oxycarbazine, presented with 6 month history of increasing
headaches. His mother reported increasing behavorial issues at school as well, specifically, angry
outbursts and crying. On examination, he had no focal deficits. Magnetic resonance imaging (MRI)
revealed a hyperintense mass measuring 25 x 16 mm on T2-weighted imaging arising from the right
septum pellucidum. There was no enhancement with contrast. The right lateral ventricle was mildly
dilated compared to the left. The patient was placed in right lateral decubitus position and underwent
right interhemispheric craniotomy for resection of mass. Gross total resection was achieved and
pathology was consistent with DNET. Unlike temporal lobe DNETs, this tumor was FGFR-1 negative and
BRAFV600E negative. He has no evidence of tumor recurrence at 15 months postoperatively. DNETs of
the septum pellucidum are a rare location for DNETs and only a few case reports have been reported to
date. DNETs of the septum pellucidum may represent a distinct clinical entity within the larger category
of DNETs as they lack BRAFV600E mutations, which are the most common genetic alteration found in
cortical DNETs.
41st Annual Meeting
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Surgical Resource Utilization after Initial Treatment of Hydrocephalus
Principle Investigator: Jonathan Pindrik, MD on behalf of the HCRN
Contributing Authors: Kulkarni AV, Riva-Cambrin J, Kestle J for the HCRN
Introduction: This study investigates the relative burden of surgical care following ventriculo-peritoneal
(VP) shunt insertion and endoscopic third ventriculostomy (ETV) with or without choroid plexus
cauterization (ETV/CPC) as initial treatment strategies for hydrocephalus.
Methods: Prospectively collected data available through the Hydrocephalus Clinical Research Network
(HCRN) was retrospectively reviewed for pediatric patients up to age 24 months undergoing initial
definitive treatment of hydrocephalus. Post-operative courses (at 1, 3, and 5 years) were studied for the
number of hydrocephalus-related procedures and the number of hospital admission days related to
surgical revision. Study patients were organized into intention-to-treat (ITT) cohorts. A discrete variable
reflecting the presence and complexity of the shunt system (0 = none; 1 = simple; 2 = complex) present
also was recorded for all study subjects.
Results: There were 1154 subjects included (Shunt, 83.9%; ETV/CPC, 9.7%; ETV alone 6.4%) with varying
ages (< 1 month, 52.8%; 1 to < 6 months, 25.0%) and etiologies of hydrocephalus (Prematurity/Post-
Hemorrhagic, 26.3%; Myelomeningocele, 22.2%). The mean number of surgical revisions differed
significantly between ETV (ETV alone or ETV/CPC; Mean = 1.0 [SD = 1.38]) and Shunt insertion (0.7
[1.29]) during the first year after surgery (p <0.001). This difference did not persist at 3 and 5 years
between any cohorts. The mean number of hospital days due to revision surgery remained similar
between ETV (7.9 [22.45]) and Shunt insertion (8.3 [26.18]) during the first year after surgery, but
demonstrated a non-significant trend towards fewer hospital days in the ETV cohort (8.2 [24.47]) as
compared to the VP shunt cohort (11.4 [31.66]) at 5 years (p = 0.070). About 95% of all patients
undergoing VP shunt insertion maintained a simple shunt system at 5 years, regardless of their ITT
cohort.
Conclusion: Among initial treatment strategies for hydrocephalus, ETV (ETV alone or ETV/CPC) carried a
higher surgical revision rate than Shunt insertion within 1 year after surgery. Otherwise, surgical
resource utilization did not differ significantly between ETV and Shunt insertion. Initial treatment
strategy did not influence complexity of the definitive shunt system when present.
41st Annual Meeting
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Standardizing the Neurosurgical Management of IVH
Alexandra Beier DO, Adriana Pena-Ariet MD, Josef Cortez MD, Kelsey Hayward BS
Introduction: Germinal matrix intraventricular hemorrhage (IVH) plagues premature infants with a high
number of patients requiring surgical intervention for their hydrocephalus. On evaluation of previous
retrospective data at the University of Florida Jacksonville-Division of Pediatric Neurosurgery, it was
clear that there was variation in the surgical management of IVH and in order to implement change,
standardization needed to occur. Therefore a quality improvement (QI) project was initiated to
standardize the neurosurgical management of IVH.
Methods: Infants with Grade III or IV IVH with a frontal occipital horn ratio (FOR) >0.4 initiated a referral
to pediatric neurosurgery, and then based on symptomatology and FOR, a cranial reservoir was placed.
Taps ensued until criteria were no longer met or a ventriculoperitoneal shunt was placed. Data on
change in head circumference (HCF) was gathered and compared to change in FOR and related to need
for tap.
Results: In comparing 5-year retrospective data to the current QI 1 year data, just over twice the
amount of consults/year were placed by neurosurgery for IVH Grade III and IV under the QI protocol (21
versus 9), with a resultant of 11 cranial reservoirs in 1 year (compared to 7 over 5 years). The
conversion rate from reservoir to shunt was still high however there was a trend to less shunts being
placed with the QI protocol (9 out of 11 versus 6 out of 7).
On analysis of the FOR and HCF, there was no association found between change in HCF and change in
FOR. However change in HCF was a significant predictor of needing a tap (p=0.015) and change in FOR
measurement was a significant predictor of tap (p=0.001)
Conclusions: The current QI project is showing a trend towards less shunting with the current protocol.
Data collection is ongoing and continued reviews will be performed to ensure the trend continues.
Change in HCF was not predictive of change in FOR, therefore head ultrasounds are still important in
evaluating these patients.
41st Annual Meeting
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Target Journal: Journal of Neurosurgery
Differences in academic productivity based on various demographic factors in academic neurosurgery
Matthew J. McPheeters*, MD, MBA1; Hakeem J. Shakir*, MD1; Joelle N. Hartke, BS1; Syed A. Adil, BS1;
Hussain Shalwani, MD1; Elad I. Levy, MD, MBA 1 Renee M. Reynolds, MD1
1University at Buffalo, Department of Neurosurgery
*Co-first authors
Background: Academic productivity is an essential quality for academic neurosurgeons. As such, an
understanding of the association between demographics and academic activity is important.
Objective: To determine if various demographic factors (sex, country of medical graduation, Ph. D.
status, and fellowship status) are associated with differing academic productivity based on h-index.
Methods: A population of academic neurosurgeons was obtained via organization websites for the 109
ACGME accredited neurosurgery training programs. Demographic and bibliometric data were obtained
from the organization websites and Scopus database respectively. A non-parametric cross-sectional
analysis was performed using a Mann-Whitney test to determine the difference in median h-index by
sex, Ph.D. status, fellowship status, and USMG vs. IMG.
Results: 1,377 academic neurosurgeons were included in the analysis with a mean h-index of 16.12 and
a median of 14. Significant differences were found in median h-indices by sex (males greater than
females; p<0.001), Ph.D. status (Ph.D greater than no Ph.D; p<0.001), and fellowship status (no
fellowship greater than fellowship; p<0.001). There was no significant difference between USMGs and
IMGs.
Conclusion: Assessing an individual’s potential for academic productivity is important in when
evaluating applicants for both residency programs and academic appointments. This study is the first of
its kind to assess the association between various demographic factors and academic productivity in
neurosurgery; however, more research is necessary to evaluate the causative nature of these factors to
be used as metrics for evaluating an individual’s academic potential.
41st Annual Meeting
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High grade intraventricular hemorrhage and post hemorrhagic hydrocephalus results in
impaired hippocampal growth and predicts poor cognitive outcomes at 2 years of age
Jennifer Strahle, Regina Triplett, Dimitrios Alexopoulos, Tara Smyser, Kayla Hannon, Cynthia Rogers,
David Limbrick, Christopher Smyser
Introduction: The hippocampus is critical for learning and memory. We have previously demonstrated
hippocampal injury and smaller hippocampal volumes in our animal model of neonatal intraventricular
hemorrhage(IVH)-induced hydrocephalus. It is unknown how preterm brain injury affects hippocampal
growth or how alterations in hippocampal development relate to neurocognitive outcomes in childhood.
Methods: Hippocampal segmentations were performed on MRI scans from 55 full-term infants, 90 very
preterm infants (born ≤30 weeks gestation) without brain injury and 68 very preterm infants with brain
injury (Cystic periventricular leukomalacia, grade III/IV IVH, post-hemorrhagic hydrocephalus(PHH))
performed at comparable postmenstrual age. These infants then underwent standardized
neurodevelopmental testing using the Bayley Scales of Infant Development at age 2 years.
Results: Preterm infants with brain injury had smaller hippocampal volumes at term equivalent age
compared to term and very preterm infants without injury, with those with grade III/IV IVH with PHH
having the smallest hippocampi. Larger ventricle size was associated with smaller hippocampal size. In
turn, smaller hippocampal volume was related to worse motor performance at age 2 years across all
infant groups. Finally, smaller left hippocampal volumes in very preterm infants with brain injury were
correlated with impaired cognitive scores at age 2 years, a relationship specific to this group.
Conclusions: These findings demonstrate that brain injury in preterm infants may impair early
hippocampal development and lead to persistent neurodevelopmental impairments at age 2 years.
41st Annual Meeting
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Juvenile Traumatic Brain Injury Results in Cognitive Deficits Associated with impaired ER stress and
early tauopathy in a juvenile rat controlled cortical impact model
Michael Hylin MD, Brandon Lucke-Wold, Aric Logsdon, Rabia Qaiser, MD
Introduction: Neurotrauma remains one of the leading causes of death in the children, however the
juvenile brain response is not completely understood. Endoplasmic reticulum (ER) stress has been
shown to contribute to injury expansion and behavioral deficits in adult rodents and furthermore has
been seen in adult post- mortem human brains diagnosed with chronic traumatic encephalopathy.
Whether endoplasmic reticulum stress contributes to injury expansion in juveniles with traumatic brain
injury (TBI) is poorly delineated. We investigated this important topic using a juvenile rat controlled
cortical impact (CCI) model. We proposed that ER stress would be significantly increased in juvenile rats
following TBI and that this would contribute to behavioral deficits using a juvenile rat model.
Method: A juvenile rat (post-natal day 28) controlled cortical impact model was used. BiP and CHOP
were measured at 4 hours in the ipsilateral peri-contusion cortex. HIF 1 alpha was measured at 48 hrs
and tau kinase measured at 1 week and 30 days.
Results: At 4 hours following injury, BiP and CHOP (markers of ER stress) were significantly elevated in
rats exposed to TBI. We found that hypoxia inducible factor 1α was significantly upregulated at 48h
following TBI, indicating that early ER stress activation induced delayed hypoxia. The early ER stress
activation additionally contributed to the activation a known tau kinase, GSK3β, by 1 week. Tau
oligomers measured by R23 were significantly increased by 30 days following TBI. The biochemical
changes following TBI were associated with increased impulsive behavior measured with elevated plus
maze, deficits in short term memory measured with novel object recognition, and deficits in spatial
memory measured with Morris water maze in juvenile rats exposed to TBI.
Conclusion: These results show that ER stress is a significant contributor to injury in juvenile rodents,
and that pharmacologically targeting ER stress early may prevent the long-term sequela associated with
TBI in juveniles. We are also looking at microRNA biomarkers in the juvenile rat TBI model and planning
on correlating it in the pediatric population.
41st Annual Meeting
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Developing a Multidisciplinary Preclinical Model for Pediatric Brain Tumors
Michael DeCuypere, MD, PhD
Department of Neurosurgery, University of Tennessee Health Science Center
Semmes-Murphey Neurologic and Spine Institute
Le Bonheur Children’s Hospital
St Jude Children’s Research Hospital, Memphis, TN
Purpose: Most brain tumors are incurable. Curing patients will require an
understanding of how each brain tumor subtype responds to conventional treatments
and how to combine these with new therapies; but acquiring this knowledge is
extremely challenging in the clinic, especially among patients with rare tumors.
Therefore, we established a platform to conduct randomized preclinical trials,
combining conventional and novel therapies, in mice with accurate models of
supratentorial ependymoma (SEP) subtypes and choroid plexus carcinoma (CPC).
Experimental Design: Neurosurgical resection and fractionated radiotherapy, alone or in
combination, were performed in mice with SEP or CPC to assess the relative value of
these treatments. Extensive drug repurposing screens, pharmacokinetic,
pharmacodynamic and efficacy studies were then employed to triage active compounds
for preclinical trials within ‘standard-of-care’ surgery and radiation regimens.
Results: SEP subtypes and CPCs displayed distinct patterns of response to surgery
and/or radiation. Clinically relevant, three-hour infusions of gemcitabine were
associated with highly-favorable toxicity, pharmacokinetic and efficacy profiles in all
models of SEP subtypes and CPC. Combination neurosurgery, radiation and gemcitabine
regimens proved significantly more effective than surgery and radiation alone, curing
one half of all animals with aggressive forms of SEP.
Conclusions: Our preclinical approach provides a comprehensive system to determine
the therapeutic activity of conventional treatments among brain tumor subtypes. It also
identifies potential new chemotherapies and allows preclinical development of complex,
combination, conventional and novel treatment regimens. Post-radiation infusions of
gemcitabine should be tested as new treatments of SEP or CPC.
41st Annual Meeting
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Microelectrode Recording and Subsequent Laser Thermal Ablation for Kluver-Bucy Syndrome: Case
report and Elucidation of Underlying Pathophysiology
Kaufman, CB; Zinkus, T; Abdelmoity, A; LePichon JB, Sullivant, S; Amaral, D.
Divisions of Neurological Surgery, Neurology, Psychiatry and Radiology, Children’s Mercy Kansas City.
UC Davis MIND Institute.
Introduction: Kluver-Bucy syndrome is a rare and enigmatic constellation of symptoms and behaviors
that includes hyperorality, hypersexuality, loss of normal fear responses, memory dysfunction, and
visual agnosia or inability to identify familiar objects. While originally described in Rhesus monkeys, it
was subsequently identified later in humans. The fundamental substrate responsible for the syndrome
is thought to be damage to the amygdala, typically, bilaterally, as can occur in cases of herpes-simplex
encephalitis (HSE.) To date, however, the understanding of the pathophysiology of the condition and
treatment options have remained limited, largely consisting of antipsychotics and behavioral therapies.
Clinical Presentation: We present a case of an 11 year old girl who suffered HSE at age five that resulted
in significant damage to her bilateral amygdala and anterior hippocampal complexes, the left side worse
than her right. She subsequently developed many of the hallmarks of Kluver-Bucy syndrome, including
hypersexuality, short term memory dysfunction, hyperorality, obsessive fixation on certain objects,
including babies, and atypical aggression. Exhaustive medical and behavioral therapies were trialed,
with varying but insufficient success to prevent worsening behaviors. MRI tractography was performed
on her amygdala bilaterally to further elucidate the associated afferent and efferent pathways. Bilateral
stereotactic EEG electrodes were then placed in each amygdala, and several days’ recordings were
obtained. At the conclusion of the monitoring, electrical stimulation of each electrode was performed,
and the electrographic and behavioral responses were recorded. Based on the summation and
interpretation of the data, a unilateral laser thermal ablation was recommended and successfully
performed, with a resultant notable improvement in her aberrant behaviors.
Conclusion: To the best of our knowledge, this is the first case outlining MRI DTI tractography,
microelectrode recording and stimulation of the amygdala, and subsequent stereotactic laser thermal
ablation in a case of Kluver-Bucy syndrome. It is our hope that the knowledge obtained in this rare and
unusual case can be used to further understand the pathophysiology underlying Kluver-Bucy syndrome,
and also shed light on possible safe and effective surgical treatment options for patient’s suffering from
this condition.
41st Annual Meeting
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Jointly provided by AANS
A new pediatric electrophysiology laboratory: potential for simultaneous single-unit and local
field potential recording during SEEG
Scellig Stone, MD, PhD
Boston Children’s Hospital / Harvard Medical School
The recent popularization of stereoelectroencephalography (SEEG) in epileptic children
undergoing invasive seizure localization affords unprecedented access to continuous neural
recordings below the surface of the pediatric brain, typically for several days at a time. Hybrid
SEEG electrodes allow simultaneous recording of both single unit and local field potentials,
through micro- and macro-electrode contacts respectively. Using single unit acquisition
systems in parallel with clinical recording equipment, electrophysiologic data of research
interest can be collected without sacrificing patient safety or the ability to perform clinically
standard invasive seizure localization. Early limited research experience with these electrodes
has remained largely confined to adult patients, leaving the pediatric epileptic brain essentially
unexplored. This presentation will outline initial proposed research efforts, discuss the
potential future clinical utility of single unit recordings in pediatric invasive seizure localization,
and consider opportunities for collaborative research.
41st Annual Meeting
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Improved Workflow, Patient Accessibility, and Resident Education with Advanced Practice
Providers in Pediatric Neurosurgery
Neena I. Marupudi, M.D., M.S.; Heather Sutton, PA-C; Megan Sigler-Worley, CPNP; Christine Gumma,
PA-C; JoAnne Vincent, DNP, CPNP; Trisha Leonard, CPNP, Brandon Piwko, CPNP; Michelle McNaughton,
CPNP, Brenna Mell, PA-C; Tracie Van Hoeck, PA-C; Sandeep Sood, M.D., Steven Ham, D.O.
Introduction: The increasing complexity and multidisciplinary nature of pediatric neurosurgery
has resulted in the reorganization of services nationally and internationally. Many programs
have incorporated advanced practice providers (APPs), such as certified pediatric nurse
practitioners (CPNP) and physician assistants (PA), to help support pediatric neurosurgeons in
their care of patients. APPs are often responsible for day-to-day management of pediatric
neurosurgery inpatients including pre- and post-operative management of patients, participate
in multidisciplinary clinics, assist surgeons in the operating room, complete consultations,
provide patient education, and also participate in research. We investigated the evolution and
role of APPs in the pediatric neurosurgery department at the Children’s Hospital of Michigan
(CHM) in Detroit, Michigan in an effort to garner continued support for their role in the care of
pediatric neurosurgery patients.
Methods: A retrospective analysis of neurosurgical patient data from inpatient and clinic
service over the past ten years was reviewed and analyzed. Survey analysis was conducted of
neurosurgical pediatric personnel (attendings, APPs, and billing staff) to identify areas of
changes, deficiency or improvements, in clinical care. Areas of evaluation included inpatient
and clinic workflow, patient accessibility for emergent/urgent/timely evaluations and
treatment, resident educational experience, and departmental clinical and research
productivity. The increasing contribution and participation of the APPs to the pediatric
neurosurgery department was specifically studied in association to these areas of evaluation.
Results: CHM staffs nine APPs (five CPNPs and four PA-Cs) dedicated to the care of pediatric
neurosurgical patients. In addition to traditional patient care roles, the APP team staffs a daily
neurosurgery walk-in clinic. The walk-in clinic has 1,030 patient encounters annually for wound
checks and acute/subacute neurosurgical symptoms. While shunt malfunction evaluations in
the Emergency Department result in 93% of patients having head CTs and x-rays of the shunt
system, focused clinic evaluations by APPs have reduced the need for imaging to only 55% of
cases that are concerning for shunt malfunction. APPs also provide 24 hour in-house on call
coverage. While rotating residents are expected to take a modest amount of call duties for
educational experience, survey analyses suggest improvements in surgical techniques, clinical
evaluation of pediatric disorders, and continuity of care by residents due to fewer post-call
days.
Conclusion: The comprehensive role of APPs in pediatric neurosurgery at CHM has facilitated
an interdisciplinary team approach, consistent clinical presence, and drastic improvement with
patient and family satisfaction. The walk-in clinic provides cost-effective and sustainable
solution to the increasing demand for specialized pediatric neurosurgical care while reducing
the costs and inconvenience associated with ER visits. The 24-hour coverage system limits
hand-off errors and improves overall patient safety. APPs have positively contributed to the
patient centered multi-disciplinary approach in pediatric neurosurgery through consistent
communication with colleagues, patients and their families.
41st Annual Meeting
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Association of Hospital and Patient-Related Factors with Outcomes of Children with Brain Tumors
Authors: Jeffrey R. Leonard, MD, Nationwide Children’s Hospital, Division of Pediatric Neurosurgery, The
Ohio State University, Columbus Ohio, [email protected]
Annie I. Drapeau, MD, Nationwide Children’s Hospital, Division of Pediatric Neurosurgery, The Ohio State
University, Columbus Ohio, [email protected]
David Kline, PhD, Center for Biostatistics, The Ohio State University, Columbus Ohio,
[email protected]
Adrienne Boczar, MPH, Nationwide Children’s Hospital, Division of Pediatric Neurosurgery, The Ohio
State University, Columbus Ohio, [email protected]
Julie C. Leonard, MD MPH, Nationwide Children’s Hospital, Department of Emergency Medicine, The
Ohio State University, Columbus Ohio, [email protected]
Introduction: Markers of quality of care in various surgical specialties have been shown to correlate with
hospital volumes. This study investigates the effect of hospital and patient-related factors on the
outcomes of children undergoing brain tumor resection.
Methods: We examined the data within the Pediatric Health Information System (PHIS) for children ages
0-17 years undergoing brain tumor resection between 2011 and 2015. Length of hospital stay (LOS) and
routine discharge home were analyzed for associations with hospital volume (low, medium and high
categories, or continuous variables), patient factors, and other hospital-related factors. Hospital volume
analysis was adjusted for patient demographic and clinical characteristics. LOS was defined as time to
routine discharge with non-routine discharge censored at time of disposition.
Results: A mean of 2,893 children per year underwent surgery in 49 U.S. hospitals. As a binary endpoint,
the odds ratio for routine discharge was 1.50 (p=0.2417), 2.07 (p=0.0303), and 1.38 (p=0.2417) for high
vs. medium, high vs. low, and medium vs. low volume hospitals, respectively. The hazard of routine
discharge in high volume hospitals was 27% higher than medium (p=0.0010) and 28% higher than low
(p=0.0003), reflecting shorter LOS in high volume centers. An increase in average annual volume of 50
patients (continuous covariate analysis) increased the hazard of routine discharge by 13% (p=0.0002),
and increased the odds of routine discharge by 32% (p=0.0892). Shorter LOS and increased odds of
discharge home was seen for older patients (HR 1.41, p<0.0001; OR 1.98, p<0.0001), caucasian race (HR
1.10, p<0.0001; OR 1.16, p=0.0113), non-complex tumors (HR 1.19, p<0.0001; OR 1.24, p=0.0011), non-
malignant tumors (HR 1.42, p<0.0001; OR 1.90, p<0.0001), and for those that did not transfer in from
another facility (HR 1.69, p<0.0001; OR 2.17, p<0.0001).
Conclusion: Referral to higher volume children’s hospitals may improve outcomes for children with
newly diagnosed complex brain tumors. Further efforts are needed to understand and correct racial
disparities in the access to specialized care.
41st Annual Meeting
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Diffuse Intrinsic Pontine Glioma (DIPG) Sequencing Reveals Epigenetic Dysregulation of Gene
Expression and BET Inhibition as a Novel Therapeutic Strategy
Amanda Saratsis MD1,2, Andrea Piunti PhD3, Tina Huang MA2, Elizabeth Bartom PhD3, Patrick Ozark BA3,
Stacy Marshall BS3, Marc Morgan PhD3, Jin Qi MD PhD2, Rintaro Hashizume MD PhD2,3, Rishi Lulla MD
MS4,5, C. David James PhD2,3 and Ali Shilatifard PhD3
(1)Division of Pediatric Neurosurgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital
of Chicago, Chicago, IL, USA
(2)Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago,
IL, USA
(3)Department of Biochemistry and Molecular Genetics, Northwestern University Feinberg School of
Medicine, Chicago, IL, USA
(4) Department of Hematology, Oncology, Neuro-Oncology & Stem Cell Transplantation, Ann & Robert
H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
(5) Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Introduction: Diffuse intrinsic pontine glioma (DIPG) is an infiltrative neoplasm with the highest
mortality of all pediatric solid tumors. Somatic Histone H3 mutations (H3K27M) occur in 80% of DIPGs,
altering chromatin structure and function. To characterize the effects of H3K27M mutation as an
oncogenic driver, we analyzed the transcriptome and epigenome of a cohort of pediatric glioma cell
lines.
Methods: Transcriptomes (RNA-Seq) and genomic enrichment of Histone proteins and
associated transcriptional regulators (ChIP-Seq) were characterized in H3K27M DIPG (n=7), H3 wild-type
pediatric high-grade glioma (n=3), neural stem cells (n=1) and astrocyte cell lines (n=1). Reads were
trimmed (base quality score >30, Trimmomatic), aligned (UCSC hg19, Tophat), normalized and
quantified (HTSeq), or formatted as bigWig coverage plots for peak calling (SICER) and genomic
enrichment mapping (Ensembl). Differential expression and enrichment patterns were identified
(edgeR) then analyzed for biological relevance (TopGO, Ingenuity Pathways Analysis). Identified
epigenetic targets were studied in vitro and in vivo.
Results: Unsupervised clustering of transcriptomes revealed two DIPG subgroups, distinct from control
and H3 wild-type lines. Increased EZH2 signaling (p<0.05), BRD4 function (p<0.05) and pol II activity at
proximal promoter and enhancer regions (p<0.01) were identified in H3K27M lines relative to H3 wild-
type. H3K27M protein co-localized with H3K27ac, pol II, BRD2 and BRD4 at actively transcribed genes,
with PRC2 excluded from H3K27M occupied regions. Neuronal differentiation was repressed in H3K27M
lines (p<0.01), consistent with morphologic changes observed after EZH2 inhibition in vitro. BRD
inhibition suppressed tumor growth in vitro and in vivo.
Conclusion: We present the largest epigenetic analysis of rare DIPG cell lines, implicating specific
pathways that promote tumor formation in H3K27M mutants. Our results indicate that H3K27M alters
the balance between H3K27me3 and H3K27ac, creating a pro-oncogenic chromatin state that promotes
DIPG, and highlighting novel epigenetic therapeutic targets. Further study of these targets is currently
underway.
41st Annual Meeting
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Purpose: Therapeutics targeting DIPG in vitro infrequently translate to clinical efficacy. The blood-brain
barrier (BBB) and rapid drug efflux via ATP-binding cassette (ABC) transporters may explain this
phenomenon. Convection-enhanced delivery (CED) circumvents the BBB, however, the mechanisms
underlying infusate clearance are poorly understood.
Experimental Design: The multi-kinase inhibitor, dasatinib, was administered systemically (25 mg/kg IP)
or via CED continuous infusion pump (0.5µL/hr at 2µM) in transgenic murine H3.3K27M mutant DIPG.
MRI was used to evaluate the rate of CED infusate (2µM dasatinib/100µM gadoteridol, single
dose) clearance and the impact of systemic ABC transporter inhibition tariquidar (5µg/kg) plus blood
brain barrier permeability reduction dexamethasone (0.5mg/kg). Histologic analysis of tumor cell
apoptosis and proliferation was completed.
Results: Both continuous delivery CED dasatinib and intraperitoneal dasatinib improved median overall
survival (OS) compared to vehicle CED (39.5 and 40 days vs. 28.5 days, respectively, p=0.009). Animals
treated with single-administration CED dasatinib had an increased median OS compared to control
animals (39 vs. 31.5 days). Systemic pretreatment with intraperitoneal dexamethasone and tariquidar
prior to single-administration CED dasatinib further increased median survival to 49 days (p=0.0305).
MRI demonstrated delayed mean time to peak gadolinium intensity in the group pretreated with
dexamethasone and tariquidar (1517s vs. 2650s, p=0.0924). Apoptosis was also highest in the
pretreatment group (P>0.001).
Conclusions: ABC transporter inhibition and BBB permeability reduction delayed CED infusate
distribution thereby increasing infusate-tumor contact time. Accordingly, pretreating animals with
tariquidar and dexamethasone prior to CED resulted in enhanced tumor cellular apoptosis and
significantly improved survival in H3.3K27M mutant DIPG.
******************
Eric M. Thompson, MD, FAANS
Assistant Professor of Neurosurgery
Assistant Professor in Pediatrics
Duke University Medical Center
Box 3272
Durham, NC 27710
Office: 919-684-5013
Fax: 919-684-8274
41st Annual Meeting
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Benign Post-operative Gadolinium Enhancement After Resection of Large Posterior Fossa Tumors in
Children
John S. Myseros
Introduction: MR imaging after brain tumor surgery is the standard by which we evaluate extent of
resection. The surgeon’s impressions and subsequent imaging are not always concordant, particularly in
patients with enhancing tumors whose MR shows persistent post-operative gadolinium enhancement.
In children with large tumors, left with large surgical cavities, significant and unexpected postoperative
enhancement incongruous with intra-operative impressions may present a clinical conundrum requiring
further evaluation, as residual tumor, based on volume and location, may play a role in the child’s
subsequent treatment.
Methods: Two infants with large posterior fossa tumors are presented. Patient A was an 11-month
female with a large hemispheric and cerebellopontine angle tumor, presenting with ataxia. Patient B
was a 6-month male with a large midline posterior fossa tumor, presenting with progressive emesis and
decreased activity. Both patients underwent aggressive gross total surgical resection based on the
surgeon’s impression and intra-operative ultrasound.
Results: Patient A had a medulloblastoma, and patient B an ATRT. Immediate post-operative MR in both
of these infants revealed significant gadolinium enhancement on T1 imaging, despite impressions at
surgery. All subsequent imaging in Patient A, before, during, and after treatment, revealed no evidence
for this drastic gadolinium enhancement. Although Patient B showed new and progressive tumor, the
significant enhancement in other areas of the posterior fossa had also resolved 16 days after surgery.
Conclusion: Substantial and confusing gadolinium enhancement on immediate post-operative MR
imaging in infants after aggressive resection of large posterior fossa tumors should be considered
carefully and prompt interval imaging in the short-term for re-evaluation, as residual tumor may play an
important role in the child’s subsequent treatment. We will discuss the possible mechanisms for this
deceptive, troublesome, but transient and benign enhancement in these young patients.
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Phase 1 Study using the IDO-inhibitor indoximod in combination with radiation and chemotherapy for
children with progressive brain tumors (NCT02502708)
Ian M. Heger1,2, Eugene P. Kennedy4, , Nicholas N. Vahanian4, Tobey J. MacDonald5, David H. Munn1,3,
and Theodore S. Johnson1,3
1Georgia Cancer Center and Departments of 2 Neurosurgery, 3 Pediatrics, Augusta University, Augusta,
GA.
4 Newlink Genetics Corporation, Ames, IA.
5Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics,
Emory University School of Medicine, Atlanta, GA.
BACKGROUND: The indoleamine 2,3-dioxygenase (IDO) pathway is a natural immune-checkpoint
mechanism often exploited by tumors to escape anti-tumor immunity. Small-molecule IDO pathway
inhibitor drugs, such as indoximod, are in multiple trials for adults. Combining indoximod
immunotherapy with radiation and chemotherapy is a highly innovative approach for treating children
with progressive brain cancer.
DESIGN/METHODS: The goal of this first-in-children trial is to assess the feasibility, safety, and
preliminary evidence of efficacy of combining indoximod either with temozolomide, or with radiation
followed by maintenance therapy with indoximod/temozolomide, for children age 3 to 21 with
progressive malignant brain tumors. The study includes two dose-escalation cohorts using a standard
3+3 design to determine a recommended phase-2 dose (RP2D) for indoximod in combination with either
temozolomide (planned n=12) or radiation (planned n=12). Indoximod dose-levels are 80%, 100%, and
120% of the adult RP2D.
RESULTS: We present up-to-date toxicity/side-effect data and follow-up results for all patients enrolled
in dose-escalation arms. Twenty nine children have enrolled, and 16 of these have been treated with
indoximod plus radiation, including children with ependymoma (n=14), medulloblastoma and malignant
gliomas (n=9). Some children received more than one radiation plan over time. All patients were heavily
pre-treated, and many patients required target volume and dose adaptation to reduce toxicity risks.
Among patients treated to date, median total radiation dose was 30 Gy (range 14-54 Gy), median
number of radiation fraction was 20 (range 1-30), and median follow-up duration was 8 months (range
2-15 months). To date, all patients have been able to complete their planned radiation and start
maintenance therapy with indoximod/temozolomide and adverse events have been manageable.
CONCLUSIONS: The combination of indoximod and radiation/chemotherapy has been well tolerated in
this patient population with good overall quality-of-life.
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Intra – Operative MRI for Brain Tumor Surgery in Children
Authors: Jean-Pierre Farmer, MD
Jeffrey Atkinson, MD
Roy Dudley, MD, PhD
Christine Saint-Martin, MD
At the Montreal Children’s Hospital we performed 293 surgeries on 255 patients using intra-
operative MRI (IMRi) from October 2009 to June 2016. In 208 cases the IMRi was used in tumor
surgery. All patients undergoing intra-operative MRI underwent post-operative MRI with similar
sequences at 3 months to assess the accuracy of the determination of the extent of resection at
the time of imaging during surgery.
Results: Fifteen patients were excluded because of the lack of adequate follow-up availability.
Therefore 193 tumor cases were eligible for this study over a 6 year and 8 month period. Of
these cases, 96 cases were felt to represent a gross total resection as estimated by the
neuroradiologist, 64 were felt to be a subtotal resection and 33 where an upfront partial
resection or biopsy was planned were excluded from the analysis. Of the 96 cases of gross total
resection, the extent of resection was influenced by the intra-operative MRI in 14 of the 96
cases where the surgeon felt compelled to continue the resection. The rate of intra-operative
MRI salvage of the complete resection is 15%.
In the gross total resection group, at 3 months, 9 patients were found to have either residual
disease or a recurrence. These represent false-negative cases. Of the 64 subtotal resections at
surgery, 5 were found to have no evidence of recurrence at the 3 month follow-up. These
represent false-positive cases. The accuracy rate was therefore 91.25%. However, 33% of the
tumors in this series were graded as WHO grade III or IV. If we excluded WHO grade III or IV
cases where changes in the post-operative scan could be attributed to regrowth of the lesion
despite adjuvant treatment, the extent of resection accuracy becomes 94.4%.
Furthermore, our experience has led us to identify intra-operative pitfalls. Blood in the tumor
bed, enhancement of the surgical bed, venous enhancement adjacent to the surgical bed, gliosis
and susceptibility artifacts related to air or blood represent challenges of interpretation. In
addition intra-operative MRI was helpful in the early detection of intra-operative complications
such as ischemia, ongoing bleeding in the tumor bed and sinus thrombosis.
Conclusion: The extent of resection accuracy of intra-operative MRI is high. MRI is also helpful
in depicting significant intra-operative complications. Early detection of the latter can influence
favorably the immediate post-operative management of the patients.
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Phase 1 safety, pharmacokinetic and imaging study of BLZ-100 Tumor Paint in pediatric brain
tumor patients
Authors: Sarah Leary, Bonnie Cole, Sandy Poliachik, Jeff Ojemann, Dennis Miller, Julie Novak,
Stacey Hansen, Jim Olson, Amy Lee
INTRODUCTION: Maximal safe surgical resection is an essential component of pediatric brain
tumor treatment. Intraoperative fluorescence guidance may enable better tumor visualization,
leading to improved surgical outcomes. BLZ-100 is a near-infrared imaging agent consisting of a
tumor-binding peptide, chlorotoxin, and the fluorescent molecule, indocyanine green. Results
from a phase 1 dose escalation clinical study are presented below.
METHODS: A 3+3 dose-escalation design was used with five pre-specified dose levels. BLZ-100
was administered as a single IV bolus 6-31 hours prior to surgery. Subjects with confirmed or
suspected brain tumor were eligible if planned for maximal safe surgical resection. Other key
eligibility requirements included normal cardiac, renal, liver and coagulation function. Dose
limiting toxicity (DLT) was defined as any related adverse event of ≥ Grade 3 severity occurring
within 7 days of BLZ-100 administration. PK samples were obtained prior to dosing and at, 10
minutes, 30 minutes, 1 hour, and 2 hours, after administration. Tumor fluorescence was
evaluated in situ and ex vivo using a Synchronized Infrared Imaging System (SIRIS). Pathologic
specimens were evaluated using the Odyssey system.
RESULTS: 15 subjects of median age 7 years (range 7 months to 17 years) were treated at 5
dose levels (1.7, 3.5, 6.9, 13.9, and 17.3 mg/m2). Diagnoses included low-grade glioma (n=7),
ependymoma (n=4), high-grade glioma (n=2), ATRT and medulloblastoma (n=1 each). No DLT
were observed and a single instance of Grade 1 hypoalbuminemia was considered possibly
related to BLZ-100. Tumor fluorescence was observed in 13 of 15 tumors including 5 out of 7
low-grade gliomas. Fluorescence intensity increased with increasing BLZ-100 dose.
CONCLUSIONS: This is the first trial to evaluate fluorescence-guided neurosurgery in children.
BLZ-100 was safe across the dose levels studied, and fluorescence was observed in the majority
of tumors evaluated. Dose expansion at 15 mg/m2 is ongoing.
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Reverse polarization of programmable shunt valves leading to inaccurate pressure level readings: A
case series.
Nathan Renali
Objective: Adjustable shunt valves rely on an interaction between a magnetic rotor within the valve and
the magnetic programmer. First-generation devices are subject to setting changes when patients
undergo MRI. We encountered two patients during routine shunt evaluations for whom there were
discrepancies between the pressure setting readings from the indicator tools and the levels as
determined by skull x-rays. The manufacturer’s product analysis concluded the cause was reverse
polarization of the valve’s magnet. Our aim was to determine how often this occurred in our pediatric
population shunted with the same valve.
Methods: Between May and September 2016, patients with this adjustable valve that underwent MRI
scans had post-MRI valve checks with the manufacturer’s interrogation devices and with skull x-rays.
Inconsistencies between the pressure settings were recorded and were reviewed with the valve
manufacturer.
Results: 17 patients were included and one new case of reverse polarization (5.9% incidence) was
identified, in addition to the two cases discovered prior to our protocol implementation. None of the
three valves demonstrated difficulty with adjustment or interpretation of the pressure level reading.
One valve was replaced with a second-generation programmable valve at the family’s request. The
other two valves were adjusted to their appropriate settings based on radiographs.
Conclusions
An inaccurate pressure level reading secondary to programmable valve reverse polarization can lead to
undesirable over- or under-drainage of CSF. The reported occurrence rate (0.007% over a two year
period according to the device manufacturer) is underestimated due to the fact that most patients do
not undergo radiographic setting confirmation following uncomplicated interrogation with the indicator
tool; three of 19 patients with this first-generation adjustable valve evaluated in our practice were
diagnosed with reverse polarization. Solutions include obtaining skull x-rays after each MRI to rule out
reverse polarization and avoiding 3T MRI when possible.
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Outpatient ASC Endoscopic Neurosurgery
Tyler G Atkins MD, David Peters MD, Mark D Van Poppel MD, Scott D Wait, MD
Carolina Neurosurgery and Spine Associates/Carolinas Healthcare System/Levine Children's Hospital
Introduction:
The evidence that appropriately selected patients and procedures are performed safer, cheaper, and
more efficiently in ambulatory surgery centers (ASC) is mounting. Initially this occurred with spinal and
peripheral nerve interventions, however, there are intracranial procedures that are appropriate for ASC.
We demonstrate that for appropriate patients, endoscopic procedures including cyst fenestration and
third ventriculostomy make ideal intracranial procedures for an ASC and present our initial experience
with neuro-endoscopy performed at an ASC.
Methods:
We performed a retrospective chart review of all neuro-endoscopy cases from August 2014 through
September, 2017 performed at a single ASC jointly owned/managed by a large neurosurgical practice
and large healthcare system. Data obtained include patient age, surgery performed, length of stay at the
surgery center, and short term follow up of any medical complications.
Results:
Sixteen endoscopic procedures were performed during the study period at the ASC, all under general
anesthesia. Patient age range was 9 to 57 years (4 pediatric patients). Median length of stay from start
of surgery to discharge was 3.5 hours with a range of 1.5 hours to 16 hours. There were no surgical or
anesthetic complications. Outcomes were in line with patients whose procedures were done as
inpatients during the same period. No patient required admission to the hospital for complications
related to surgery within the first post operative month. Two patients presented to the emergency
department post operative day 1 with complaint of headache, but did not require admission.
Conclusion:
For appropriately selected patients and indications, neuro-endoscopic procedures are performed with
safety at an ASC and discharged rapidly. Outcomes are consistent with inpatient procedures with
reduced cost.
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It was hypothesized that wound complications could be reduced by cerebrospinal fluid
(CSF) diversion at the time of myelomeningocele (MMC) closure. A retrospective review of 88
patients with MMC is in press for Pediatric Neurosurgery. This manuscript demonstrates that a
statistically significant 0% of patients with hydrocephalus undergoing external ventricular
drainage (EVD) or shunt placement at the time of closure had wound complications, while 10%
of patients without CSF diversion had wound complications. We propose a randomized
controlled trial of EVD, subgaleal shunt, or ventriculoperitoneal shunt placement at the time of
closure in MMC patients with hydrocephalus.
Stephanie Greene, MD
Associate Professor of Neurological Surgery
University of Pittsburgh School of Medicine
Director of Vascular Neurosurgery
Director of Perinatal Neurosurgery
Children's Hospital of Pittsburgh
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Tong Yang, MD
Background: Hydrocephalus is a commonly encountered condition in neurosurgery.
Tremendous progress has been made in the understanding of the pathological development,
and clinical management of this heterogeneous and multi-factorial disease entity. However, the
underlying molecular pathways involved in the eventual manifestation of hydrocephalus are still
not well known.
Method: Cerebrospinal fluid (CSF) samples collected from pediatric patients treated for
hydrocephalus due to various conditions were used to obtain genomic DNA material.
Polymerase Chain Reaction (PCR) amplification of the gene Dlg5 (an evolutionarily conserved
gene encoding a protein involved in cell polarity) exons were performed on the genomic DNA
samples. Shotgun sequencing was used to identify mutations.
Results: CSF samples from 28 patients were used to conduct the study. A missense mutation
was identified. One patient was found to be homozygous for the mutation by using the
traditional Sanger’s sequencing method to evaluate the mutation region.
Conclusion: The pathogenesis of hydrocephalus is a multifactorial process. With the rapid
advancement in large-scale genomic sequencing techniques, it is possible to identify potential
new players at the molecular level, which might be involved in the development of
hydrocephalus.
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Developing Three-dimensional Human Brain Tumor Models for Personalized Drug Screening
Min D. Tang-Schomer1,2, Markus Bookland1, Todd Jensen2, David Kaplan3, and Christine M.
Finck1,2
1. Department of Pediatrics and Surgery, Connecticut Children’s Medical Center, Hartford, CT. 2.
University of Connecticut Health Center, Farmington, CT. 3. Department of Biomedical
Engineering, Tufts University, Medford, MA.
Introduction
Pediatric cancer remains the leading cause of non-traumatic deaths among children. In many of
the malignant brain tumors including medulloblastomas and glioblastomas, rare stem-like cells
are found to possess self-renewal and proliferative capacity not evident in the remaining cell
population1. These stem-like cells are resistant to conventional chemotherapy, and become a
source of tumor recurrence. This refractory population derives from neoplastic cells that
exhibits marked heterogeneity in proliferation and differentiation. To target the heterogeneous
drug-resistant sub-populations of tumor cells, development of a personalized brain tumor
model aimed at patient specific drug screening is timely2. Brain tumor models, to date, have
relied upon two dimensional in vitro and xenograft in vivo models that lack human tumor
microenvironment, generate inaccurate drug uptake, and altered pharmacokinetics of the
selected drug3.
The purpose of this work is to develop in vitro 3D human patient-derived brain tumor models
for personalized drug screening.
Methods
An in vitro 3D human brain tumor model is under development using a silk-based scaffold that
is seeded with cells isolated directly from a surgically resected pediatric brain tumor. This
culture system could be used as a ‘test-bed’ to screen drugs targeting individual patient.
Dissociated tumor cells were plated at 40,000 cells/per scaffold of 5 mm diameter by 2 mm
height. For comparison, cells were grown on SD plate cultures including uncoated, poly-lysine
coated, collagen coated, and Matrigel coated. Cultures were immunostained with neuronal
marker TUJ1, glial cell marker GFAP (red), and nuclei stain DAPI. Flow cytometry analysis of cells
extracted from cultures was performed for standard neural and cancer stem cell markers.
Results
3D silk-scaffold cultures of patient-derived medulloblastoma cells showed higher levels of
Nestin and CD133 expression than conventional 2D culture methods (9% vs 1%, 7% vs 2%,
respectively) and lower levels of TUJ1 expression (17% and 20%). Cell viability was comparable
in each system.
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Conclusion
These data show key differences between primary brain tumor cells in 3D versus 2D cultures.
Patient-derived brain tumor cells grow as spheroids throughout the 3D silk scaffold-based
culture system, unlike the highly differentiated cell phenotype on 2D plates. The in vivo-like
tumor growth is accompanied by higher expression of neural stem-like and self-renewal
markers, and decreased expression of neural differentiation markers in the 3D silk-based
culture systems compared to 2D cultures.
References
1. Singh SK, et al., Nature 2004;432(7015):396-401.
2. ParkA. Time 2015;185(11):42-7.
3. Hatzis C, et al, Cancer Res 2014;74(15):4016-23.
4. Tang-Schomer MD., et al., PNAS, 2014 ;111(38):13811-6.
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Ian S Mutchnick
[email protected]
I have three main research foci. First, I am interested in the difference between information
and meaning in the human context. Many of us feel we have a true look at Reality. But all
perceptual experience is mediated via a biological transduction system and transmitted to
conscious system of experience that is both poorly defined and demonstrably biased on a
neurobiological level. A better understanding of information versus meaning may have
significant implications for understanding human conflict and I am actively involved in the
mediation of the Israeli/Palestinian conflict. On a more clinical level, I am involved in developing
protocols to reduce surgical site infections through both more widespread understanding (staff
education) as well as creating processes in the OR that minimize risk while allowing for both
ergonomics and the necessities of human resource management. This is pushed along by
increasing CMS involvement in financial incentives for best practices. Finally, the human gut
represents the largest collection of neurons outside the brain. Increasingly, it is clear that
modulation of the neuroimmune apparatus may have widespread clinical benefits. We are
initiating a project to better characterize the autonomic and neuroimmune effects of vagal
nerve stimulation in a collaborate project with gastroenterology.
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“How long is too long? Determining the length of the distal catheter when implanting a
ventriculoperitoneal shunt.”
Authors: Libby Kosnik-Infinger, M.D., M.P.H., Edward J. Kosnik M.D., W. Alexander Vandergrift,
III., M.D.
Object: With modern surgical techniques and technological advancements in ventricular
peritoneal shunts (VPS)s, pediatric neurosurgeons are more successful in treating congenital
hydrocephalus therefore allowing their patients to grow into adulthood. When inserting a
ventricular peritoneal shunt in an infant, a surgeon must insert enough tubing in the abdomen
to allow the child to grow to full adult height. The aim of this study was to compute the growth
rate of the torso in a child to determine the appropriate length of distal peritoneal tubing to
include on insertion of a VPS.
Methods: An IRB approved retrospective review of X-Rays was completed of newborns,
children, and adults to measure the dimensions of the thorax and peritoneal cavity. We
calculated the average, median, and standard deviation of age, T1-T12 length, T12-Iliac length,
and total length of the torso. We then computed the growth rate of the torso per year in our
patients, and compared that to the growth rate of a standard US growth chart from the CDC.
Results: In total, 142 patients were measured. The average length of T1-T12 was 8.24 cm in a
newborn female, 8.86 cm in a newborn male, 27.34 cm in an adult female, and 29.56 cm in an
adult male. We also compared the rate of growth of children in our study to the CDC growth
charts. The torso growth rate per year was 1.55 cm/year in females, and 1.76 cm/year in
males. The growth rate on the whole body length CDC growth chart was 5.71 cm/year in
females and 6.35 cm/year in males.
Conclusions: Our measurements indicate that the torso grows at a lower rate than the whole
body length. If a clinician adds together the length of tubing needed to get from the distal end
of the valve to T1 (approximately 20cm) and the length of T1-T12 (approximately 30 cm) and
then extra length to insert into the peritoneum (30cm) then the total length of the distal
catheter can be shortened upon VPS implantation to approximately 80 cm to help avoid intra-
abdominal complications.
Key words: ventriculoperitoneal shunt, distal catheter, shunt malfunction
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William Loudon
As a brief introduction, I have been practicing pediatric neurosurgery at the Children’s Hospital
of Orange County in Orange, CHOC in Mission Viejo, and University of California at Irvine. Having
earned my PhD at M.D. Anderson, and my post-doc at Massey Cancer in Virginia, I have a strong
brain tumor research interest.
We have developed an ex-vivo tissue culture system (Organotypic Slice Culture System) to
reconstitute a patient’s own tumor (derived from their cancer-stem cells) in 300 micron thick
slices of their brain tissue. We propose that this “personilzed” OCS model may provide a valuable
universal platform to study tumor biology, screen therapeutic options, etc., customized for the
individual patient. We have followed OSC culture survival for over 6 months. Tumor cells invade
the tissue slice within 30 min of application, and subsequently develop and track through the
tissue slice. In contrast, neural stem cells invade the slice, but tend not to migrate. These NSC
exhibit development of neural processes with the brain tissue architecture. We propose to
further develop this model to achieve a high-throughput research/diagnostic tool.
Early in my clinical practice I developed a Stereotactic Radiosurgery Practice to compliment my
surgical practice. Utilization of Radiation Therapy for the treatment of pediatric patients remains
highly controversial. We are currently preparing a manuscript presenting our 12 year experience
with Gamma Knife radiosurgery. The physics employed by GK stereotactic radiosurgery offers
the potential for significantly decreasing exposure of healthy brain to ionizing radiation, and
therefore may offer significant safety benefits for pediatric patients. We have treated
approximately 200 patients who were less than 16 years of age at the time of treatment.
Approximately 170 treatments were for tumors and 30 for AVMs. Over this timeframe, we report
no complications of GK treatment, including the absence of the development of any secondary
malignancies. AVM obliteration rates are completely comparable to those reported in adult
populations. The outcomes of GK for pediatric brain tumors is also extremely favorable. Specific
applications have proven exceedingly valuable. Examples include low grade tumors not
amenable to safe surgical resection, recurrent metastatic disease in patients who have received
maximal conventional radiation and failed chemotherapy options. Over the last decade, we have
found GK treatment to be effective, extremely well tolerated and safe in the pediatric population.
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Minimally Invasive Resection of Subcortical Pediatric Brain Tumors and Vascular
Malformations using a Novel Navigable Tubular Retractor System
Authors: Ronald Young, II MD, Martina Cartwright, PhD, Erin Kiehna, MD
Introduction: Resection of subcortical and intraventricular brain tumors and vascular lesions in
children is often challenging due to the impact ofconventional retractors on immature cortex.
Modern navigable tubular retractors combined with a transsulcal approach offer a minimally
invasive alternative to traditional microscopic resection and may limit white matter injury by
dissipating the retractor force radially. We present the largest pediatric experience with tubular
retractor systems for pediatric brain tumors and vascular malformations.
Methods: A prospective secure database of BrainPath™ (NICO Inc. Indianapolis, IN) cases is
maintained by NICO, with physician consent. Patients are de-identified. The database was
queried for patients <18 years, tumor/lesion location, size, pathology, and operative details.
Results: A navigable tubular retractor system enabling a transsulcal approach was used in 36
pediatric patients for subcortical/deep seated tumors (n=21), intraventricular tumors (n=9) or
vascular lesions (n=6) with a median age = 9.6 yrs (range 23 days-17 yrs). Lesion volumes
average 12.5 cc (range 4-33 cc). Mean operative time was 3:11 and median length of stay was
48 hours. Extent of resection matched the intended resection without complication. Patients
were neurologically intact on follow up, with the exception of a preexisting visual field cut in
one.
Discussion: BrainPath is an FDA cleared device designed to access deep-seated brain tumors in
adults. Our experience with 36 pediatric patients demonstrates that safe and effective surgery
using a small craniotomy and a navigable BrainPath tubular retractor can be used in children as
young as 23 days to resect lesions located in the subcortical, deep white matter and
intraventricular regions.
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Over 30 months resource utilization for first time procedures for Chiari type 1 malformations was
analyzed. Total hospital charges were used as a proxy for inpatient resource utilization. Specific
parameters recorded were: syrinx, operative time, surgeon, length of stay, dural graft use, postoperative
location, need for intensive care intervention, and quality of decompression.
There were 63 children who underwent first time Chiari 1 decompressions. Mean hospital charge per
admission was $77,988 with a standard deviation of $25,600, and a range from $43,463.03 to
$175,563.05. Dural graft was used in 56%. Syrinx was present in 57%. Operative times averaged 128
minutes, 161 minutes with a dural graft, and 79 minutes without. Mean length of stay was 2.3 days, 3.0
days with dural graft, and 1.6 days without. No intensive care interventions were necessary. Potentially
unsatisfactory decompression as determined by follow up imaging and symptoms occurred in 12
children. In six of these 12 children a dural graft was utilized. Only two of these 12 children so far have
undergone repeat decompressions for potentially inadequate initial decompressions. One of these had a
dural graft at initial surgery.
Mean operative times (88, 94, 164, 177 minutes), use of dural graft (58, 27, 77, 63%), mean length of
stay (1.5, 2.2, 3.1, 3.0 days), and mean hospital charges ($64,249, $61,146, $94,017, $97,020) were non-
uniform amongst four surgeons. The strongest variable influencing hospital charges was operative time,
followed by length of stay. Postoperative ICU admission did increase hospital charges, but the effect
was diluted by the variables of operative time and length of stay. Of the 12 children with potentially
unsatisfactory decompressions five were operated by the surgeon that utilized dural grafts the most and
four were operated by the surgeon that utilized dural grafts the least.
Inpatient resource utilization for first time Chiari I malformation decompressions as determined by
hospital charges is mostly dependent upon operative time and length of stay. These factors are highly
correlative to each surgeon. There does not appear to be a valid reason for routine postoperative
monitoring in the ICU. While dural grafting was associated with longer operative times and hence
greater resource utilization the data does not show a difference in outcomes whether a dural graft was
utilized or not. The outcomes of no duroplasty decompressions are not uniform amongst our surgeons
indicating likely difference in techniques. In this era of “Big Data” it is important to analyze variables
that we as surgeons can influence to improve our economic efficiency of delivering care while
maintaining and improving quality of outcomes. These variables are operative time, dural grafting, ICU
utilization, and length of stay.
Paul Grabb, MD
Children’s Mercy Hospital
Kansas City, MO
4M2ndAenentiunagl
American Society of Pediatric Neurosurgeons
Save the Date
JANUARY 27–FEBRUARY 1, 2019
THE GRAND HYATT KAUA’I RESORT & SPA
KOLOA, ISLAND OF KAUAI, HI
American Society of
Pediatric Neurosurgeons
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ASPN Membership Directory Albert, MD, Gregory
Spouse: Denise
Abbott, M.D., FAANS, FAAP, Rick Arkansas Children's Hospital
Spouse: Lainy 1 Children's Way, Slot 838
Pediatric Neurosurgery Little Rock, AR 72202
Montefiore Medical Center Email: [email protected]
111 E. 210th St. Phone: 501-364-1100
Bronx, New York 10467
Email: [email protected] Albright, M.D., A. Leland
Phone: 718-920-8512 Senior Member
Spouse: Susan Ferson
Ackerman, M.D., Laurie Kijabe Hospital
Indianapolis, Indiana 46202 P.O. Box 20
Email: [email protected] Kijabe, Wisconsin 220
Phone: 317-274-8852 Email: [email protected]
Adelson, M.D., P. David Aldana, MD, Philipp
Spouse: Barbara Jean Spouse: Carmina Montesa Aldana
Barrow Neurological Institute at Phoenix Lucy Gooding Pediatric Neurosurgery Center
Children's Hospital 836 Prudential Drive
Phoenix Childrens Hospital Suite 1005
1919 East Thomas Road Jacksonville, Florida 32207
Phoenix, Arizona 85016 Email: [email protected]
Email: [email protected] Phone: 904-633-0780
Phone: 602-933-0923
Alden, MD, Tord
Ahn, M.D., Edward Spouse: Carrie Alden
The Johns Hopkins Hospital Division of Neurosurgery
Phipps 560 225 E. Chicago Ave, Box 28
600 N. Wolfe Street Chicago, IL 60611
Baltimore, MD 21287 Email: [email protected]
Email: [email protected] Phone: 312-227-4220
Ajani, M.D., Olufemi Anderson, M.D., Richard
Spouse: Nike New York, New York 10032
McMaster Children's Hospital Email: [email protected]
1200 Main St. W.
Hamilton, ON L8N 3Z5
Email: [email protected]
Phone: 905-521-2100
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Aronin, M.D., Patricia Berger, M.D., Thomas
Senior Member Senior Member
Spouse: Bill Sherrill Childrens Hospital Medical Center
1201 Havre Lafitte Dr Elland and Bethesda Avenue
Austin, Texas 78746 Cincinnati, Ohio 44229
Email: [email protected] Email: [email protected]
Phone: 512-347-9788 Phone: 513-559-4725
Avellino, MD, MBA, Anthony Bhatia, M.D., Sanjiv
Spouse: Jennifer Miami, Florida 33155
OSF Healthcare Email: [email protected]
530 NE Glen Oak Avenue
Room 3550 Blount, M.D., Jeffrey
Peoria, IL 61615 Spouse: Dana
Email: [email protected] JRL 400, Childrens Hospital of Alabama
Phone: 309-655-3821 1600 7th Avenue South
Birmingham, Alabama 35233
Bauer, MD, David Email: [email protected]
Spouse: Supreet Phone: 205-638-9653
One Medical Center Drive
Lebanon, NH 3756 Bollo, MD, Robert
Email: [email protected] Primary Children's Hospital
Phone: 603-653-9880 100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Baumgartner, M.D., James Email: [email protected]
Spouse: Linda Phone: 801-662-5340
615 E. Princeton Street, Suite 540
Orlando, Florida 32789 Boop, M.D., Frederick
Email: [email protected] Spouse: Lee Ann
Phone: 407-236-0006 Semmes-Murphey Neurologic & Spine Institute
6325 Humphreys Blvd
Bell, M.D., William Memphis, Tennessee 38120
Senior Member Email: [email protected]
Spouse: Frankie Phone: 901-259-5321
Neurosurgical Associates of the Carolinas, PA
2810 Maplewood Avenue Bowman, M.D., Robin
Winston-Salem, North Carolina 27103 Spouse: Joseph Allegretti, MD
Email: [email protected] 225 E. Chicago Ave. # 28
Phone: 336-768-1811 Chicago, Illinois 60611
Email: [email protected]
Phone: 312-227-4220
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
Boydston, M.D., Ph.D., William Burke, M.D., Michael
Spouse: Anne Boydston Spouse: Glenda
Pediatric Neurosurgery Associates, Suite 540 Neuroscience Institute at Renaissance
5455 Meridian Mark Rd. 2821 Michaelangelo Dr Ste 200
Atlanta, Georgia 30342 Edinburg, Texas 78539-1406
Email: [email protected] Email: [email protected]
Phone: 404-255-6509 Phone: 956-362-8215
Bristol, M.D., Ruth Campbell, MD, Jeffrey
Spouse: Felipe Albuquerque Spouse: Kelly Welch
Phoenix Childrens Medical Group - Division of Neurosurgery
Neurosurgery A.I. duPont Hospital for Children
1919 E Thomas Rd 1600 Rockland Road
Phoenix, AZ 85016 Wilmington, Delaware 19803
Email: [email protected] Email: [email protected]
Phone: 602-933-0482 Phone: 302-494-5307
Brockmeyer, M.D., Douglas Canady, M.D., Alexa
Pediatric Neurosurgery Senior Member
Primary Childrens Medical Center Spouse: George Davis
100 North Medical Drive Suite 2400 6064 Forest Green Road
Salt Lake City, Utah 84113-1100 Pensacola, Florida 32505
Email: [email protected] Email: [email protected]
Phone: 801-588-3400 Phone: 850-477-7091
Browd, M.D., Ph.D., Samuel Carey, M.D., MBA, Carolyn
Spouse: Lynn 601 5th Street South
OA.9.220 - Neurosurgery St. Petersburg, Florida 33701
4800 Sand Point Way NE Email: [email protected]
Seattle, WA 98105 Phone: 727-767-8181
Email: [email protected]
Chapman, M.D., Paul
Bruce, M.D., Derek Senior Member
Senior Member Neurological Surgery
Spouse: Frances Massachusetts General Hospital
2577 Township Road 55 Fruit Street, GRB 502
Quakertown, Pennsylvania 18951 Boston, Massachusetts 2114
Email: [email protected] Email: [email protected]
Phone: 610-346-7808 Phone: 617-726-3887
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
Cheek, M.D., William Couture, MD, Daniel
Senior Member Spouse: Karen
Spouse: Mary Winston-Salem, NC 27157
3009 Robinhood Email: [email protected]
Houston, Texas 77005 Phone: 336-716-9728
Email: [email protected]
Phone: 713-669-9928 Crone, M.D., Kerry
Senior Member
Ciricillo, MD, Samuel Spouse: Susan
2800 L Street Division of Pediatric Neursourgery
Suite 500 Cincinnati Children's
Sacramento, California 95816 3333 Burnet Avenue, ML2016
Email: [email protected] Cincinnati, Ohio 44229-3039
Phone: 916-454-6850 Email: [email protected]
Phone: 513-636-4726
Cochrane, MD FRSC(C), David
Senior Member Curry, MD, Daniel
Spouse: Barbara Spouse: Jennifer Schmidt
1503G Texas Children's Hospital, Section fo Pediatric
Hospital for Sick Children Neurosurgery
555 University Avenue 6621 Fannin St
Toronto, Ontario M5G 1X8 CCC Suite 1230
Email: [email protected] Houston, Texas 77030
Phone: 416-813-6425 Email: [email protected]
Phone: 832- 822-3950
Cohen, MD, FACS, FAAP, Alan
Spouse: Shenandoah Robinson, MD Danielpour, M.D., Moise
The Johns Hopkins Hospital Spouse: Joy
600 North Wolfe Street Los Angeles, California 90048
Phipps 556 Email: [email protected]
Baltimore, Maryland 21287 Phone: 310-423-7900
Email: [email protected]
Phone: 410-955-7851 Dauser, M.D., Robert
Senior Member
Collins, MD, FAANS, John Spouse: Susan
Spouse: Mary Anne Collins-Stauffer 6621 Fannin
The Children's Hospital of Richmond at Virginia Houston, Texas 77030
Commonwealth University Email: [email protected]
417 North 11th Street, 6th Floot Phone: 832-822-3950
Box 980631
Richmond, Virginia 23298-0631
Email: [email protected]
Phone: 804-828-2456
41st Annual Meeting
The American Society of Pediatric Neurosurgeons
Jointly provided by AANS
Dias, M.D., Mark Drake, M.D., James
Spouse: Anita Spouse: Jane
Department of Neurosurgery Division of Neurosurgery
Penn State Milton S. Hershey Medical Center The Hospital for Sick Children
500 University Drive 555 University Avenue #1504
Hershey, Pennsylvania 17033 Toronto, Ontario M5G 1X8
Email: [email protected] Email: [email protected]
Phone: 717-531-8807 Phone: 416-813-6125
DiPatri, Jr., MD, Arthur Duhaime, M.D., Ann-Christine
Spouse: Amy Spouse: Stanley A. Pelli
Anne & Robert H. Lurie Children's Hospital of Pediatric Neurosurgery
Chicago Massachusetts General Hospital
Division of Pediatric Neurosurgery 15 Parkman Street, Wang 331
225 E. Chicago Avenue, Box #28 Boston, Massachusetts 2114
Chicago, Illinois 60611 Email: [email protected]
Email: [email protected] Phone: 617-643-3399
Phone: 312-227-4220
Duncan, M.D., Charles
Dirks, MD, PhD, FRCSC, Peter Senior Member
Spouse: Tara Williams Spouse: Laura R. Ment, M.D.
Hospital for Sick Children Neurosurgery Department
University of Toronto Yale University School of Medicine
555 University Ave. P.O. Box 208082
Toronto, Ontario M5G 1X8 New Haven, Connecticut 6520
Email: [email protected] Email: [email protected]
Phone: 416-813-6426 Phone: 203-785-2809
DiRocco, M.D., Concezio Duncan III, M.D., PhD, John
Senior Member Spouse: Lisa
Universita Cattolica Del Sacro Cuore Department of Pediatric Neuroscience
Agostino Gemelli #8 Kaiser Foundation Hospital
Rome, Rome 168 710 Lawrence Expressway
Email: [email protected] Santa Clara, California 95051
Phone: 396-321-5470 Email: [email protected]
Phone: 408-851-4110
Donahue, M.D., David
Spouse: Angela Durham, MD MS, Susan
Cook Childrens Medical Center Spouse: Max Miller
Department of Neurosurgery University of Vermont Medical Center
801 7th Ave Suite 120 111 Colchester Ave.
Fort Worth, Texas 76104- 272 Burlington, VT 5401
Email: [email protected] Email: [email protected]
Phone: 682-885-7840 Phone: 802-847-8777
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ASPN 2018 Syllabus Handout
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