Neonatal Onset Research Articles

Chapter 21 - Neonatal hypotonia and neuromuscular conditions

The differential diagnosis of neonatal hypotonia is a complex task, as in newborns hypotonia can be the presenting sign of different underlying causes, including peripheral and central nervous system involvement and genetic and metabolic diseases. This chapter describes how a combined approach, based on the combination of clinical signs and new genetic techniques, can help not only to establish when the hypotonia is related to peripheral involvement but also to achieve an accurate and early diagnosis of the specific neuromuscular diseases with neonatal onset. The early identification of such disorders is important, as this allows early intervention with disease-specific standards of care and, more importantly, because of the possibility to treat some of them, such as spinal muscular atrophy, with therapeutic approaches that have recently become available.

Whole Exome Sequencing Revealed a Candidate Gene for Finkelstein-Seidlmayer Disease

Background: Finkelstein-Seidlmayer disease (FSD) is a benign cutaneous small-vessel leukocytoclastic vasculitis syndrome, which normally affects children between 2-60 months in a male-to-female ratio of 2:1. Skin lesions may appear as papules, erythematous macules, or urticaria. They are symmetric, sharp-edged and favouring the face, ears and extremities. Frequently they are targetoid, annular, medallion-like, or cockade. Fever and extracutaneous involvement are rare and spontaneous resolution occurs in 1-3 weeks. Case Information: In 2015, we reported a familial occurrence of FSD. Patients described in that article were the mother and all her three sons. All of them had a history of recurrent and relapsing non-thrombocytopenic, red-to-purpuric skin lesions, with a neonatal-onset. There was no systemic involvement. Anamnestic data revealed that maternal aunt, cousin and grandmother had also a positive history of neonatal onset of an acute cockade purpura and oedema. At that time, we suspected a genetic form of FSD with an autosomal dominant transmission or X-linked inheritance and incomplete penetrance. Method and Results: Blood samples were obtained from all available family members and a whole exome sequencing (WES) was performed on various affected and non-affected members of this family. The genetic analysis identified a common new mutation in the HCK gene. Conclusion: Up now, FSD is considered a sporadic disease and no genetic researches have been published on affected patients. We performed WES on a previously reported familiar case of FSD and the result was a common mutation in HCK gene. We found out the mutation on all the analysed affected and obligate-carrier members of the family. HCK gene encodes for a hematopoietic cell kinase protein, which is a member of the SRC family of cytoplasmic tyrosine kinases (SFK). We propose that HCK gene could be a candidate gene in the pathophysiology of some types of FSD. We also discuss the autosomal dominant transmission and incomplete penetrance of these specific types of disease.

Isolated Sulfite Oxidase Deficiency: Response to Dietary Treatment in a Patient with Severe Neonatal Presentation

Abstract Isolated sulfite oxidase deficiency (ISOD) is a devastating, neurometabolic disorder caused by mutations in the SUOX gene necessary for the final step in the sulfur-containing amino acid catabolic pathway. Patients classically present in the neonatal period with neurologic manifestations. Biochemical findings include elevated sulfocysteine, low cystine and undetectable homocysteine with normal uric acid levels. Other associated biochemical markers include elevated plasma alpha-aminoadipic semialdehyde and piperideine-6-carboxylic acid. We report a patient with classic neonatal onset ISOD (refractory seizures, hypertonicity, brain abnormalities, pathogenic SUOX mutations). Her clinical course was marked by extreme irritability, prompting the use of a low methionine and cystine diet to decrease toxic metabolites thought to be contributing to her symptoms. Biochemical markers and extreme irritability improved with dietary treatment (methionine=30mg/kg/day). She died of sepsis in early infancy, precluding long term follow-up. This case reviews the potential benefits and limitations of diet therapy in this rare disorder.

While waiting for a vaccine: opportunities for optimization of neonatal group B streptococcal (GBS) disease prevention in Israel.

To quantify effects of different strategies for decreasing neonatal early onset GBS sepsis (EOGBS) in Israel. A risk allocation model for EOGBS among infants ≥ 35w was adapted to Israeli data. Effects of strategies for antepartum (APS) and intrapartum (IPS) screening, and intrapartum (IAP) and/or postpartum antibiotic prophylaxis (PAP) were calculated. Estimated EOGBS attack rates (AR) with APS in 90%, IAP in 90%, may reduce AR to 0.18/1000. A rapid intrapartum test would further decrease AR to 0.16/1000, while reducing IAP from 21.3 to 12.5% of women. For babies with risk factors and GBS+ who do not receive IAP, further risk reduction could be achieved by PAP. IAP remains the main intervention to decrease EOGBS. IAP and PAP together may reduce EOGBS present incidence by 40%. Combining rapid intrapartum screening with selective IAP and selective PAP for remaining gaps, would be the most efficient strategy.

The effect of hypoglycaemia on neurocognitive outcome in children and adolescents with transient or persistent congenital hyperinsulinism.

To examine the hypoglycaemic effect on neurodevelopmental outcome in patients with transient and persistent congenital hyperinsulinism (CHI) born in the 21st century. A cohort of 117 patients (66 males, 51 females) with CHI aged 5 to 16years (mean age 8y 11mo, SD 2y 7mo) were selected from a Finnish nationwide registry to examine all the patients with similar methods. Neurodevelopment was first evaluated retrospectively. The 83 patients with no risk factors for neurological impairment other than hypoglycaemia were recruited and 44 participated (24 males, 20 females; mean age 9y 7mo, SD 3y 1mo) in neuropsychological assessment with the Wechsler Intelligence Scale for Children, Fourth Edition and the Finnish version of the Developmental Neuropsychological Assessment, Second Edition domains of attention, language, memory, sensorimotor, and visual functioning. In retrospective analysis, transient and persistent CHI groups had similar prevalences of mild (22% and 18% respectively) or severe (5% and 7% respectively) neurodevelopmental difficulties. In clinical assessment, the neurocognitive profile was within the average range in both groups, but children with persistent CHI showed significant but restricted deficits in attention, memory, visual, and sensorimotor functions compared with the general population. The transient CHI group did not differ from the standardization samples. Besides the more apparent broader neurological deficits, children with persistent CHI have an increased risk for milder specific neurocognitive problems, which should be considered in the follow-up. Children with persistent congenital hyperinsulinism showed deficits in attention, memory, visual, and sensorimotor functions. The deficits were potentially of hypoglycaemic origin. Children with transient hyperinsulinism did not differ from the general population.

Effect of the neonatal early onset sepsis calculator on pharmacy‐prepared empirical antibiotics

AbstractBackgroundThe Kaiser Permanente early onset sepsis (EOS) calculator was introduced in 2016 for infants who were born at ≥35 weeks gestation or more (≥35GA) at a principal referral and specialist hospital for women and newborns in Western Australia to reduce unnecessary antibiotic administration in healthy neonates.AimThe aim of this study was to determine the effect of the EOS calculator on antibiotic orders aseptically prepared by the pharmacy.MethodsThe study retrospectively compared pharmacy data over two periods, before (2015) and after (2016) implementation.ResultsAfter implementation, the number of gentamicin prefilled syringes (PFS) distributed decreased by 41.6% (1466 doses). In addition, the number of ≥35GA neonates receiving benzylpenicillin PFS decreased by 33.9% (222 neonates), and the overall rate (number of neonates receiving a benzylpenicillin PFS/occupied bed days) decreased from 2.24% to 1.48% (p < 0.0001).ConclusionThe introduction of the EOS calculator has reduced the empirical antibiotic use in ≥35GA neonates at the King Edward Memorial Hospital.

Fourteen new mutations of BCKDHA, BCKDHB and DBT genes associated with maple syrup urine disease (MSUD) in Malaysian population

Maple syrup urine disease (MSUD) is a rare autosomal recessive metabolic disorder. This disorder is usually caused by mutations in any one of the genes; BCKDHA, BCKDHB and DBT, which represent E1α, E1β and E2 subunits of the branched-chain α-keto acid dehydrogenase (BCKDH) complex, respectively. This study presents the molecular characterization of 31 MSUD patients. Twenty one mutations including 14 new mutations were identified. The BCKDHB gene was the most commonly affected (45.2%) compared to BCKDHA gene (16.1%) and DBT gene (38.7%). In silico webservers predicted all mutations were disease-causing. In addition, structural evaluation disclosed that all new missenses in BCKDHA, BCKDHB and DBT genes affected stability and formation of E1 and E2 subunits. Majority of the patients had neonatal onset MSUD (26 of 31). Meanwhile, the new mutation; c.1196C > G (p.S399C) in DBT gene was noted to be recurrent and found in 9 patients. Conclusion: Our findings have expanded the mutational spectrum of the MSUD and revealed the genetic heterogeneity among Malaysian MSUD patients. We also discovered the p.S399C from DBT gene was noted as a recurrent mutation in Malay community and it suggested the existence of common and unique mutation in Malay population.

GNPTAB c.2404C\u2009>\u2009T nonsense mutation in a patient with mucolipidosis III alpha/beta: a case report

BackgroundMucolipidosis alpha/beta is an inborn error of metabolism characterized by deficiency of GlcNAc-1-phosphotransferase, in which essential alpha/beta subunits are encoded by the GNPTAB gene. The autosomal recessive condition is due to disruptions of hydrolase mannose 6-phosphate marker generation, defective lysosomal targeting and subsequent intracellular accumulation of non-degraded material. Clinical severity depends on residual GlcNAc-1-phosphotransferase activity, which distinguishes between the milder type III disease and the severe, neonatal onset type II disease.Case presentationWe report the clinical, biochemical and genetic diagnosis of mucolipidosis III alpha/beta in a two-year-old Chinese boy who initially presented with poor weight gain, microcephaly and increased tone. He was confirmed to harbor the common splice site mutation c.2715 + 1G > A and the nonsense variant c.2404C > T (p.Q802*). Clinically, the patient had multiple phenotypic features typical of mucopolysaccharidosis including joint contractures, coarse facial features, kypho-lordosis, pectus carinatum and umbilical hernia. However, the relatively mild developmental delay compared to severe type I and type II mucopolysaccharidosis and the absence of macrocephaly raised the possibility of the less commonly diagnosed mucolipidosis alpha/beta. Critical roles of lysosomal enzyme activity assay, which showed elevated α-iduronidase, iduronate sulfatase, galactose-6-sulphate sulphatase, arylsulfatase B and α-hexosaminidase activities; and genetic study, which confirmed the parental origin of both mutations, were highlighted.ConclusionsThe recently reported nonsense variant c.2404C > T in the GNPTAB gene is further recognized and this contributes to the genotype-phenotype spectrum of mucolipidosis alpha/beta.

CONGENITAL MYOPATHIES (CNM): P.142X-linked myotubular myopathy with the presence of nemaline rods on muscle biopsy

X-linked myotubular myopathy (XLMTM) is a rare muscular disorder with neonatal onset associated with severe hypotonia, weakness, respiratory failure, macrosomia and severe morbidity and mortality. It is classified as centronuclear myopathy based on pathologic description. The typical features include central nuclei in >25% of the fibers with abnormal oxidative stain distribution and type I atrophic fiber predominance. Here, we present a proband born from non-consanguineous parents with a neonatal presentation of severe muscle weakness, respiratory failure, mild ptosis, pectum excavatum and ischiotibialis muscle contraction. Care was withdrawn at 14 days of age. The muscle biopsy showed internalized nuclei, atrophic type I fibers, mild abnormal SDH staining and the presence of rods on Gömöri Trichome staining and in electron microscopy. An initial nemaline myopathy gene panel did not reveal any mutation in the known causative genes. An expanded neuromuscular panel including 117 genes, identified a de-novo mutation in MTM1 c.1262G>A (p.Arg421Gln). This mutation has been previously reported, causing a disruption of the phosphatase domain. Since mutations in MTM1 have not been previously associated with the presence of rods on muscle biopsy, we decided to analyze the transcriptome of the muscle, looking for non-coding mutations in the known nemaline myopathy genes. However extensive analysis did not identify any variants, novel junctions or transcript level abnormalities. In conclusion, we report a patient with a genetic diagnosis of XLMTM with a predominance of rods on muscle biopsy. Previous reports including this specific mutation did not describe rods on muscle biopsy. Possible explanations include the presence of modifier genes or a second gene mutation not yet associated with nemaline myopathy. Furthers studies will be needed for better understanding.

Bacterial sensitivity pattern of neonatal early onset sepsis in a tertiary care hospital in Assam

Bacterial sensitivity pattern of neonatal early onset sepsis in a tertiary care hospital in Assam

Adeno-associated viral gene therapy corrects a mouse model of argininosuccinic aciduria

Argininosuccinic aciduria (ASA) is the second most common genetic disorder affecting the urea cycle. The disease is caused by deleterious mutations in the gene encoding argininosuccinate lyase (ASL); total loss of ASL activity results in severe neonatal onset of the disease, which is characterized by hyperammonemia within a few days of birth that can rapidly progress to coma and death. The long-term complications of ASA, such as hypertension and neurocognitive deficits, appear to be resistant to the current treatment options of dietary restriction, arginine supplementation, and nitrogen scavenging drugs. Treatment-resistant disease is currently being managed by orthotopic liver transplant, which shows variable improvement and requires lifetime immunosuppression. Here, we developed a gene therapy strategy for ASA aimed at alleviating the symptoms associated with urea cycle disruption by providing stable expression of ASL protein in the liver. We designed a codon-optimized human ASL gene packaged within adeno-associated virus serotype 8 (AAV8) as a vector for targeted delivery to the liver. To evaluate the therapeutic efficacy of this approach, we utilized a murine hypomorphic model of ASA. Neonatal administration of AAV8 via the temporal facial vein extended survival in ASA hypomorphic mice, although not to wild-type levels. Intravenous injection into adolescent hypomorphic mice led to increased survival and body weight and correction of metabolites associated with the disease. Our results demonstrate that AAV8 gene therapy is a viable approach for the treatment of ASA.

Mutation Study of Malaysian Patients with Ornithine Transcarbamylase Deficiency: Clinical, Molecular, and Bioinformatics Analyses of Two Novel Missense Mutations of the OTC Gene.

Ornithine transcarbamylase deficiency (OTCD), an X-linked disorder that results from mutations in the OTC gene, causes hyperammonemia and leads to various clinical manifestations. Mutations occurring close to the catalytic site of OTCase can cause severe OTCD phenotypes compared with those caused by mutations occurring on the surface of this protein. In this study, we report two novel OTC missense mutations, Q171H and N199H, found in Malaysian patients. Q171H and N199H caused neonatal onset OTCD in a male and late OTCD in a female, respectively. In silico predictions and molecular docking were performed to examine the effect of these novel mutations, and the results were compared with other 30 known OTC mutations. In silico servers predicted that Q171H and N199H, as well as 30 known missense mutations, led to the development of OTCD. Docking analysis indicated that N-(phosphonoacetyl)-L-ornithine (PALO) was bound to the catalytic site of OTCase mutant structure with minimal conformational changes. However, the mutations disrupted interatomic interactions in the catalytic site. Therefore, depending on the severity of disruption occurring at the catalytic site, the mutation may affect the efficiency of mechanism and functions of OTCase.

Prenatal, Neonatal, and Early Childhood Features in Congenital Myotonic Dystrophy

Congenital myotonic dystrophy (CDM) is the neonatal onset and most severe presentation of Myotonic Dystrophy type 1. Since it first description, perinatal complications have been detailed including prolonged hospital stay, respiratory and feeding therapy during the neonatal period, although long-term complications are less documented. Present a prospective cohort of CDM and compare it to the literature of other CDM case series, to adequately describe and contrast the prenatal, neonatal and infancy features of CDM. A 5-year cohort of CDM eligible cases was conducted via the Canadian Pediatric Surveillance Program. 38 patients met the inclusion criteria. Comparison to other CDM case series published in the literature between 1992 and 2016 about perinatal and infancy morbidity. From a total of 118 cases, the most frequent features were Polyhydramnios (58%), feeding therapy (77%), intubation and ventilation (58%); neonatal death was reported in 16% of the cases; the most frequent long-term morbidity were respiratory tract infections. We performed a detailed description of the main perinatal features of CDM and precise documentation of the mortality and morbidity during the first five years of life. This is an essential step in the knowledge of the natural history of CDM.

Congenital myasthenic syndromes in adulthood : Challenging, rare but treatable

The congenital myasthenic syndromes (CMS) represent aheterogeneous group of diseases with abroad spectrum of phenotypes. The common characteristic is an inherited genetic defect of the neuromuscular junction. Although in some patients the specific gene defect remains to be detected, the increasing identification of causative genes in recent years has already provided unique insights into the functionality of structural proteins at the neuromuscular junction. Neonatal and early childhood onset is observed in most CMS subtypes; however, late onset in adolescence or adulthood also occurs and establishing the diagnosis at these stages imposes particular challenges. To enable appropriate therapeutic interventions for an at least in principle treatable condition, determining the genetic cause is warranted. In this overview, the critical clinical and diagnostic features of the different CMS subtypes are presented and illustrated using typical cases. Furthermore, specific diagnostic clues are outlined. Finally, the overlap between CMS and muscular dystrophies is discussed. Illustrating characteristic patient examples, the essential clinical and additional diagnostic findings of various CMS subtypes and special diagnostic indications are presented.

Phenotype study of SCN2A gene related epilepsy

Objective: To summarize the phenotype of epileptic children with SCN2A mutations. Methods: Epileptic patients who were treated in the Pediatric Department of Peking University First Hospital from September 2006 to October 2017 and detected with SCN2A mutations by targeted next-generation sequencing were enrolled. Clinical manifestations of all patients were analyzed retrospectively. Results: A total of 21 patients (16 boys and 5 girls) with SCN2A mutations were collected. Twenty-one SCN2A mutations were identified. Ten patients had mutations inherited from one of their parents and 11 patients had de novo mutations. The age of epilepsy onset was from 2 days to 2 years and 6 months: six patients with seizure onset in neonates (29%) , six patients with seizure onset between 1 month and 3 months of age (29%), three patients with seizure onset between 4 months and 6 months of age, two patients with seizure onset between 7 months and one year of age, and four patients with seizure onset beyond one year of age. Multiple seizure types were observed. The focal seizure was the most common seizure type which was observed in 18 patients (86%) . Spasm seizure was observed in 6 patients (29%) . Other seizure types were rare. In 19 patients, seizures manifested in clusters (90%) . In 3 patients, seizures manifested fever-sensitive. Nine of ten patients with inherited SCN2A mutations had normal development. However, all patients with de novo SCN2A mutations had mild or severer development delay. In 21 patients with SCN2A mutations, five were diagnosed with benign familial infantile epilepsy, 3 with benign familial neonatal-infantile epilepsy, 3 with Ohtahara syndrome, 3 with West syndrome, 2 with encephalopathy with early infantile onset epilepsy, one with febrile seizures plus, one with Dravet syndrome, one with encephalopathy with childhood-onset epilepsy, one with autism with epilepsy and one with intellectual disability with epilepsy. Conclusions: The clinical features of patients with SCN2A mutations include that main seizure onset is the neonate and early infancy, and the main seizure type is the focal seizure, manifested in clusters. The large spectrum of SCN2A-related epilepsy, which not only includes epilepsy with a comparatively favorable prognosis, but also epileptic encephalopathy. De novo mutations often lead to severe phenotype with development delay.

A Neonate with Exaggerated Startle and Tonic Spasms

AbstractHyperekplexia is a rare, potentially treatable inherited disorder of glycinergic neurotransmission, which is characterized by neonatal onset exaggerated startle response to somatosensory, auditory stimuli, and episodic tonic spasm. Prolonged tonic spasms can be life-threatening and associated with apnea and bradycardia. Awareness about this condition avoids misdiagnosis such as tonic seizures and epilepsy. We describe a term newborn with episodic tonic stiffness mistaken for seizures. Classical exaggerated startle reaction, positive head retraction response to glabellar tap, and characteristic video electroencephalogram confirmed the diagnosis.

Early liver transplantation in neonatal-onset and moderate urea cycle disorders may lead to normal neurodevelopment.

Urea cycle disorders (UCDs) are inherited metabolic diseases that lead to hyperammonemia. Neurodevelopmental outcomes of patients with UCDs depend on the maximum ammonia concentration (MAC) in the blood during onset. MAC ≥360μM is a marker of poor neurodevelopmental outcomes. We investigated the neurodevelopmental outcomes and MAC at onset for 177 patients with UCDs in Japan (median age, 8years and 2months; range, 10days-72years), including 57 patients with male ornithine transcarbamylase (OTCD), 59 patients with female OTCD, 23 patients with carbamoyl-phosphate synthetase 1 deficiency (CPSD), 28 patients with arginosuccinate synthetase deficiency, 9 patients with arginosuccinate lyase deficiency (ALD), and 1 patient with arginase 1 deficiency. Neurodevelopmental outcomes of patients with CPSD and ALD were poor because most had neonatal onset with blood MAC ≥300μM at onset. Although OTCD, particularly female late-onset OTCD, has good neurodevelopmental outcomes among those with UCDs, it is not necessarily a mild disease with good long-term outcomes. Patients with severe UCDs and MAC ≥300μM at onset should undergo liver transplantation (LT). Moreover, this study suggested that if the onset of UCD began during the neonatal period, then even UCD patients with MAC <300μM at onset should undergo LT to protect the brain.

A child with neonatal onset multi-systemic inflammatory disease (NOMID)

A child with neonatal onset multi-systemic inflammatory disease (NOMID)

Incorporating epilepsy genetics into clinical practice: a 360\xb0evaluation

We evaluated a new epilepsy genetic diagnostic and counseling service covering a UK population of 3.5 million. We calculated diagnostic yield, estimated clinical impact, and surveyed referring clinicians and families. We costed alternative investigational pathways for neonatal onset epilepsy. Patients with epilepsy of unknown aetiology onset < 2 years; treatment resistant epilepsy; or familial epilepsy were referred for counseling and testing. We developed NGS panels, performing clinical interpretation with a multidisciplinary team. We held an educational workshop for paediatricians and nurses. We sent questionnaires to referring paediatricians and families. We analysed investigation costs for 16 neonatal epilepsy patients. Of 96 patients, a genetic diagnosis was made in 34% of patients with seizure onset < 2 years, and 4% > 2 years, with turnaround time of 21 days. Pathogenic variants were seen in SCN8A, SCN2A, SCN1A, KCNQ2, HNRNPU, GRIN2A, SYNGAP1, STXBP1, STX1B, CDKL5, CHRNA4, PCDH19 and PIGT. Clinician prediction was poor. Clinicians and families rated the service highly. In neonates, the cost of investigations could be reduced from £9362 to £2838 by performing gene panel earlier and the median diagnostic delay of 3.43 years reduced to 21 days. Panel testing for epilepsy has a high yield among children with onset < 2 years, and an appreciable clinical and financial impact. Parallel gene testing supersedes single gene testing in most early onset cases that do not show a clear genotype-phenotype correlation. Clinical interpretation of laboratory results, and in-depth discussion of implications for patients and their families, necessitate multidisciplinary input and skilled genetic counseling.

S115. Multimodal intraoperative neurophysiology monitoring during the resection of a 4th ventricular mass in a 2 year-old boy with hemifacial spasm and seizure

Hemifacial spasm is a disorder of the seventh cranial nerve characterised by irregular, involuntary, clonic or tonic spasms of the facial muscles. In adults it is typically a primary disorder, predominantly affecting females in the fourth and fifth decades. Neonatal onset is much rarer, in and in most instances associated with a posterior fossa mass. We report the case of a 2 year-old boy who, soon after a normal and term delivery, developed unilateral hemifacial twitching. An associated ipsilateral mass in the floor of the fourth ventricle was subsequently seen on magnetic resonance imaging of the brain. A craniotomy was performed for resection of the visualised mass. A complex post anaesthetic Neurophysiology set up for intraoperative neurophysiology monitoring (IONM) and mapping was required. Brainstem auditory evoked potentials (BAEP), trans-cranial electrical motor evoked potentials (tceMEP) from face and upper limb, somatosensory evoked potentials (SEP) from the upper limbs, cranial nerve mapping and electrocorticography (ECOG) were all performed. Subdermal needle electrodes were used to record from orbicularis oris, oculi, masseter, lateral rectus and abductor pollicus brevis muscles bilaterally for tcMEPs and cranial nerve monitoring. A monopolar stimulator with needle reference was used to stimulate the cranial nerves. Buds placed in the auditory canals were used for BAEP stimulation and held in with bone wax. After opening and exposure, an 8-contact depth electrode was placed into the lesion to record resting ECOG in a referential montage, checking for interictal epileptiform activity. SEPs were obtained from stimulation of the ulnar nerves in both upper limbs and recording from corkscrew electrodes on the scalp. Cranial nerve mapping allowed the surgical team to avoid damaging the intact structures. ECOG provided real-time interictal data directly from the lesion, with no intralesional epileptiform abnormalities recorded. At closure there were no significant changes from baseline SEPs and tceMEPs. The lesion was fully resected, and the patient had a post-operative neurological exam with no deficits noted as predicted by closing neurophysiology data. To date, the patient has had no further episodes. IONM played a pivotal role during this procedure for the surgical team to tailor their surgical approach safely with maximal resection.