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Associate Professor of Neurological Surgery Associate Director, Center for Skull Base Surgery Director, Surgical Neuroanatomy Lab Director, Fiber Tractography Lab
Juan Carlos Fernandez-Miranda, MD, is associate professor of neurological surgery, associate director of the Center for Cranial Base Surgery, and director of the Surgical Neuroanatomy Lab and Fiber Tractography Lab at the University of Pittsburgh School of Medicine. He joined the faculty at the University of Pittsburgh Department of Neurological Surgery on July 1, 2008 to complete a two-year clinical fellowship in open and minimally invasive skull base, pituitary, and brain surgery with Amin Kassam, MD, Paul Gardner, MD, and Daniel Prevedello, MD.
Prior to joining the faculty at University of Pittsburgh, Dr. Fernandez-Miranda completed a clinical fellowship in cerebrovascular surgery at the University of Virginia—under the direction of Neal F. Kassell, MD—and a two-year research fellowship in microsurgical neuroanatomy at the University of Florida—under the mentoring of Albert L. Rhoton, Jr., MD.
Dr. Fernandez-Miranda, a native from Madrid, Spain, received his medical degree from the Complutense University of Madrid and completed his neurological surgery residency at “La Paz” University Hospital of Madrid. Upon completion of his residency, he was awarded the Sanitas Prize 2006 to the best medical postgraduate trainee in Spain.
Dr. Fernandez-Miranda’s clinical focus is endoscopic endonasal skull base and pituitary surgery, open skull base surgery, and complex brain surgery. His research interests lie in the study of surgical neuroanatomy and brain connectivity, and the application of innovative techniques into the operating room. He has published near 100 scientific peer-review papers, and he has lectured extensively at national and international scientific meetings and professional courses.
The Surgical Neuroanatomy Lab that he directs has a dual educational and research role aiming to improve surgical techniques and outcomes by mastering knowledge of relevant surgical neuroanatomy. Many national and international physicians have conducted training and research at the Surgical Neuroanatomy Lab. The lab has three main research areas: microsurgical neuroanatomy, endoscopic skull base anatomy, and white matter anatomy.
Dr. Fernandez-Miranda has major publications and awards on each of these areas, and his research work has contributed significantly to the development and expansion of endoscopic skull base surgery. The Fiber Tractography Lab is focused on the application of advanced fiber mapping techniques—High-Definition Fiber Tractography (HDFT)—for presurgical planning and intraoperative navigation to facilitate brain function preservation and improve resection rates in patients with complex brain lesions.
Dr. Fernandez-Miranda’s work is also centered on studying the structure and connectivity of the fiber tracts forming the “normal” human brain, and their structural alteration in patients with brain tumors, vascular lesions, stroke, and neurodegenerative diseases.
In addition to his clinical and research activities, Dr. Fernandez-Miranda is greatly devoted to teaching and education of 3D surgical neuroanatomy and techniques at local, national, and international venues.
Dr. Fernandez-Miranda's publications can be reviewed through the National Library of Medicine's publication database.
Endoscopic pituitary surgery; minimally invasive endoscopic skull base and brain surgery; open skull base surgery; brain tumors. Research focuses on surgical neuroanatomy (microsurgical neuroanatomy, endoscopic skull base anatomy, and white matter anatomy), advanced brain imaging techniques, and brain connectivity
Spanish Society of Neurosurgery, Spanish Ministry of Science and Education
European Association of Neurosurgical Societies, European Board of Neurosurgery
Children's Hospital of Pittsburgh of UPMC
American Association of Neurological Surgeon
Congress of Neurological Surgeons
European Association of Neurosurgical Societies
German Skull Base Society
International Head and Neck Scientific Group
Joint Section on Tumors – AANS & CNS
North American Skull Base Society
Spanish Society of Neurosurgery
A better road map for neurosurgeons
May 5, 2013
• Surgical Neuroanatomy Lab:
1) Presurgical Assessment of Fiber Tracts and Surgical Planning
Cavernous malformations: Using HDFT, we aimed to characterize the perilesional changes in the white matter around cavernous malformations located both in the supra- and the infratentorial compartments. The perilesional changes were consistent with both disruption and/ or displacement of the white matter around the cavernous malformations. We also evaluated these perilesional white matter changes better using a combined qualitative and quantitative model. The usefulness of the qualitative information was assessed in relation to the surgical trajectory planning and subsequent reduction of morbidity associated with the surgical resection. Using quantitative anisotropy (QA), we assessed the integrity of the perilesional tracts in a segmental fashion with potential future applications for prognostication and neurological recovery. Our results with respect to the supratentorial cavernous malformations were published in the Journal of Neurosurgery.
CNS tumours: We carried out a preliminary evaluation of the qualitative data obtained from the HDFT and assessed its utility in the surgical trajectory planning for high grade gliomas. In particular, the usefulness of the HDFT in demonstrating white matter tracts in their accurate spatial orientation in the perilesional oedematous zones was assessed. These findings have been submitted to the journal Neuro-oncology.
2) Neuroanatomy of the Fiber Tracts
The human superior fronto-occipital fasciculus does not exist: Human Connectome based tractographic study with microdissection validation.
The superior fronto-occipital fasciculus (SFOF), a long association bundle that connects frontal and occipital lobe, is well-documented in monkey but is controversial in human brain. Its assumed role is in visual processing and spatial awareness. To date, anatomical and neuroimaging studies on human and animal brains are not in agreement about the existence, course and terminations of SFOF. To clarify the existence of the SFOF in human brains, we applied deterministic fiber tractography to a template of 80 healthy subjects from the Human Connectome Project (HCP) and validated the results with white matter microdissection of post-mortem human brains. The imaging results showed that previous reconstructions of the SFOF were generated by two false continuations, namely between superior thalamic peduncle (STP) and stria terminalis (ST), and ST and posterior thalamic peduncle (PTP). The anatomical microdissection confirmed this finding. Hence, the SFOF does not exist in the human brain.
3) Application in Neurodegenerative Disorders
Amyotrophic lateral sclerosis (ALS): In a series of patients with ALS we have been able to demonstrate changes in the white matter of the brain in a longitudinal fashion. These changes have correlated with clinical progression in patients with ALS. The aim of the program has been to develop a tool with which these white matter changes can be monitored over time. The hope is that with future drug trials in these conditions, an imaging biomarker will allow us to indirectly test the effectiveness of novel treatments. A detailed description of our analytical approach in ALS has been published as a methods article in the Frontiers in Human Neuroscience.
Huntington’s disease (HD): Preliminary results have been encouraging in this group. We have been able to see changes in multiple areas of the brain and have been able to track their progression. Both in patients with ALS and HD, we have adapted a methodology (automated) that can be used to track progression of their disease in relation to a normal population. Preliminary results from the analysis of data from the HD patients have been presented in a recently accepted paper (in press) in BBA: Molecular Basis of Disease. Importantly using our analytical approach, we have been able to see changes in the so-called premanifest group where subjects with genetically identified abnormalities have not yet clinically manifested the disease.
• Fiber Tractography (HDFT) Lab:
1) Endoscopic Endonasal Approach to the Optic Canal: Anatomical Considerations and Surgical Relevance
In this recently completed study, using endonasal sphenoidal landmarks, we proposed an anatomical classification for the optic nerve (ON). In particular we have emphasized the distinction of the preforaminal ON from the intracanalicular segment in the osseous optic canal. The implication of these findings was explored for preoperatively ascertaining the presence of true optic canal invasion in cases with tuberculum sellae menigiomas. A step-by-step surgical strategy for carrying out maximal optic canal decompression and subsequent safe dural opening was developed in relation to the anatomical findings.
2) Endoscopic Endonasal Transclival Transcondylar Approach for Foramen Magnum Meningioma: Anatomical and Technical Note
Here we aim to determine the amount of condyle to be resected in order to obtain appropriate exposure of the lateral wall of the foramen magnum. Five colored silicon-injected anatomic specimens were dissected at the Surgical Neuroanatomy Lab at the University of Pittsburgh to simulate endonasal access to the foramen magnum region in a stepwise manner. Each specimen was imaged with a CT scan twice, pre-dissection and post-dissection. The mean volume of condyle resection in five specimens (10 condyles) was 18% (range, 9.7%– 28.3%). This amount of medial condyle resection was efficient in all specimens to expose the lateral wall of the foramen magnum and identify the entrance of the vertebral artery into the posterior fossa.
3) Surgical Anatomy of the Maxillary Nerve
A classification scheme for the different segments of the maxillary nerve has been developed based upon the anatomical dissection. Specifically implication of the presence of the interdural segment of the maxillary nerve has been explored in relation to the ability to resect lesions extending posteriorly towards the Meckel’s cave without violating the integrity of the middle fossa dura.