1
|
Wójtowicz K, Przepiorka L, Kujawski S, Maj E, Marchel A, Kunert P. Retrospective Application of Risk Scores to Unruptured Anterior Communicating Artery Aneurysms. J Clin Med 2024; 13:789. [PMID: 38337482 PMCID: PMC10856240 DOI: 10.3390/jcm13030789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Treatment decisions for unruptured intracranial aneurysms (UIAs) pose a challenge for neurosurgeons, prompting the development of clinical scales assessing hemorrhage risk to provide management guidance. This study compares recommendations from the PHASES and UIA treatment scores (UIATS) applied to anterior communicating artery (AComA) UIAs against real-world management. METHODS While UIATS recommends management, for PHASES, an aneurysm with score of 10 or more was considered "high-risk". Analysis involved assessing the concordance in each group alongside comparison to real-word management. RESULTS Among 129 patients, 46.5% were observed and 53.5% were treated. PHASES scores were significantly higher in the treatment group (p = 0.00002), and UIATS recommendations correlated with real-world decisions (p < 0.001). We observed no difference in the frequencies of UIATS recommendations between high- and low-risk groups. When comparing the UIATS and PHASES, 33% of high-risk aneurysms received a UIATS conservative management recommendation. In 39% of high-risk aneurysms, the UIATS recommendation was not definitive. Conversely, 27% of low-risk aneurysms obtained a UIATS UIA repair recommendation. Overall, concordance between PHASES and UIATS was 32%. CONCLUSIONS Significant discordance in therapeutic suggestions underscores the predominant influence of center experience and individual assessments. Future studies should refine and validate decision-making strategies, potentially exploring alternative applications or developing tailored scales.
Collapse
Affiliation(s)
- Katarzyna Wójtowicz
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
| | - Lukasz Przepiorka
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-077 Bydgoszcz, Poland
| | - Edyta Maj
- Second Department of Clinical Radiology, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland (A.M.); (P.K.)
| |
Collapse
|
2
|
Abdollahifard S, Farrokhi A, Kheshti F, Jalali M, Mowla A. Application of convolutional network models in detection of intracranial aneurysms: A systematic review and meta-analysis. Interv Neuroradiol 2023; 29:738-747. [PMID: 35549574 PMCID: PMC10680951 DOI: 10.1177/15910199221097475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Intracranial aneurysms have a high prevalence in human population. It also has a heavy burden of disease and high mortality rate in the case of rupture. Convolutional neural network(CNN) is a type of deep learning architecture which has been proven powerful to detect intracranial aneurysms. METHODS Four databases were searched using artificial intelligence, intracranial aneurysms, and synonyms to find eligible studies. Articles which had applied CNN for detection of intracranial aneurisms were included in this review. Sensitivity and specificity of the models and human readers regarding modality, size, and location of aneurysms were sought to be extracted. Random model was the preferred model for analyses using CMA 2 to determine pooled sensitivity and specificity. RESULTS Overall, 20 studies were used in this review. Deep learning models could detect intracranial aneurysms with a sensitivity of 90/6% (CI: 87/2-93/2%) and specificity of 94/6% (CI: 0/914-0/966). CTA was the most sensitive modality (92.0%(CI:85/2-95/8%)). Overall sensitivity of the models for aneurysms more than 3 mm was above 98% (98%-100%) and 74.6 for aneurysms less than 3 mm. With the aid of AI, the clinicians' sensitivity increased to 12/8% and interrater agreement to 0/193. CONCLUSION CNN models had an acceptable sensitivity for detection of intracranial aneurysms, surpassing human readers in some fields. The logical approach for application of deep learning models would be its use as a highly capable assistant. In essence, deep learning models are a groundbreaking technology that can assist clinicians and allow them to diagnose intracranial aneurysms more accurately.
Collapse
Affiliation(s)
- Saeed Abdollahifard
- Research center for neuromodulation and pain, Shiraz, Iran
- Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirmohammad Farrokhi
- Research center for neuromodulation and pain, Shiraz, Iran
- Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Kheshti
- Research center for neuromodulation and pain, Shiraz, Iran
- Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahtab Jalali
- Research center for neuromodulation and pain, Shiraz, Iran
- Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| |
Collapse
|
3
|
Wójtowicz K, Przepiorka L, Kujawski S, Marchel A, Kunert P. Unruptured Anterior Communicating Artery Aneurysms: Management Strategy and Results of a Single-Center Experience. J Clin Med 2023; 12:4619. [PMID: 37510733 PMCID: PMC10380186 DOI: 10.3390/jcm12144619] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Although anterior communicating artery (AComA) unruptured intracranial aneurysms (UIAs) comprise one of the largest aneurysm subgroups, their complex adjacent neurovasculature and increased risk of rupture impede optimal management. In the present study, we analyzed the results of our diverse strategy in AComA UIAs with the additional goal of assessing the risk of treatment and the incidence of hemorrhage. We analyzed 131 patients, of which each was assessed by a multidisciplinary neurovascular team and assigned to observation (45.8%), endovascular treatment (34.4%) or microsurgery (19.8%). Median aneurysm sizes were 3, 7.2 and 7.75 mm, respectively. In the observation group, four (7.1%) aneurysms (initially <5 mm) grew over a median time of 63.5 months and were treated endovascularly. We found that fewer patients in the observation group were smokers (p = 0.021). The aneurysm size ratio was different between the combined treatment versus the observation group (p < 0.0001). Noteworthily, there were no hemorrhages in the observational group. Mortality for all patients with available follow-up was 2.4% (3/124) and permanent morbidity was 1.6% (2/124) over a mean follow-up of 64.2 months. These compelling rates refer to a high-risk group with potentially devastating consequences in which we have decreased the annual risk of hemorrhage to 0.14%.
Collapse
Affiliation(s)
- Katarzyna Wójtowicz
- Department of Neurosurgery, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Lukasz Przepiorka
- Department of Neurosurgery, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-077 Bydgoszcz, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, 02-091 Warsaw, Poland
| |
Collapse
|
4
|
The use of stereotactic MRI-guided laser interstitial thermal therapy for the treatment of pediatric cavernous malformations: the SUNY Upstate Golisano Children's Hospital experience. Childs Nerv Syst 2023; 39:417-424. [PMID: 36416952 DOI: 10.1007/s00381-022-05701-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 10/03/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavernous malformations (CM) are central nervous system lesions characterized by interlaced vascular sinusoids coated with endothelial cells without intervening parenchyma. Magnetic resonance imaging-guided laser interstitial thermal therapy (MRIgLITT) is a minimally invasive treatment modality that can precisely treat pathologic cerebral tissue, making it an effective alternative for the management of cavernomas. We describe the outcomes of a series of pediatric patients with cavernous brain malformations treated with MRIgLITT between 2014 and 2018 at our institution. METHODS We retrospectively analyzed 11 cavernomas in 6 pediatric patients treated with MRIgLITT. Both the Visualase System® and/or Neuroblate® systems were used. A variation of the surgical technique on the application of the laser was developed. Post-ablation MRIs were obtained to assess ablated areas. RESULTS A total of 11 cavernomas in 6 patients were treated with MRIgLITT. Median age was 15 years (12 to 17 years); 75% were males. Presenting symptoms were headache (75%) and seizures (25%). Two patients presented with multiple CMs. All lesions in this study were supratentorial (cerebral hemispheres 81.8%, corpus callosum 9.1%, basal ganglia 9.1%). Our surgical technique was well-tolerated, with no significant adverse events observed. Hospital stay for all patients was less than 48 hours. CONCLUSION MRIgLITT is an effective minimally invasive technique for the treatment of pediatric CMs. It represents a useful and safe tool, when other therapeutic alternatives may represent a greater risk of surgical morbidity.
Collapse
|
5
|
Acosta JM, Cayron AF, Dupuy N, Pelli G, Foglia B, Haemmerli J, Allémann E, Bijlenga P, Kwak BR, Morel S. Effect of Aneurysm and Patient Characteristics on Intracranial Aneurysm Wall Thickness. Front Cardiovasc Med 2021; 8:775307. [PMID: 34957259 PMCID: PMC8692777 DOI: 10.3389/fcvm.2021.775307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The circle of Willis is a network of arteries allowing blood supply to the brain. Bulging of these arteries leads to formation of intracranial aneurysm (IA). Subarachnoid hemorrhage (SAH) due to IA rupture is among the leading causes of disability in the western world. The formation and rupture of IAs is a complex pathological process not completely understood. In the present study, we have precisely measured aneurysmal wall thickness and its uniformity on histological sections and investigated for associations between IA wall thickness/uniformity and commonly admitted risk factors for IA rupture. Methods: Fifty-five aneurysm domes were obtained at the Geneva University Hospitals during microsurgery after clipping of the IA neck. Samples were embedded in paraffin, sectioned and stained with hematoxylin-eosin to measure IA wall thickness. The mean, minimum, and maximum wall thickness as well as thickness uniformity was measured for each IA. Clinical data related to IA characteristics (ruptured or unruptured, vascular location, maximum dome diameter, neck size, bottleneck factor, aspect and morphology), and patient characteristics [age, smoking, hypertension, sex, ethnicity, previous SAH, positive family history for IA/SAH, presence of multiple IAs and diagnosis of polycystic kidney disease (PKD)] were collected. Results: We found positive correlations between maximum dome diameter or neck size and IA wall thickness and thickness uniformity. PKD patients had thinner IA walls. No associations were found between smoking, hypertension, sex, IA multiplicity, rupture status or vascular location, and IA wall thickness. No correlation was found between patient age and IA wall thickness. The group of IAs with non-uniform wall thickness contained more ruptured IAs, women and patients harboring multiple IAs. Finally, PHASES and ELAPSS scores were positively correlated with higher IA wall heterogeneity. Conclusion: Among our patient and aneurysm characteristics of interest, maximum dome diameter, neck size and PKD were the three factors having the most significant impact on IA wall thickness and thickness uniformity. Moreover, wall thickness heterogeneity was more observed in ruptured IAs, in women and in patients with multiple IAs. Advanced medical imaging allowing in vivo measurement of IA wall thickness would certainly improve personalized management of the disease and patient care.
Collapse
Affiliation(s)
- Jason M. Acosta
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Anne F. Cayron
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Nicolas Dupuy
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Graziano Pelli
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernard Foglia
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Julien Haemmerli
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Eric Allémann
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Philippe Bijlenga
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Brenda R. Kwak
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sandrine Morel
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
- *Correspondence: Sandrine Morel
| |
Collapse
|
6
|
Guo Y, Guo XM, Zhao K, Yang MF. Aspirin and growth, rupture of unruptured intracranial aneurysms: A systematic review and meta-analysis. Clin Neurol Neurosurg 2021; 209:106949. [PMID: 34562772 DOI: 10.1016/j.clineuro.2021.106949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Aspirin has been suggested as a potential therapeutic strategy to prevent the growth and rupture of unruptured intracranial aneurysms (UIAs), but there is still controversy. The aim of this systematic review and meta-analysis is to determine the association between aspirin use and growth, rupture of UIAs. METHODS We performed a systematic literature search of electronic databases to identify cohort and case-control studies investigating the relationship between aspirin use and growth or rupture of UIAs. Pooled odds ratio (OR) with corresponding 95% confidence interval (CI) were calculated using a random effects model. Heterogeneity among studies was quantified using the I2 statistic, and potential publication bias was assessed using funnel plots. Sensitivity analysis was performed to verify the robustness of the intention-to-treat results. Subgroup analysis was conducted according to the frequency of aspirin use. RESULTS We identified 8 studies comprising 10,518 participants. The risk of bias was low to moderate. The pooled estimate showed that aspirin use was associated with a lower likelihood of growth of UIAs (OR = 0.25, 95% CI = 0.11-0.55; p = 0.0005) without statistical heterogeneity (p for Cochran Q statistic = 0.62, I2 = 0%). Likewise, aspirin intake also significant decreased 58% risk of intracranial aneurysms rupture (OR = 0.42, 95% CI = 0.29-0.60; p < 0.00001) with moderate heterogeneity (p for Cochran Q statistic = 0.005, I2 = 66%). Similar results were observed in the sensitivity analysis. Pooled OR of aspirin frequency subgroup analysis for less than or equal to 2 times per week was 0.82 (95%CI = 0.40-1.72; I2 = 0%), for at least 3 times per week to daily was 0.25 (95%CI = 0.12-053; I2 = 0%), for daily was 0.59 (95%CI: 0.47-0.74; I2 = 0%), and for unknown was 0.26 (95%CI: 0.15-0.45; I2 = 51%). CONCLUSIONS The results of this systematic review and meta-analysis indicates a beneficial effect of aspirin on growth and rupture of UIAs.
Collapse
Affiliation(s)
- Yu Guo
- Graduate School, Qinghai University, Xining, Qinghai, China
| | - Xin-Mei Guo
- Biomedical Engineering Research Center, Kunming Medical University, Kunming, Yunnan, China
| | - Kai Zhao
- Graduate School, Qinghai University, Xining, Qinghai, China
| | - Ming-Fei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China.
| |
Collapse
|
7
|
Chang M JE, Alejandro SA, Paganelli SL, Vela Rojas EJ, Viera Neves AP, Da Costa MD, Dória-Netto HL, Campos Filho JM, Chaddad-Neto F. Microsurgical Treatment for Posthemorrhagic Cavernoma of Frontal Lobe Coexisting with Unruptured Ipsilateral Middle Cerebral Artery Aneurysm. World Neurosurg 2021; 156:27. [PMID: 34508908 DOI: 10.1016/j.wneu.2021.08.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
Cerebral cavernous malformations, also known as cavernomas, are vascular abnormalities of the brain that are clinically associated with a variety of neurologic symptoms that may include hemorrhagic strokes. They are the most common vascular abnormality, representing 10%-25% of all vascular malformations.1 Lesions associated with cavernomas include developmental venous anomalies, capillary telangiectasias, and other vascular malformations2 but not intracranial aneurysms. The latter association is extremely rare; in fact, there is only 1 case reported in the literature, in which the cavernoma was obscured by the presence of a cerebral hemorrhage and an unruptured aneurysm, which was presumed to be the primary cause of the bleeding, thereby misleading the surgeons to treat only the aneurysm.2 There are different alternatives for the management of different types of lesions.3-5 In this 3-dimensional operative video (Video 1), we present a case of a cavernoma associated with hemorrhage coexisting with an unruptured aneurysm in which we achieved complete resolution of both with microsurgical treatment through a pterional approach.6 The patient consented to publication of images.
Collapse
Affiliation(s)
- José Ernesto Chang M
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil
| | | | | | | | | | | | - Hugo Leonardo Dória-Netto
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil
| | - José Maria Campos Filho
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil
| | - Feres Chaddad-Neto
- Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil.
| |
Collapse
|
8
|
Wójtowicz K, Kunert P, Przepiórka Ł, Marchel A. Warning Signs in the Era of Unruptured Intracranial Aneurysms: Report on 2 Cases of Fatal Aneurysmal Hemorrhage. Cerebrovasc Dis Extra 2021; 11:77-80. [PMID: 34350866 PMCID: PMC8647099 DOI: 10.1159/000517421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction The timing of treatment remains unresolved for patients with unruptured intracranial aneurysms (UIAs) and headaches, particularly when the pain is short term, localized, and related to the aneurysm site. We lack evidence to support the notion that when a headache accompanies an aneurysm, it elevates the risk of rupture. Results We describe 2 cases of fatal subarachnoid hemorrhage in patients with a history of headache and known aneurysms. Both of these patients had good indications for treatment: a young age and an aneurysm >7 mm, and both were qualified for elective surgery. However, both patients died of fatal aneurysm ruptures before the planned surgery. Conclusion These cases suggested that treatment should be started as soon as possible, when a UIA is diagnosed based on a short-term period of severe headaches or when a UIA is observed and then severe headaches appear. There is no straightforward guideline for treatment timing in these patients. However, in this era of UIAs, the significance of sentinel headaches should be reevaluated. Given the incidence of headaches in the general population and the very low risk of aneurysm rupture, there may be a tendency to neglect the role of headache as a possible warning sign.
Collapse
Affiliation(s)
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Przepiórka
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
9
|
Catapano JS, Nguyen CL, Frisoli FA, Sagar S, Baranoski JF, Cole TS, Labib MA, Whiting AC, Ducruet AF, Albuquerque FC, Lawton MT. Small intracranial aneurysms in the Barrow Ruptured Aneurysm Trial (BRAT). Acta Neurochir (Wien) 2021; 163:123-129. [PMID: 33034770 DOI: 10.1007/s00701-020-04602-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of small ruptured aneurysms (SRAs) remains controversial, with literature reporting difficulty with endovascular versus microsurgical approaches. This paper analyzes outcomes after endovascular coiling and microsurgical clipping among patients with SRAs prospectively enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). METHOD All BRAT patients were included in this study. Patient demographics, aneurysm size, aneurysm characteristics, procedure-related complications, and outcomes at discharge and at 1-year and 6-year follow-up were evaluated. A modified Rankin scale (mRS) score > 2 was considered a poor outcome. RESULTS Of 73 patients with SRAs, 40 were initially randomly assigned to endovascular coiling and 33 to microsurgical clipping. The rate of treatment crossover was significantly different between coiling and clipping; 25 patients who were assigned to coiling crossed over to clipping, and no clipping patients crossed over to coiling (P < 0.001). Among SRA patients, 15 underwent coiling and 58 underwent clipping; groups did not differ significantly in demographic characteristics or aneurysm type (P ≥ 0.11). Mean aneurysm diameter was significantly greater in the endovascular group (3.0 ± 0.3 vs 2.6 ± 0.6; P = 0.02). The incidence of procedure-related complications was similar for endovascular and microsurgical treatments (odds ratio [95% confidence interval], 1.0 [0.1-10.0], P = 0.98). Both groups had comparable overall outcome (mRS score > 2) at discharge and 1-year and 6-year follow-up (P = 0.48 and 0.73, respectively). CONCLUSIONS Most SRA patients in the BRAT underwent surgical clipping, with a high rate of crossover from endovascular approaches. Endovascular treatment was equivalent to surgical clipping with regard to procedure-related complications and neurologic outcomes.
Collapse
Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Candice L Nguyen
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Fabio A Frisoli
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Soumya Sagar
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Tyler S Cole
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Mohamed A Labib
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Alexander C Whiting
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA.
| |
Collapse
|
10
|
Abstract
Unruptured intracranial aneurysms measuring <7 mm in diameter have become increasingly prevalent due to advances in diagnostic imaging. The most feared complication is aneurysm rupture leading to a subarachnoid hemorrhage. Based on the current literature, the 3 main treatments for an unruptured intracranial aneurysm are conservative management with follow-up imaging, endovascular coiling, or surgical clipping. However, there remains no consensus on the best treatment approach. The natural history of the aneurysm and risk factors for aneurysm rupture must be considered to individualize treatment. Models including population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from a prior aneurysm, site of aneurysm score, Unruptured Intracranial Aneurysm Treatment Score, and advanced neuroimaging can assist physicians in assessing the risk of aneurysm rupture. Macrophages and other inflammatory modulators have been elucidated as playing a role in intracranial aneurysm progression and eventual rupture. Further studies need to be conducted to explore the effects of therapeutic drugs targeting inflammatory modulators.
Collapse
|
11
|
Zanaty M, Roa JA, Nakagawa D, Chalouhi N, Allan L, Al Kasab S, Limaye K, Ishii D, Samaniego EA, Jabbour P, Torner JC, Hasan DM. Aspirin associated with decreased rate of intracranial aneurysm growth. J Neurosurg 2020; 133:1478-1485. [PMID: 31662579 DOI: 10.3171/2019.6.jns191273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aspirin has emerged as a potential agent in the prevention of rupture of intracranial aneurysms (IAs). In this study, the authors' goal was to test if aspirin is protective against aneurysm growth in patients harboring multiple IAs ≤ 5 mm. METHODS The authors performed a retrospective review of a prospectively maintained database covering the period July 2009 through January 2019. Patients' data were included if the following criteria were met: 1) the patient harbored multiple IAs; 2) designated primary aneurysms were treated by surgical/endovascular means; 3) the remaining aneurysms were observed for growth; and 4) a follow-up period of at least 5 years after the initial treatment was available. Demographics, earlier medical history, the rupture status of designated primary aneurysms, aneurysms' angiographic features, and treatment modalities were gathered. RESULTS The authors identified 146 patients harboring a total of 375 IAs. At the initial encounter, 146 aneurysms were treated and the remaining 229 aneurysms (2-5 mm) were observed. During the follow-up period, 24 (10.48%) of 229 aneurysms grew. All aneurysms observed to grow later underwent treatment. None of the observed aneurysms ruptured. Multivariate analysis showed that aspirin was significantly associated with a decreased rate of growth (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.05-0.63). Variables associated with an increased rate of growth included hypertension (OR 14.38, 95% CI 3.83-53.94), drug abuse (OR 11.26, 95% CI 1.21-104.65), history of polycystic kidney disease (OR 9.48, 95% CI 1.51-59.35), and subarachnoid hemorrhage at presentation (OR 5.91, 95% CI 1.83-19.09). CONCLUSIONS In patients with multiple IAs, aspirin significantly decreased the rate of aneurysm growth over time. Additional prospective interventional studies are needed to validate these findings.
Collapse
Affiliation(s)
| | | | - Daichi Nakagawa
- 3Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nohra Chalouhi
- 4Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | | | | | | | - Daizo Ishii
- 6Department of Neurosurgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | | | - Pascal Jabbour
- 4Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - James C Torner
- 8Epidemiology and Public Health, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | |
Collapse
|
12
|
Removal of Double Cavernous Angioma of the Frontal Lobe using a Three-Dimensional Printed Model: A Case Report. J UOEH 2020; 42:217-222. [PMID: 32507845 DOI: 10.7888/juoeh.42.217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cerebral cavernous angiomas are vascular anomalies with dilated spaces. We report the case of rare double cavernous angiomas causing higher brain dysfunction. A 74-year-old man exhibited cognitive dysfunction. Magnetic resonance imaging showed two tumors with hemorrhage in the left frontal lobe. Preoperative diagnosis was hemorrhage caused by cavernous angiomas. A 3D model of the double cavernous angioma was made to confirm their association with cortical veins and tumors. Tumors were removed using a single small corticotomy. This is the first report of a rare double cavernous angioma and the 3D printed model facilitated removal of the tumors.
Collapse
|
13
|
Antunes CM, Marques RSF, Machado MJS, Marques LTM, Filipe MAR, Fernandes JS, Alegria CMG. Emergency surgery for brainstem cavernoma haemorrhage with severe neurological presentation. Is it indicated and worthwhile? Br J Neurosurg 2020; 34:427-433. [PMID: 32290713 DOI: 10.1080/02688697.2020.1753170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Brainstem Cavernoma (BSCM) haemorrhage is a complex condition, especially when patients present rapid neurological deterioration. Traditionally, these patients were initially treated by non-interventional means. Surgery was generally reserved for cases who presented a 'benign' evolution in a subacute/delayed fashion. Timing of surgery remains controversial. Since rebleeding is frequent and carries a high mortality, many of these patients do not tolerate this approach. Urgent/emergent surgery may be indicated and lifesaving.Methods: A single center experience is reported in which an aggressive approach was used with urgent/emergency surgery carried out on patients with BSCM haemorrhage and rapid neurological deterioration, ventilatory impairment and/or coma. A review of 5 consecutive cases where urgent/emergent surgery was performed is presented. The pre-operative status, pre- and post-operative examinations, surgical approach and neurological residual deficits/outcomes are reported.Results: Four females and one male with ages ranging from 36 to 66 years with rapid neurological deterioration, ventilatory impairment and/or coma were operated between 2011 and 2018. Favourable outcomes were observed with a modified Rankin Scale varying from 1 to 4. Cranial nerve deficits as well as motor and sensitive deficits were observed but all the patients recovered cognitive integrity.Conclusions: Our small series reveals an acceptable outcome with ultra-early surgery. This approach appears to be a valid option when there is rapid neurological deterioration, respiratory impairment and/or early onset coma. However, further studies are required to elucidate the optimal strategy.
Collapse
|
14
|
Liu Z, Ajimu K, Yalikun N, Zheng Y, Xu F. Potential Therapeutic Strategies for Intracranial Aneurysms Targeting Aneurysm Pathogenesis. Front Neurosci 2019; 13:1238. [PMID: 31849575 PMCID: PMC6902030 DOI: 10.3389/fnins.2019.01238] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/01/2019] [Indexed: 12/20/2022] Open
Abstract
Subarachnoid hemorrhage resulting from intracranial aneurysms (IAs) is associated with high rates of morbidity and mortality. Although trigger mechanisms in the pathogenesis of IAs have not been fully elucidated, accumulating evidence has demonstrated that inflammation acts as a critical contributor to aneurysm pathogenesis. IAs is initiated by disruption and dysfunction of endothelial cells (ECs) caused by abnormal wall shear stress (WSS). Subsequently, vascular inflammation can trigger a series of biochemical reactions resulting in vascular smooth muscle cell (VSMC) apoptosis and migration, accompanied by inflammatory cell infiltration, secretion of various cytokines, and inflammatory factors. These changes result in degradation of vascular wall, leading to the progression and eventual rupture of IAs. Increasing our knowledge of the pathogenesis of these lesions will offer physicians new options for prevention and treatment. In this study, we review aneurysmal pathogenesis to seek for safe, effective, and non-invasive therapeutic strategies.
Collapse
Affiliation(s)
- Zhao Liu
- Department of Neurosurgery, Jingjiang People's Hospital, Taizhou, China
| | - Kuerban Ajimu
- Department of Neurosurgery, First People's Hospital of Kashgar, Kashgar, China
| | - Naibijiang Yalikun
- Department of Neurosurgery, Hotan District People's Hospital, Hotan, China
| | - Yongtao Zheng
- Department of Neurosurgery, Shanghai Medical College, Huashan Hospital Fudan University, Shanghai, China
| | - Feng Xu
- Department of Neurosurgery, Shanghai Medical College, Huashan Hospital Fudan University, Shanghai, China.,Department of Neurosurgery, Kashgar Prefecture Second People's Hospital, Kashgar, China
| |
Collapse
|
15
|
Abstract
Advances in neuroimaging and its widespread use for screening have increased the diagnosis of unruptured intracranial aneurysms (UIAs), including small-sized UIAs. The clinical management of these small-sized UIAs requires a patient-specific judgment of the risk of aneurysm rupture, if not treated, versus the risk of complications from surgical or endovascular treatment. Experienced cerebrovascular teams recommend treating small UIAs in young patients or in patients with more than one aneurysm rupture risk factor who also have a reasonable life expectancy. However, individual overall assessment of risk is critical for patients with UIAs to decide the next steps of care.
Collapse
Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Arnau Benet
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
16
|
Current Perspectives in Imaging Modalities for the Assessment of Unruptured Intracranial Aneurysms: A Comparative Analysis and Review. World Neurosurg 2018; 113:280-292. [PMID: 29360591 DOI: 10.1016/j.wneu.2018.01.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Intracranial aneurysms (IAs) are pathologic dilatations of cerebral arteries. This systematic review summarizes and compares imaging techniques for assessing unruptured IAs (UIAs). This review also addresses their uses in different scopes of practice. Pathophysiologic mechanisms are reviewed to better understand the clinical usefulness of each imaging modality. METHODS A literature review was performed using PubMed with these search terms: "intracranial aneurysm," "cerebral aneurysm," "magnetic resonance angiography (MRA)," computed tomography angiography (CTA)," "catheter angiography," "digital subtraction angiography," "molecular imaging," "ferumoxytol," and "myeloperoxidase". Only studies in English were cited. RESULTS Since the development and improvement of noninvasive diagnostic imaging (computed tomography angiography and magnetic resonance angiography), many prospective studies and meta-analyses have compared these tests with gold standard digital subtraction angiography (DSA). Although computed tomography angiography and magnetic resonance angiography have lower detection rates for UIAs, they are vital in the treatment and follow-up of UIAs. The reduction in ionizing radiation and lack of endovascular instrumentation with these modalities provide benefits compared with DSA. Novel molecular imaging techniques to detect inflammation within the aneurysmal wall with the goal of stratifying risk based on level of inflammation are under investigation. CONCLUSIONS DSA remains the gold standard for preoperative planning and follow-up for patients with IA. Newer imaging modalities such as ferumoxytol-enhanced magnetic resonance imaging are emerging techniques that provide critical in vivo information about the inflammatory milieu within aneurysm walls. With further study, these techniques may provide aneurysm rupture risk and prediction models for individualized patient care.
Collapse
|
17
|
Bhogal P, Martinez R, Gansladt O, Bäzner H, Henkes H, Aguilar M. Management of Unruptured Saccular Aneurysms of the M1 Segment with Flow Diversion : A Single Centre Experience. Clin Neuroradiol 2016; 28:209-216. [PMID: 27942770 DOI: 10.1007/s00062-016-0553-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/21/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The optimal strategy for the treatment of M1 segment aneurysms has not yet been determined as both standard microneurosurgical and endovascular techniques can pose challenges. We sought to determine the efficacy of flow diverting stents to treat small, unruptured aneurysms of the M1 segment. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated with flow diversion for an unruptured saccular aneurysm of the middle cerebral artery (MCA) between February 2009 and February 2016. The relationship to early cortical branches, aneurysm fundus size, number and type of flow diverting stent (FDS), complications and follow-up data were recorded. RESULTS In total 15 patients were identified that matched our inclusion criteria (11 female and 4 male). The average age of the patients was 58.3 years (range 14-76 years). All patients had a single aneurysm affecting the M1 segment of the MCA, 10 (66.6%) of which were related to early cortical branches and 10 aneurysms were located on the left (66.6%). The average aneurysm fundus size was 3 mm (range 2-9 mm) and 13 patients had follow-up angiographic studies. In total, 8 aneurysms were completely excluded, and 6 remained incompletely occluded (3 modified Raymond-Roy classification [mRRC] II and 3 mRRC IIIa). One patient suffered a stroke and another patient had an iatrogenic vessel dissection that was not flow limiting. CONCLUSION Flow diversion can be used to treat small, unruptured aneurysms of the M1 segment of the MCA and even though side vessel occlusion can occur clinically relevant infarction occurs infrequently.
Collapse
Affiliation(s)
- Pervinder Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
| | - Rosa Martinez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - Oliver Gansladt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Marta Aguilar
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| |
Collapse
|
18
|
Clinical outcome following medical treatment of cavernous malformation related epilepsy. Seizure 2016; 45:64-69. [PMID: 27936450 DOI: 10.1016/j.seizure.2016.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/05/2016] [Accepted: 11/14/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The study was conducted to assess the long-term outcome of antiepileptic drug (AED) treatment in drug-naïve patients with cavernous malformation (CM) related epilepsy (CRE). METHOD This is a retrospective, single-center, long-term observational study of 34 patients with previously untreated seizures related to CM. All patients were followed-up for at least two years. Drug resistant epilepsy (DRE) was defined as two or more seizures per year after trial of two appropriate AEDs. Patients who had only one seizure during the previous one year were assigned as "epilepsy with rare seizures (ERSs)". RESULTS Terminal 1-year seizure remission (1-YTR) was achieved in 22 (64.7%) patients, nine (26.5%) patients were diagnosed as DRE, and three (8.8%) patients were as ERSs. 1-YTR was achieved in 18 (52.9%) patients by the first drug regimen and in additional four (11.8%) patients by the second drug regimen. None of nine patients who failed to first two drug regimens did achieve 1-YTR. The location of CM in the temporal lobe was the only prognostic factor predicting a poor seizure outcome (p=0.012). CONCLUSION The outcome of AEDs therapy in patients who were presented with new onset of CRE was quite comparable with that of patients with newly diagnosed epilepsy. Failure to achieve seizure-free after adequate trials of two AEDs seems appropriate as the criteria for their referral to surgical treatment. For patients with temporal lobe CRE, earlier presurgical evaluation may be considered justifiable once they failed to an adequate trial of the first drug.
Collapse
|
19
|
Zanaty M, Daou B, Chalouhi N, Starke RM, Jabbour P, Hasan D. Evidence That a Subset of Aneurysms Less Than 7 mm Warrant Treatment. J Am Heart Assoc 2016; 5:JAHA.116.003936. [PMID: 27509908 PMCID: PMC5015310 DOI: 10.1161/jaha.116.003936] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA
| | - Badih Daou
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA
| | - Robert M Starke
- Department of Neurological Surgery and Radiology, University of Miami, FL
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA
| | - David Hasan
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA
| |
Collapse
|
20
|
Akobo S, Rizk E, Loukas M, Chapman JR, Oskouian RJ, Tubbs RS. The odontoid process: a comprehensive review of its anatomy, embryology, and variations. Childs Nerv Syst 2015; 31:2025-34. [PMID: 26254085 DOI: 10.1007/s00381-015-2866-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The odontoid process is a critical component of the cranio-cervical junction. Therefore, clinicians who diagnose, treat, or operate this region need a strong background in regard to the embryology, anatomy, and anatomical variations that may be seen for the odontoid process. METHODS A literature review was performed, using standard search engines, to explore the morphology, embryology, and anatomical variants of the odontoid process. CONCLUSIONS A sound understanding of the development of the odontoid process, both in normal and in variant forms, as well as its phenotypical morphology is a prerequisite for the diagnosis and treatment of patients presenting with disorders affecting the cranio-cervical spine.
Collapse
Affiliation(s)
- Seleipiri Akobo
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Elias Rizk
- Neurological Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | | | | | | |
Collapse
|
21
|
Abstract
In recent years, the utilization of diagnostic imaging of the brain and spine in children has increased dramatically, leading to a corresponding increase in the detection of incidental findings of the central nervous system. Patients with unexpected findings on imaging are often referred for subspecialty evaluation. Even with rational use of diagnostic imaging and subspecialty consultation, the diagnostic process will always generate unexpected findings that must be explained and managed. Familiarity with the most common findings that are discovered incidentally on diagnostic imaging of the brain and spine will assist the pediatrician in providing counseling to families and in making recommendations in conjunction with a neurosurgeon, when needed, regarding additional treatments and prognosis.
Collapse
|
22
|
Neuro-ophthalmic Assessment in Unruptured Intracranial Aneurysms. World Neurosurg 2015; 84:12-4. [PMID: 25753235 DOI: 10.1016/j.wneu.2015.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 02/28/2015] [Indexed: 11/20/2022]
|
23
|
Chalouhi N, Zanaty M, Whiting A, Yang S, Tjoumakaris S, Hasan D, Starke RM, Hann S, Hammer C, Kung D, Rosenwasser R, Jabbour P. Safety and efficacy of the Pipeline Embolization Device in 100 small intracranial aneurysms. J Neurosurg 2015; 122:1498-502. [PMID: 25635478 DOI: 10.3171/2014.12.jns14411] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Flow diverters are increasingly used for treatment of intracranial aneurysms. In most series, the Pipeline Embolization Device (PED) was used for the treatment of large, giant, complex, and fusiform aneurysms. Little is known about the use of the PED in small aneurysms. The purpose of this study was to assess the safety and efficacy of the PED in small aneurysms (≤ 7 mm). METHODS A total of 100 consecutive patients were treated with the PED at the authors' institution between May 2011 and September 2013. Data on procedural safety and efficacy were retrospectively collected. RESULTS The mean aneurysm size was 5.2 ± 1.5 mm. Seven patients (7%) had sustained a subarachnoid hemorrhage. All except 5 aneurysms (95%) arose from the anterior circulation. The number of PEDs used was 1.2 per aneurysm. Symptomatic procedure-related complications occurred in 3 patients (3%): 1 distal parenchymal hemorrhage that was managed conservatively and 2 ischemic events. At the latest follow-up (mean 6.3 months), 54 (72%) aneurysms were completely occluded (100%), 10 (13%) were nearly completely occluded (≥ 90%), and 11 (15%) were incompletely occluded (< 90%). Six aneurysms (8%) required further treatment. Increasing aneurysm size (OR 3.8, 95% CI 0.99-14; p = 0.05) predicted retreatment. All patients achieved a favorable outcome (modified Rankin Scale Score 0-2) at follow-up. CONCLUSIONS In this study, treatment of small aneurysms with the PED was associated with low complication rates and high aneurysm occlusion rates. These findings suggest that the PED is a safe and effective alternative to conventional endovascular techniques for small aneurysms. Randomized trials with long-term follow-up are necessary to determine the optimal treatment that leads to the highest rate of obliteration and the best clinical outcomes.
Collapse
Affiliation(s)
- Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Mario Zanaty
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Alex Whiting
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Steven Yang
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 2Department of Neurosurgery, University of Iowa, Iowa City, Iowa; and
| | - Robert M Starke
- 3Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Shannon Hann
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Christine Hammer
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Kung
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| |
Collapse
|
24
|
Management of cerebral cavernous malformations: from diagnosis to treatment. ScientificWorldJournal 2015; 2015:808314. [PMID: 25629087 PMCID: PMC4300037 DOI: 10.1155/2015/808314] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 08/16/2014] [Indexed: 01/01/2023] Open
Abstract
Cerebral cavernous malformations are the most common vascular malformations and can be found in many locations in the brain. If left untreated, cavernomas may lead to intracerebral hemorrhage, seizures, focal neurological deficits, or headaches. As they are angiographically occult, their diagnosis relies on various MR imaging techniques, which detect different characteristics of the lesions as well as aiding in planning the surgical treatment. The clinical presentation and the location of the lesion are the most important factors involved in determining the optimal course of treatment of cavernomas. We concisely review the literature and discuss the advantages and limitations of each of the three available methods of treatment—microsurgical resection, stereotactic radiosurgery, and conservative management—depending on the lesion characteristics.
Collapse
|
25
|
Salmeron BJ. The emotional nature of rescue medicine assessments. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:27-29. [PMID: 25674954 PMCID: PMC4332553 DOI: 10.1080/15265161.2014.990762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Betty Jo Salmeron
- NIDA-IRP, Neuroimaging Research Branch, 251 Bayview Blvd, NIDA-IRP, Baltimore, 21224, USA
| |
Collapse
|
26
|
Theofanis T, Chalouhi N, Dalyai R, Starke RM, Jabbour P, Rosenwasser RH, Tjoumakaris S. Microsurgery for cerebral arteriovenous malformations: postoperative outcomes and predictors of complications in 264 cases. Neurosurg Focus 2014; 37:E10. [DOI: 10.3171/2014.7.focus14160] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors conducted a study to assess the safety and efficacy of microsurgical resection of arteriovenous malformations (AVMs) and determine predictors of complications.
Methods
A total of 264 patients with cerebral AVMs were treated with microsurgical resection between 1994 and 2010 at the Jefferson Hospital for Neuroscience. A review of patient data was performed, including initial hemorrhage, clinical presentation, Spetzler-Martin (SM) grade, treatment modalities, clinical outcomes, and obliteration rates. Univariate and multivariate analyses were used to determine predictors of operative complications.
Results
Of the 264 patients treated with microsurgery, 120 (45%) patients initially presented with hemorrhage. There were 27 SM Grade I lesions (10.2%), 101 Grade II lesions (38.3%), 96 Grade III lesions (36.4%), 31 Grade IV lesions (11.7%), and 9 Grade V lesions (3.4%). Among these patients, 102 (38.6%) had undergone prior endovascular embolization. In all patients, resection resulted in complete obliteration of the AVM. Complications occurred in 19 (7.2%) patients and resulted in permanent neurological deficits in 5 (1.9%). In multivariate analysis, predictors of complications were increasing AVM size (OR 3.2, 95% CI 1.5–6.6; p = 0.001), increasing number of embolizations (OR 1.6, 95% CI 1.1–2.2; p = 0.01), and unruptured AVMs (OR 2.7, 95% CI 1–7.2; p = 0.05).
Conclusions
Microsurgical resection of AVMs is highly efficient and can be undertaken with low rates of morbidity at high-volume neurovascular centers. Unruptured and larger AVMs were associated with higher complication rates.
Collapse
Affiliation(s)
- Thana Theofanis
- 1 Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- 1 Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Richard Dalyai
- 1 Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- 1 Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Pascal Jabbour
- 1 Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H. Rosenwasser
- 1 Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1 Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| |
Collapse
|
27
|
Vascular endothelial growth factor blockade: A potential new therapy in the management of cerebral arteriovenous malformations. JOURNAL OF MEDICAL HYPOTHESES AND IDEAS 2014. [DOI: 10.1016/j.jmhi.2013.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
28
|
Bashir MR, Bhatti L, Marin D, Nelson RC. Emerging applications for ferumoxytol as a contrast agent in MRI. J Magn Reson Imaging 2014; 41:884-98. [PMID: 24974785 DOI: 10.1002/jmri.24691] [Citation(s) in RCA: 242] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/18/2014] [Indexed: 12/12/2022] Open
Abstract
Ferumoxytol is an ultrasmall superparamagnetic iron oxide (USPIO) agent initially approved by the Food and Drug Administration (FDA) as an iron replacement therapy for patients with anemia due to chronic renal failure. Recently, ferumoxytol has been investigated extensively as an intravenous contrast agent in magnetic resonance imaging (MRI). Since it causes regional T1 and T2 * shortening in vivo, conventional pulse sequences can be used following ferumoxytol administration to demonstrate signal enhancement or loss. Ferumoxytol can be administered as a rapid bolus and has a long intravascular half-life on the order of 14-15 hours, making it a potentially useful agent for vascular and perfusion-weighted MRI. In comparison to other USPIOs, ferumoxytol is less limited by allergic and idiosyncratic reactions. Furthermore, since ferumoxytol is an iron-based agent with no potential for causing nephrogenic systemic fibrosis, it may be useful as an alternative to gadolinium-based contrast agents in patients with compromised renal function. Ferumoxytol is ultimately taken up by macrophages/the reticuloendothelial system in the liver, spleen, and lymph nodes, and this uptake mechanism is being explored as a novel imaging technique for vascular lesions, tumors, and lymph nodes. This article reviews the properties of ferumoxytol relevant to MRI as well as many of the uses for the agent currently under investigation.
Collapse
Affiliation(s)
- Mustafa R Bashir
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | | |
Collapse
|
29
|
Stereotactic radiosurgery with neoadjuvant embolization of larger arteriovenous malformations: an institutional experience. BIOMED RESEARCH INTERNATIONAL 2014; 2014:306518. [PMID: 24579080 PMCID: PMC3919115 DOI: 10.1155/2014/306518] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 11/28/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study investigates the safety and efficacy of a multimodality approach combining staged endovascular embolizations with subsequent SRS for the management of larger AVMs. METHODS Ninety-five patients with larger AVMs were treated with staged endovascular embolization followed by SRS between 1996 and 2011. RESULTS The median volume of AVM in this series was 28 cm(3) and 47 patients (48%) were Spetzler-Martin grade IV or V. Twenty-seven patients initially presented with hemorrhage. Sixty-one patients underwent multiple embolizations while a single SRS session was performed in 64 patients. The median follow-up after SRS session was 32 months (range 9-136 months). Overall procedural complications occurred in 14 patients. There were 13 minor neurologic complications and 1 major complication (due to embolization) while four patients had posttreatment hemorrhage. Thirty-eight patients (40%) were cured radiographically. The postradiosurgery actuarial rate of obliteration was 45% at 5 years, 56% at 7 years, and 63% at 10 years. In multivariate analysis, larger AVM size, deep venous drainage, and the increasing number of embolization/SRS sessions were negative predictors of obliteration. The number of embolizations correlated positively with the number of stereotactic radiosurgeries (P < 0.005). CONCLUSIONS Multimodality endovascular and radiosurgical approach is an efficacious treatment strategy for large AVM.
Collapse
|
30
|
Zanaty M, Chalouhi N, Tjoumakaris SI, Rosenwasser RH, Jabbour PM. Endovascular management of cerebral aneurysm : review of the literature. Transl Stroke Res 2013; 5:199-206. [PMID: 24323730 DOI: 10.1007/s12975-013-0311-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/06/2013] [Accepted: 11/08/2013] [Indexed: 10/26/2022]
Abstract
Management of intracranial aneurysms remains controversial. For unruptured aneurysms, many factors should be taken into account before deciding the type of treatment and whether to treat or not. Ruptured aneurysms on the other hand are almost always treated. Still, the question remains what are the indicators that one must rely on to decide what treatment suits the patient best. We present a review on the management of intracranial aneurysm while focusing on endovascular aspects.
Collapse
Affiliation(s)
- Mario Zanaty
- Department of Neurological Surgery, Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University, 909 Walnut St., 2nd Floor, Pennsylvania, PA, 19107, USA
| | | | | | | | | |
Collapse
|
31
|
Chalouhi N, Jabbour P, Magnotta V, Hasan D. Molecular imaging of cerebrovascular lesions. Transl Stroke Res 2013; 5:260-8. [PMID: 24323714 DOI: 10.1007/s12975-013-0291-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/23/2013] [Accepted: 09/26/2013] [Indexed: 01/19/2023]
Abstract
Inflammation is a key component in the pathogenesis of cerebrovascular lesions. Two agents have emerged as promising possibilities for imaging cerebrovascular lesions. These agents are ferumoxytol and myeloperoxidase (MPO)-specific paramagnetic magnetic resonance (MR) contrast agent. Ferumoxytol is an iron oxide nanoparticle coated by a carbohydrate shell that is used in MRI studies as an inflammatory marker as it is cleared by macrophages. Ferumoxytol-enhanced MRI allows noninvasive assessment of the inflammatory status of cerebral aneurysms and arteriovenous malformations and, possibly, may differentiate "unstable" lesions that require early intervention from "stable" lesions that can be safely observed. Several pilot studies have also suggested that MPO-specific paramagnetic MR contrast agent, di-5-hydroxytryptamide of gadopentetate dimeglumine, may allow imaging of inflammation in the wall of saccular aneurysms in animal models. However, studies in human subjects have yet to be performed. In this paper, we review current data regarding ferumoxytol-enhanced MRI and MPO-specific paramagnetic MR contrast agent and discuss current and future applications.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | | | | | | |
Collapse
|
32
|
Shigematsu T, Fujinaka T, Yoshimine T, Imamura H, Ishii A, Sakai C, Sakai N. Endovascular Therapy for Asymptomatic Unruptured Intracranial Aneurysms. Stroke 2013; 44:2735-42. [DOI: 10.1161/strokeaha.111.000609] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
National registration studies (the Japanese Registry of Neuroendovascular Therapy [JR-NET] and JR-NET2) have determined the current status and outcomes of neuroendovascular therapy (neuro-EVT). We analyzed short-term outcomes of EVT for asymptomatic unruptured intracranial aneurysms (UIAs).
Methods—
We extracted periprocedural information about EVT for 4767 asymptomatic UIAs from 31 968 registered procedural records of all EVT in the JR-NET and JR-NET2 databases. We assessed the features of the aneurysms and procedures, immediate radiographic findings, procedure-related complications, and clinical outcomes at 30 days after the procedures.
Results—
We located 80.0% of UIAs in the anterior circulation, and the most frequent were paraclinoid. The diameter of 2.5%, 32.9%, 51.9%, 12.0%, and 0.7% of the UIAs was <3, 3 to 4, 5 to 9, 10 to 19, and >20 mm, respectively. EVT failed in only 2.1%. Adjunctive techniques were applied in 54.8% of procedures. Pre- and postprocedural antiplatelet agents were prescribed in 85.6% and 84.0%, respectively, of the procedures. The immediate radiographic outcomes of 57.7%, 31.9%, and 10.0% of the UIAs comprised complete occlusion, residual necks, and residual aneurysms, respectively. Complications that were associated with 9.1% of procedures comprised 2.0% hemorrhagic and 4.6% ischemic, and the 30-day morbidity and mortality rates were 2.12% and 0.31%, respectively.
Conclusions—
The radiographic results of EVT for asymptomatic UIAs in Japan were acceptable, with low mortality and morbidity rates.
Collapse
Affiliation(s)
- Tomoyoshi Shigematsu
- From the Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Japan (T.S., T.F., T.Y.); Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan (H.I., N.S.); Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan (A.I.); and Division of Neuroendovascular Treatment, Institute of Biomedical Research and Innovation, Kobe, Japan (C.S.)
| | - Toshiyuki Fujinaka
- From the Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Japan (T.S., T.F., T.Y.); Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan (H.I., N.S.); Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan (A.I.); and Division of Neuroendovascular Treatment, Institute of Biomedical Research and Innovation, Kobe, Japan (C.S.)
| | - Toshiki Yoshimine
- From the Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Japan (T.S., T.F., T.Y.); Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan (H.I., N.S.); Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan (A.I.); and Division of Neuroendovascular Treatment, Institute of Biomedical Research and Innovation, Kobe, Japan (C.S.)
| | - Hirotoshi Imamura
- From the Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Japan (T.S., T.F., T.Y.); Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan (H.I., N.S.); Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan (A.I.); and Division of Neuroendovascular Treatment, Institute of Biomedical Research and Innovation, Kobe, Japan (C.S.)
| | - Akira Ishii
- From the Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Japan (T.S., T.F., T.Y.); Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan (H.I., N.S.); Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan (A.I.); and Division of Neuroendovascular Treatment, Institute of Biomedical Research and Innovation, Kobe, Japan (C.S.)
| | - Chiaki Sakai
- From the Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Japan (T.S., T.F., T.Y.); Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan (H.I., N.S.); Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan (A.I.); and Division of Neuroendovascular Treatment, Institute of Biomedical Research and Innovation, Kobe, Japan (C.S.)
| | - Nobuyuki Sakai
- From the Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Japan (T.S., T.F., T.Y.); Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan (H.I., N.S.); Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan (A.I.); and Division of Neuroendovascular Treatment, Institute of Biomedical Research and Innovation, Kobe, Japan (C.S.)
| |
Collapse
|
33
|
Chalouhi N, Jabbour P, Magnotta V, Hasan D. The emerging role of ferumoxytol-enhanced MRI in the management of cerebrovascular lesions. Molecules 2013; 18:9670-83. [PMID: 23945642 PMCID: PMC6270297 DOI: 10.3390/molecules18089670] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 08/08/2013] [Indexed: 12/22/2022] Open
Abstract
Inflammation is increasingly being understood to be a key component to the pathophysiology of cerebrovascular lesions. Ferumoxytol, an iron oxide nanoparticle coated by a carbohydrate shell, has been used in MRI studies as an inflammatory marker because it is cleared by macrophages. Ferumoxytol-enhanced MRI has emerged as an important tool for noninvasive assessment of the inflammatory status of cerebrovascular lesions, namely aneurysms and arteriovenous malformations. Moreover, preliminary evidence suggests that ferumoxytol-enhanced MRI could be applied as a non-invasive tool to differentiate “unstable” lesions that require early intervention from “stable” lesions in which observation may be safe. Assessment of the effects of anti-inflammatory pharmacological interventions on cerebrovascular lesions is also a potentially crucial application of the technique. Future improvements in technique and MRI signal quantification will certainly pave the way for widespread and efficient use of ferumoxytol-enhanced MRI in clinical practice. In this paper, we review current data regarding ferumoxytol-enhanced MRI and discuss its current/potential applications and future perspectives.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA; E-Mails: (N.C.); (P.J.)
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA; E-Mails: (N.C.); (P.J.)
| | - Vincent Magnotta
- Department of Neurosurgery, University of Iowa, Iowa City, IA 52242, USA; E-Mail:
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, IA 52242, USA; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-319-384-8669; Fax: +1-319-356-2237
| |
Collapse
|
34
|
Hasan DM, Chalouhi N, Jabbour P, Dumont AS, Kung DK, Magnotta VA, Young WL, Hashimoto T, Richard Winn H, Heistad D. Evidence that acetylsalicylic acid attenuates inflammation in the walls of human cerebral aneurysms: preliminary results. J Am Heart Assoc 2013; 2:e000019. [PMID: 23525414 PMCID: PMC3603234 DOI: 10.1161/jaha.112.000019] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Inflammatory cells and molecules may play a critical role in formation and rupture of cerebral aneurysms. Recently, an epidemiologic study reported that acetylsalicylic acid (ASA) decreases the risk of aneurysm rupture. The goal of this study was to determine the effects of ASA on inflammatory cells and molecules in the walls of human cerebral aneurysms, using radiographic and histological techniques. Methods and Results Eleven prospectively enrolled patients harboring unruptured intracranial aneurysms were randomized into an ASA‐treated (81 mg daily) group (n=6) and an untreated (control) group (n=5). Aneurysms were imaged at baseline using ferumoxytol‐enhanced MRI to estimate uptake by macrophages. After 3 months, patients were reimaged before undergoing microsurgical clipping. Aneurysm tissues were collected for immunostaining with monoclonal antibodies for cyclooxygenase‐1 (COX‐1), cyclooxygenase‐2 (COX‐2), microsomal prostaglandin E2 synthase‐1 (mPGES‐1), and macrophages. A decrease in signal intensity on ferumoxytol‐enhanced MRI was observed after 3 months of ASA treatment. Expression of COX‐2 (but not COX‐1), mPGES‐1, and macrophages was lower in the ASA group than in the control group. Conclusions This study provides preliminary radiographical and histological evidence that ASA may attenuate the inflammatory process in the walls of human cerebral aneurysms. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01710072.
Collapse
Affiliation(s)
- David M Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Functional reorganization oF the primary motor cortex in a patient with a large arteriovenous malFormation involving the precentral gyrus. Transl Neurosci 2013. [DOI: 10.2478/s13380-013-0122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractIt is known that the brain can compensate for deficits induced by acquired and developmental lesions through functional reorganization of the remaining parenchyma. Arteriovenous malformations (AVM) usually appear prenatally before a functional regional organization of the brain is fully established and patients generally do not present with motor deficits even when the AVM is located in the primary motor area indicating the redistribution of functions in cortical areas that are not pathologically altered. Here we present reorganization of the motor cortex in a patient with a large AVM involving most of the left parietal lobe and the paramedian part of the left precentral gyrus that is responsible for controlling the muscles of the lower limbs. Functional MRI showed that movements of both the right and left feet activated only the primary motor cortex in the right hemisphere, while there was no activation in the left motor cortex. This suggests that complete ipsilateral control over the movements of the right foot had been established in this patient. A reconstruction of the corticospinal tract using diffusion tensor imaging showed a near-complete absence of corticospinal fibers from the part of the left precentral gyrus affected by the AVM. From this clinical presentation it can be concluded that full compensation of motor deficits had occurred by redistributing function to the corresponding motor area of the contralateral
Collapse
|
36
|
Chalouhi N, Ali MS, Starke RM, Jabbour PM, Tjoumakaris SI, Gonzalez LF, Rosenwasser RH, Koch WJ, Dumont AS. Cigarette smoke and inflammation: role in cerebral aneurysm formation and rupture. Mediators Inflamm 2012; 2012:271582. [PMID: 23316103 PMCID: PMC3532877 DOI: 10.1155/2012/271582] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 10/27/2012] [Indexed: 12/17/2022] Open
Abstract
Smoking is an established risk factor for subarachnoid hemorrhage yet the underlying mechanisms are largely unknown. Recent data has implicated a role of inflammation in the development of cerebral aneurysms. Inflammation accompanying cigarette smoke exposure may thus be a critical pathway underlying the development, progression, and rupture of cerebral aneurysms. Various constituents of the inflammatory response appear to be involved including adhesion molecules, cytokines, reactive oxygen species, leukocytes, matrix metalloproteinases, and vascular smooth muscle cells. Characterization of the molecular basis of the inflammatory response accompanying cigarette smoke exposure will provide a rational approach for future targeted therapy. In this paper, we review the current body of knowledge implicating cigarette smoke-induced inflammation in cerebral aneurysm formation/rupture and attempt to highlight important avenues for future investigation.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Muhammad S. Ali
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Robert M. Starke
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Pascal M. Jabbour
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Stavropoula I. Tjoumakaris
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - L. Fernando Gonzalez
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Robert H. Rosenwasser
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Walter J. Koch
- Center for Translational Medicine and George Zallie and Family Laboratory for Cardiovascular Gene Therapy, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Aaron S. Dumont
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA
| |
Collapse
|
37
|
Hasan D, Chalouhi N, Jabbour P, Dumont AS, Kung DK, Magnotta VA, Young WL, Hashimoto T, Winn HR, Heistad D. Early change in ferumoxytol-enhanced magnetic resonance imaging signal suggests unstable human cerebral aneurysm: a pilot study. Stroke 2012; 43:3258-65. [PMID: 23138441 DOI: 10.1161/strokeaha.112.673400] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The clinical significance of early (ie, within the first 24 hours) uptake of ferumoxytol by macrophages in the wall of human cerebral aneurysms is not clear. The purpose of this study was to determine whether early uptake of ferumoxytol suggests unstable cerebral aneurysm. METHODS Thirty unruptured aneurysms in 22 patients were imaged with magnetic resonance imaging 24 hours after infusion of ferumoxytol. Eighteen aneurysms were also imaged 72 hours after infusion of ferumoxytol. Aneurysm dome tissue was collected from 4 patients with early magnetic resonance imaging signal changes, 5 patients with late signal changes, and 5 other patients with ruptured aneurysms. The tissue was immunostained for expression of cyclooxygenase-1, cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages. RESULTS In 23% (7/30) of aneurysms, there was pronounced early uptake of ferumoxytol. Four aneurysms were clipped. The remaining 3 aneurysms were managed conservatively; all 3 ruptured within 6 months. In 53% (16 of 30) of aneurysms, there was pronounced uptake of ferumoxytol at 72 hours. Eight aneurysms were surgically clipped, and 8 were managed conservatively; none ruptured or increased in size after 6 months. Expression of cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages was similar in unruptured aneurysms with early uptake of ferumoxytol and ruptured aneurysms. Expression of these inflammatory molecules was significantly higher in aneurysms with early uptake of ferumoxytol versus aneurysms with late uptake. CONCLUSIONS Uptake of ferumoxytol in aneurysm walls within the first 24 hours strongly suggests aneurysm instability and probability of rupture within 6 months, and may warrant urgent intervention.
Collapse
Affiliation(s)
- David Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, JCP 1616, Iowa City, IA 52242, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Chalouhi N, Jabbour P, Andrews DW. Stereotactic radiosurgery for cavernous malformations: is it effective? World Neurosurg 2012; 80:e185-6. [PMID: 23111229 DOI: 10.1016/j.wneu.2012.10.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 10/23/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | | | | |
Collapse
|
39
|
Chalouhi N, Theofanis T, Jabbour P, Dumont AS, Gonzalez LF, Starke RM, Dalyai RT, Hann S, Rosenwasser R, Tjoumakaris S. Safety and Efficacy of Intraoperative Angiography in Craniotomies for Cerebral Aneurysms and Arteriovenous Malformations. Neurosurgery 2012; 71:1162-9. [DOI: 10.1227/neu.0b013e318271ebfc] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
In an era of indocyanine angiography, the routine use of intraoperative angiography (IOA) in the surgical treatment of aneurysms and vascular malformations is controversial.
OBJECTIVE:
To retrospectively assess the safety and efficacy of IOA and to determine predictors of surgical revision.
METHODS:
Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 101 arteriovenous malformations (AVMs), and 16 arteriovenous fistulas.
RESULTS:
In 80 of 976 aneurysms (8.2%), IOA prompted clip repositioning. The reason for readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both in 2.4% of cases. In multivariate analysis, increasing aneurysm size (P < .001), ruptured aneurysm (P < .001), and increasing number of vessels injected (P < .001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (P = .06). IOA revealed residual nidus/fistula requiring further intervention in 9 of 101 AVMs (8.9%) and 3 of 16 arteriovenous fistulas (18.8%). Of 9 AVMs requiring a surgical revision, 2 (22.2%) were Spetzler-Martin grade II, 5 (55.6%) were grade III, and 2 (22.2%) were grade IV. Mean Spetzler-Martin grade was 3.0 in AVMs requiring surgical revision compared with 2.3 in those not requiring revision (P = .05). IOA-related complications were all transient or minor and occurred in 0.99% of patients; none resulted in permanent morbidity.
CONCLUSION:
IOA remains a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in > 8% of cases. Easy access to an angiographer and routine use of IOA are important factors contributing to procedural safety and efficacy.
Collapse
Affiliation(s)
- Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Thana Theofanis
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aaron S. Dumont
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - L. Fernando Gonzalez
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Richard T. Dalyai
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Shannon Hann
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| |
Collapse
|
40
|
De Novo MGC4607 Gene Heterozygous Missense Variants in a Child with Multiple Cerebral Cavernous Malformations. J Mol Neurosci 2012; 47:475-80. [DOI: 10.1007/s12031-012-9741-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/27/2012] [Indexed: 10/28/2022]
|