1
|
Ramesh R, Haddad AF, Letchuman V, Lee YM, Rinaldo L, Abla AA, Savastano LE, Raper DMS. Patient-reported outcome measures in cerebrovascular neurosurgery. J Neurosurg 2024; 140:1357-1368. [PMID: 38000069 DOI: 10.3171/2023.9.jns231067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/05/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE The object of this study was to describe the use of patient-reported outcome measures (PROMs) in cerebrovascular neurosurgery and to outline a framework for incorporating them into future cerebrovascular research. METHODS Following the standardized PRISMA guidelines, the authors performed a search of the PubMed and Embase databases in February 2023 using filters to investigate six specific cerebrovascular pathologies/procedures: subarachnoid hemorrhage (SAH), intracranial hemorrhage, ischemic stroke, arteriovenous malformation, chronic subdural hematoma, and carotid artery stenosis. PROMs in the identified articles were distinguished and classified as generic, symptom specific, or disease specific. RESULTS A total of 259 studies including 51 PROMs were eligible for inclusion in the review. Most of the PROMs were generic or symptom specific. Only 5 PROMs were disease specific, and all of these pertained to stroke or SAH. CONCLUSIONS There are only a limited number of disease-specific PROMs available for cerebrovascular pathologies and outcomes. Further validation of existing measures in independent cohorts, expanded incorporation of disease-specific PROMs in prospective trials, and the development of new PROMs specific to cerebrovascular conditions are critical to a better understanding of the impact of cerebrovascular diseases and novel therapies on patient lives.
Collapse
Affiliation(s)
- Rithvik Ramesh
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Young M Lee
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Lorenzo Rinaldo
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Luis E Savastano
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California
| |
Collapse
|
2
|
Osorio RC, Raygor KP, Rinaldo L, Fox CK, Bhasin N, Abla AA, Gupta N. Risk factors associated with in-hospital complications for pediatric sickle-cell disease-associated moyamoya syndrome: a nationwide cross-sectional study. Childs Nerv Syst 2024:10.1007/s00381-024-06363-2. [PMID: 38530413 DOI: 10.1007/s00381-024-06363-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Sickle-cell disease-associated moyamoya syndrome (SCD-MMS) carries a high risk for recurrent strokes and cerebrovascular morbidity in children. However, few data are available about complications that occur in children hospitalized with SCD-MMS. The purpose of this analysis was to determine the risk factors for in-hospital complications in pediatric SCD-MMS admissions, and thus aid physicians in optimizing future treatment plans. METHODS A national database of pediatric hospital admissions was examined across the years 2003-2019. ICD-9 and ICD-10 diagnosis codes were analyzed to identify discharges with a primary diagnosis of SCD-MMS and identify in-hospital complications, defined as complication-associated diagnostic codes logged during the same admission. Patient demographics, comorbidities, and hospital characteristics were examined using univariate and multivariate logistic regression analyses to determine associations with in-hospital complications. RESULTS In total, 274 admissions with a primary diagnosis of SCD-MMS were identified. During 64 (23.4%) admissions, transfusion therapy was given, and in 86 admissions (31.4%), surgical revascularization was performed. In 10 admissions (3.6%), a total of 11 in-hospital complications were identified. After multivariate regression, both comorbid chronic lung disease (adjusted OR 5.3 [1.1, 26.9], P = 0.04) and surgical revascularization (adjusted OR 10.2 [2.0, 52.4], P = 0.006) were associated with development of complications. CONCLUSIONS In this nationwide database of pediatric SCD-MMS hospitalizations, comorbid chronic lung disease and surgical revascularization were associated with development of in-hospital complications. Patients with comorbid chronic lung disease or who are admitted for revascularization may warrant closer monitoring and greater medical optimization during the hospitalization.
Collapse
Affiliation(s)
- Robert C Osorio
- Department of Neurological Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, USA
| | - Lorenzo Rinaldo
- Department of Neurological Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, USA
| | - Christine K Fox
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Neha Bhasin
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, USA.
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
3
|
Becerril-Gaitan A, Ding D, Ironside N, Buell TJ, Kansagra AP, Lanzino G, Brinjikji W, Kim L, Levitt MR, Abecassis IJ, Bulters D, Durnford A, Fox WC, Blackburn S, Chen PR, Polifka AJ, Laurent D, Gross B, Hayakawa M, Derdeyn C, Amin-Hanjani S, Alaraj A, van Dijk JMC, Potgieser ARE, Starke RM, Peterson EC, Satomi J, Tada Y, Abla AA, Winkler EA, Du R, Lai PMR, Zipfel GJ, Chen CJ, Sheehan JP. The VEBAS score: a practical scoring system for intracranial dural arteriovenous fistula obliteration. J Neurointerv Surg 2024; 16:272-279. [PMID: 37130751 DOI: 10.1136/jnis-2023-020282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Tools predicting intracranial dural arteriovenous fistulas (dAVFs) treatment outcomes remain scarce. This study aimed to use a multicenter database comprising more than 1000 dAVFs to develop a practical scoring system that predicts treatment outcomes. METHODS Patients with angiographically confirmed dAVFs who underwent treatment within the Consortium for Dural Arteriovenous Fistula Outcomes Research-participating institutions were retrospectively reviewed. A subset comprising 80% of patients was randomly selected as training dataset, and the remaining 20% was used for validation. Univariable predictors of complete dAVF obliteration were entered into a stepwise multivariable regression model. The components of the proposed score (VEBAS) were weighted based on their ORs. Model performance was assessed using receiver operating curves (ROC) and areas under the ROC. RESULTS A total of 880 dAVF patients were included. Venous stenosis (presence vs absence), elderly age (<75 vs ≥75 years), Borden classification (I vs II-III), arterial feeders (single vs multiple), and past cranial surgery (presence vs absence) were independent predictors of obliteration and used to derive the VEBAS score. A significant increase in the likelihood of complete obliteration (OR=1.37 (1.27-1.48)) with each additional point in the overall patient score (range 0-12) was demonstrated. Within the validation dataset, the predicted probability of complete dAVF obliteration increased from 0% with a 0-3 score to 72-89% for patients scoring ≥8. CONCLUSION The VEBAS score is a practical grading system that can guide patient counseling when considering dAVF intervention by predicting the likelihood of treatment success, with higher scores portending a greater likelihood of complete obliteration.
Collapse
Affiliation(s)
- Andrea Becerril-Gaitan
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Dale Ding
- Neurosurgery Department, University of Louisville, Louisville, Kentucky, USA
| | - Natasha Ironside
- Neurosurgery Department, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas J Buell
- Neurosurgery Department, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Akash P Kansagra
- Neurosurgery Department, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Louis Kim
- Neurosurgery Department, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Neurosurgery Department, University of Washington, Seattle, Washington, USA
| | | | - Diederik Bulters
- Neurosurgery Department, University of Southampton, Southampton, UK
| | - Andrew Durnford
- Neurosurgery Department, University of Southampton, Southampton, UK
| | - W Christopher Fox
- Neurosurgery Department, Mayo Clinic Jacksonville Campus, Jacksonville, Florida, USA
| | - Spiros Blackburn
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Peng Roc Chen
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Adam J Polifka
- Neurosurgery Department, University of Florida, Gainesville, Florida, USA
| | - Dimitri Laurent
- Neurosurgery Department, University of Florida, Gainesville, Florida, USA
| | - Bradley Gross
- Neurosurgery Department, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Minako Hayakawa
- Radiology and Interventional Radiology Department, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Colin Derdeyn
- Radiology and Interventional Radiology Department, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sepideh Amin-Hanjani
- Neurosurgery Department, University Hospitals/Case Western Reserve University, Cleveland, Ohio, USA
| | - Ali Alaraj
- Neurosurgery Department, University of Illinois Chicago, Chicago, Illinois, USA
| | - J Marc C van Dijk
- Neurosurgery Department, University of Groningen, Groningen, The Netherlands
| | | | - Robert M Starke
- Neurosurgery Department, University of Miami Miller School of Medicine, Miami, Florida, USA
- Radiology Department, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric C Peterson
- Neurosurgery Department, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Junichiro Satomi
- Neurosurgery Department, University of Tokushima, Tokushima, Japan
| | - Yoshiteru Tada
- Neurosurgery Department, University of Tokushima, Tokushima, Japan
| | - Adib A Abla
- Neurosurgery Department, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Neurosurgery Department, University of California San Francisco, San Francisco, California, USA
| | - Rose Du
- Neurosurgery Department, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pui Man Rosalind Lai
- Neurosurgery Department, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory J Zipfel
- Neurosurgery Department, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ching-Jen Chen
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason P Sheehan
- Neurosurgery Department, University of Virginia Health System, Charlottesville, Virginia, USA
| |
Collapse
|
4
|
Raygor KP, Caton MT, Tonetti DA, Baker A, Dubnicoff TB, Abla AA. Staged stent-assisted, transcirculatory coiling of partially-thrombosed, mixed saccular and fusiform SCA aneurysm. Interv Neuroradiol 2024; 30:126. [PMID: 35850562 PMCID: PMC10956447 DOI: 10.1177/15910199221108312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/11/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022] Open
Abstract
SCA aneurysms are rare, making data on their management sparse compared to other posterior circulation aneurysms. While saccular aneurysms at the SCA origin can be treated with primary coiling or surgical clipping, fusiform and distal SCA aneurysms often require endovascular techniques such as stent-assisted coil embolization or parent vessel occlusion. We present a case of a mixed saccular/fusiform SCA aneurysm that underwent staged stent-assisted coil embolization. A right SCA stent was placed in the first stage. Given the acute angle between the BA and the SCA, microcatheter access and stent placement proved challenging. The decision was made to allow the stent to endothelialize and return in a staged fashion to perform a trans-radial, transcirculatory (trans-left PCoA, trans-left PCA) coil embolization. This provided a straight course between the left P1 segment and the right SCA origin, allowing easy microcatheter navigation through the stent and into the aneurysm for coil embolization.
Collapse
Affiliation(s)
- Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - M Travis Caton
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Todd B Dubnicoff
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| |
Collapse
|
5
|
Raygor KP, Caton MT, Tonetti DA, Dubnicoff TB, Abla AA. Intermediate-porosity stent for coil-reconstruction of mixed saccular-fusiform basilar trunk aneurysm. Interv Neuroradiol 2024; 30:127. [PMID: 35916413 PMCID: PMC10956458 DOI: 10.1177/15910199221113643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/16/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Vertebrobasilar junction and basilar trunk aneurysms are extremely difficult to treat, with significant morbidity associated with bypass-trapping procedures. As a result, endovascular techniques including flow diversion and stent-assisted coil embolization have become the mainstay of treatment.1-3 Traditional flow diverters pose risk of occlusion of basilar perforator arteries while traditional stents used as adjuncts for coil-embolization often have high porosity and cannot function as flow diverters. On the other hand, the LVIS stent uniquely provides more porosity than other flow diverters,4,5 allowing patency of perforators while also being amenable to stent-assisted coiling. We present a case of a mixed saccular and fusiform basilar trunk aneurysm that underwent LVIS stent-assisted coil embolization. Using bifemoral access with triaxial systems, one microcatheter was placed in the aneurysm sac and another was used to deploy a stent from the basilar apex into the right vertebral artery. A durable angiographic outcome was observed at 9 months.
Collapse
Affiliation(s)
- Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - M Travis Caton
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Todd B Dubnicoff
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| |
Collapse
|
6
|
Reynolds CD, Caton MT, Baker A, Smith ER, Amans MR, Cooke DL, Dowd CF, Higashida RT, Gupta N, Abla AA, Auguste K, Fox CH, Fullerton H, Hetts SW. Clarifying the clinical landscape of pediatric spinal arteriovenous shunts: an institutional experience and individual patient-data meta-analysis. J Neurointerv Surg 2023; 16:94-100. [PMID: 36922033 DOI: 10.1136/jnis-2022-019797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Pediatric spinal arteriovenous shunts (SAVS) are rare lesions with heterogeneous pathogenesis and clinical manifestations. OBJECTIVE To evaluate the clinical characteristics, angioarchitecture, and technical/clinical outcomes in SAVS through a large single-center cohort analysis and meta-analysis of individual patient data. METHODS A retrospective institutional database identified children (aged 0-21 years) who underwent digital subtraction spinal angiography (DSA) for SAVS between January 1996 and July 2021. Clinical data were recorded to evaluate angioarchitecture, generate modified Aminoff-Logue gait disturbance scores (AL) and McCormick grades (MC), and assess outcomes. We then performed a systematic literature review following PRISMA-IPD (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for individual patient data) guidelines, extracting similar data on individual patients for meta-analysis. RESULTS The cohort consisted of 28 children (M:F=11:17) with 32 SAVS lesions, with a mean age of 12.8±1.1 years at diagnosis. At presentation, SAVS were most highly concentrated in the cervical region (40.6%). Children had a median AL=2 and MC=2, with thoracolumbar AVS carrying the greatest disability. Among treated cases, complete obliteration was achieved in 48% of cases and median AL scores and MC grades both improved by one point. Systematic literature review identified 161 children (M:F=96:65) with 166 SAVS lesions with a mean age of 8.7±0.4 years. Among studies describing symptom chronicity, 37/51 (72.5%) of children presented acutely. At presentation, children had a median AL=4 and MC=3, with thoracolumbar AVS carrying the highest MC grades. After intervention, median AL and MC both improved by one point. CONCLUSIONS This study provides epidemiologic information on the location, onset, and presentation of the full spectrum of pediatric SAVS, highlighting the role of targeted treatment of high-risk features.
Collapse
Affiliation(s)
- Conner D Reynolds
- Department of Medical Imaging, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - M Travis Caton
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Eric R Smith
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kurtis Auguste
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christine H Fox
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Heather Fullerton
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
7
|
Rinaldo L, Wilkinson S, Dubnicoff TB, Rubio RR, Abla AA. Transpeduncular Approach for Resection of Ruptured Fourth Ventricular Arteriovenous Malformation. World Neurosurg 2023; 180:69. [PMID: 37714456 DOI: 10.1016/j.wneu.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023]
Abstract
The lateral recess of the fourth ventricle can be challenging to access surgically. We present a case of a previously ruptured arteriovenous malformation (AVM) of the fourth ventricle that was surgically resected via a retrosigmoid craniotomy and transinferior cerebellar peduncular approach. The patient is a 54-year-old female who experienced an intraventricular hemorrhage several months before presentation to our institution. Imaging studies suggested the presence of an AVM located in the right lateral recess of the fourth ventricle. After discussion of all possible treatment options, the patient elected to proceed with surgical resection. To access the lesion, we performed a retrosigmoid craniotomy and entered into the fourth ventricle via s small incision in the inferior cerebellar peduncle. Postoperative imaging demonstrated complete removal of the AVM nidus. Video 1 demonstrates this approach and discusses the anatomic landmarks used to guide resection.
Collapse
Affiliation(s)
- Lorenzo Rinaldo
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean Wilkinson
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Todd B Dubnicoff
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.
| |
Collapse
|
8
|
Rinaldo L, Abla AA. Trapping and side-to-end superior cerebellar artery to superior cerebellar artery bypass for treatment of fusiform superior cerebellar artery aneurysm. J Clin Neurosci 2023; 118:12-15. [PMID: 37832265 DOI: 10.1016/j.jocn.2023.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/26/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023]
Abstract
We describe the technical nuances of in-situ bypass for treatment of a fusiform superior cerebellar artery (SCA) aneurysm via surgical trapping and a side-to-end in-situ bypass between duplicated SCAs. Our patient is a 40-year-old male who presented with an incidental aneurysm of the proximal right superior cerebellar artery (SCA). Formal angiography was performed that demonstrated a fusiform morphology of the aneurysm, as well as a duplicated SCA on that side. After extensive counseling, the patient elected to undergo surgical clip reconstruction with possible bypass. A large frontotemporal craniotomy was performed and a combined transsylvian-subtemporal approach to the ventral anterolateral brainstem was performed. After identifying the aneurysm, the tentorium was incised posterior to the insertion of the trochlear nerve to widen the operative field. An end-to-side anastomosis between the duplicated SCAs was performed, followed by trapping of the diseased arterial segment. The patient had an oculomotor nerve palsy post-operatively, however this resolved by his six-month follow-up. In-situ bypass is a viable technique for revascularizing the SCA territory during clip reconstruction of fusiform aneurysms. A duplicated SCA allows for an SCA to SCA bypass. Incising the tentorium can increase visualization of donor and recipient vessels and facilitate performance of the anastomosis.
Collapse
Affiliation(s)
- Lorenzo Rinaldo
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Adib A Abla
- Department of Neurologic Surgery, University of Miami School of Medicine, Miami, FL, USA.
| |
Collapse
|
9
|
Rinaldo L, Rodriguez Rubio R, Abla AA. Use of Proximal Suboccipital Segment of Occipital Artery as Donor for Posterior Circulation Revascularization Surgery: Technical Note. World Neurosurg 2023; 180:37-41. [PMID: 37741336 DOI: 10.1016/j.wneu.2023.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The distal suboccipital segment of the occipital artery is commonly used as a donor vessel for aneurysms of the posterior circulation requiring revascularization techniques. Isolating this segment of vessel can be challenging due to its course in and out of the various layers of the suboccipital musculature. METHODS We describe the use of the proximal suboccipital segment of the occipital artery within the occipital groove at the lateral skull base as a donor segment for an interposition graft in revascularization surgery. We present a case detailing the use of this technique for treatment of a dissecting PICA aneurysm and photographs from cadaveric dissections demonstrating relevant anatomy. RESULTS Our patient is a 62-year-old man who presented with a high-grade subarachnoid hemorrhage from a proximal dissecting-type aneurysm of the posterior inferior cerebellar artery (PICA). Endovascular options were limited to coil sacrifice of the parent vessel, and thus the patient was taken for a far lateral craniotomy, trapping of the aneurysm, and revascularization of the PICA territory via a saphenous vein interposition graft sewn proximally and distally to the occipital artery within the occipital groove and a cortical segment of the affected PICA, respectively. Postoperative imaging demonstrated filling of the PICA territory via the graft, and the patient ultimately recovered from his subarachnoid hemorrhage. CONCLUSIONS The use of the proximal suboccipital segment of the occipital artery is a viable option for a donor in posterior fossa revascularization surgery.
Collapse
Affiliation(s)
- Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Roberto Rodriguez Rubio
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA.
| |
Collapse
|
10
|
Raygor KP, Rinaldo L, Dubnicoff TB, Shih T, Chang EF, Abla AA. Awake Craniotomy and Electrocorticography-Guided Extended Lesionectomy of Motor Cortex Cavernoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e286. [PMID: 37441797 DOI: 10.1227/ons.0000000000000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 05/19/2023] [Indexed: 07/15/2023] Open
Affiliation(s)
- Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Lorenzo Rinaldo
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Todd B Dubnicoff
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Tina Shih
- Department of Neurology, University of California, San Francisco, California, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| |
Collapse
|
11
|
Bartoletti V, Norri N, El-Sayed I, Abla AA, Rodriguez Rubio R. Endonasal Endoscopic Anatomy of the Orbito-Cavernous-Pterygopalatine Interface: Multilayer Anatomical Description and Landmarks to Define the Limits of the Compartments. World Neurosurg 2023; 178:e79-e95. [PMID: 37422190 DOI: 10.1016/j.wneu.2023.06.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Despite growing interest in the endoscopic endonasal approach (EEA) to the medial orbital apex (OA), a comprehensive description of the multilayer topology lying at the intersection of the regional compartments is missing. METHODS An EEA to the OA, pterygopalatine fossa, and cavernous sinus was performed in 20 specimens. A 360° layer-by-layer dissection was performed taking into consideration relevant anatomical aspects of the interface and documented with 3-dimensional technologies. Endoscopic landmarks were analyzed to provide an outline of the compartments and identify critical structures. Additionally, the consistency of a previously described reference called orbital apex convergence prominence was analyzed and a method to identify its position was introduced. RESULTS The orbital apex convergence prominence was an inconsistent finding (15%). However, a craniometric method introduced in this study proved to be reliable to reach the orbital apex convergence point. Additional structures such as the sphenoethmoidal suture and a 3-suture junction (sphenoethmoidal-palatoethmoidal-palatosphenoidal) helped to identify the posterior limit of the OA and define a keyhole to access the compartments of the interface. We defined the bone limits of the "optic risk zone," an area where the optic nerve is more susceptible to damage. Furthermore, an orbital fusion line (periorbita-dura-periosteum) was identified and divided into 4 segments according to adjacent structures: optic, cavernous, pterygopalatine, and infraorbital. CONCLUSIONS Understanding cranial landmarks and the folds of the layers covering the orbito-cavernous-pterygopalatine interface can facilitate tailoring an EEA to the medial orbital space and avoid unnecessary exposure of sensitive anatomy in the vicinity.
Collapse
Affiliation(s)
- Viola Bartoletti
- Neurosurgery, Department of Neuroscience, University of Padua, Padua, Italy; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Nicolo Norri
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Neurosurgery Department, Sant'Anna University Hospital, Ferrara, Italy
| | - Ivan El-Sayed
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Adib A Abla
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA.
| |
Collapse
|
12
|
Garcia JH, Carrete L, Rutledge WC, Raygor KP, Winkler EA, Pereira MP, Nelson J, Kim H, Cooke DL, Hetts SW, Lawton MT, Abla AA. Factors Associated with Unfavorable Clinical Presentations in Patients with Ruptured BrainArteriovenous Malformations. World Neurosurg 2023; 178:e72-e78. [PMID: 37422187 DOI: 10.1016/j.wneu.2023.06.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Rupture of brain arteriovenous malformations (bAVMs) carries potentially devastating consequences. For patients presenting with ruptured bAVMs, several clinical grading systems have been shown to predict long-term patient morbidity and may be taken into consideration when making clinical decisions. Unfortunately, use of these scoring systems is typically limited to their prognostic value and offer little to patients in therapeutic benefit. Tools are needed not only to predict prognosis for patients experiencing ruptured bAVMs but to gain insight into what characteristics predispose patients to poor long-term outcomes before they rupture. Our objective was to find clinical, morphologic, and demographic variables that correlate with unfavorable clinical grades on presentation in patients with ruptured bAVMs. METHODS We retrospectively reviewed a cohort of patients with ruptured bAVMs. Linear regression models were used to test whether Glasgow Coma Scale (GCS) and Hunt-Hess scores on presentation(outcomes) were associated with patient and arteriovenous malformation (AVM) characteristics (predictors) individually. RESULTS GCS and Hunt-Hess were assessed following bAVM rupture for 121 brain cases. The median age at rupture was 28.5 years, and 62 (51%) were female. Smoking history was associated with worse GCS; current and past smokers had GCS scores 1.33 points lower on average than nonsmokers (95% confidence interval [CI] -2.59 to -0.07, P = 0.039) and had worse Hunt-Hess scores (0.42, 95% CI 0.07-0.77, P = 0.019). Associated aneurysms were associated with worse GCS (-1.60, 95% CI -3.16 to -0.05, P = 0.043) and trended towards worse Hunt-Hess scores (0.42 points, 95% CI -0.01 to 0.86, P = 0.057). CONCLUSIONS Patient smoking status and presence of an AVM associated aneurysm were shown to have modest correlations with unfavorable clinical grades (Hunt-Hess, GCS) on presentation, with unfavorable clinical grades being associated with long-term patient prognosis following bAVM rupture. Further investigation using AVM-specific grading scales and external data are needed to determine the utility of these and other variables in clinical practice for patients with bAVM.
Collapse
Affiliation(s)
- Joseph H Garcia
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Luis Carrete
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matheus Prado Pereira
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
| |
Collapse
|
13
|
Rinaldo L, Morshed RA, Wilkinson S, Dubnicoff TB, Abla AA. Intradural Anterior Petrosectomy for In Situ Occlusion of Ruptured Trigeminal Nerve Root Entry Zone Arteriovenous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e159-e160. [PMID: 37195060 DOI: 10.1227/ons.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/16/2023] [Indexed: 05/18/2023] Open
Affiliation(s)
- Lorenzo Rinaldo
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramin A Morshed
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Sean Wilkinson
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Todd B Dubnicoff
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
14
|
Tawil ME, Chryssikos T, Rechav Ben-Natan A, Ambati VS, Guney E, Shah V, Abla AA, Mummaneni PV. Resection of a Thoracic Intradural Extramedullary Cavernoma Using Real-Time Intraoperative Ultrasound: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e174. [PMID: 37306964 PMCID: PMC10637418 DOI: 10.1227/ons.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/06/2023] [Indexed: 06/13/2023] Open
Affiliation(s)
- Michael E. Tawil
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Timothy Chryssikos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Alma Rechav Ben-Natan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Vardhaan S. Ambati
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ekin Guney
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Vinil Shah
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Adib A. Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
15
|
Graffeo CS, Srinivasan VM, Frisoli F, Lang MJ, Mascitelli JR, Burkhardt JK, Walcott BP, Owen CM, Rodriguez-Hernandez A, Abla AA. Commentary: Twenty Years, 10 Fellows, 1 Article: Reflections on Cerebrovascular Training and the Evolution of Basilar Apex Aneurysm Treatments. Neurosurgery 2023; 93:e7-e9. [PMID: 37074050 DOI: 10.1227/neu.0000000000002500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 04/20/2023] Open
Affiliation(s)
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia , Pennsylvania , USA
| | - Fabio Frisoli
- Atlantic Neurosurgical Specialists, Morristown , New Jersey , USA
| | - Michael J Lang
- Department of Neurosurgery, UPMC, Pittsburgh , Pennsylvania , USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas San Antonio, San Antonio , Texas , USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia , Pennsylvania , USA
| | - Brian P Walcott
- Department of Neurosurgery, University of Oklahoma, Norman , Oklahoma , USA
- Department of Neurosurgery, University of Pennsylvania, Philadelphia , Pennsylvania , USA
- Atlantic Neurosurgical Specialists, Morristown , New Jersey , USA
- Department of Neurosurgery, UPMC, Pittsburgh , Pennsylvania , USA
- Department of Neurosurgery, University of Texas San Antonio, San Antonio , Texas , USA
- Department of Neurosurgery, Kaiser Permanente Orange County Anaheim Medical Center, Anaheim , California , USA
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Universidad Autónoma, Barcelona , Spain
- Department of Neurological Surgery, UCSF, San Francisco , California , USA
| | - Christopher M Owen
- Department of Neurosurgery, Kaiser Permanente Orange County Anaheim Medical Center, Anaheim , California , USA
| | - Ana Rodriguez-Hernandez
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Universidad Autónoma, Barcelona , Spain
| | - Adib A Abla
- Department of Neurological Surgery, UCSF, San Francisco , California , USA
| |
Collapse
|
16
|
Tonetti DA, Rinaldo L, Raygor KP, Dubnicoff TB, El-Sayed IH, Abla AA. Common Carotid-Greater Saphenous-M2 Bypass for Myoepithelial Carcinoma Encasing the Carotid Artery. World Neurosurg 2023:S1878-8750(23)00731-3. [PMID: 37268186 DOI: 10.1016/j.wneu.2023.05.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/04/2023]
Abstract
Revascularization of the anterior circulation using a high-capacitance graft is sometimes necessary for the treatment of cervical tumors encasing the internal carotid artery (ICA). In this surgical video, we aim to demonstrate the technical nuances of high-flow extra- to intracranial bypass using a saphenous vein graft. The patient is a 23-year-old female who presented with a four-month history of an enlarging left-sided neck mass, dysphagia and 25-lb weight loss. CT and MR imaging demonstrated an enhancing lesion encasing the cervical internal carotid artery (ICA). The patient underwent an open biopsy that established a diagnosis of a myoepithelial carcinoma. The patient was advised to undergo attempted gross total resection, which would require sacrifice of the cervical internal carotid artery. After the patient failed a balloon test-occlusion of the left ICA, it was decided to perform a cervical ICA to middle cerebral artery (MCA) M2 bypass using a saphenous vein graft followed by tumor resection in staged fashion. Post-operative imaging demonstrated complete tumor removal and filling of the left anterior circulation via the saphenous vein graft. This video discusses important pre- and post-operative considerations as well as highlights the technical nuances of this complex procedure. High-flow ICA to MCA bypass using a saphenous vein graft can be employed to facilitate gross total resection of malignant tumors encasing the cervical internal carotid artery.
Collapse
Affiliation(s)
- Daniel A Tonetti
- Department of Neurosurgery, Cooper Neurological Institute, Camden, NJ, USA
| | - Lorenzo Rinaldo
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Kunal P Raygor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Todd B Dubnicoff
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
17
|
Bartoletti V, Rios-Zermeno J, El-Sayed I, Abla AA, Rodriguez Rubio R. Morphometric Analysis of the Ophthalmic and Central Retinal Arteries via the Endoscopic Endonasal Trans-Ethmoidal Approach: Surgical Relevance of Vascular Components within the Medial Intraconal Zones. World Neurosurg 2023:S1878-8750(23)00563-6. [PMID: 37100115 DOI: 10.1016/j.wneu.2023.04.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The endoscopic endonasal approach (EEA) offers a minimally invasive route to treat medial intraconal space (MIS) lesions. Understanding the configuration of the ophthalmic artery (OphA) and the central retinal artery (CRA) is crucial. METHODS An EEA to the MIS was performed on 30 orbits. The description of the intraorbital part of the OphA was divided into three segments and classified as type 1 and type 2 and the MIS was divided into three surgical zones (A, B, C). The CRA's origin, course, and point of penetration (PP) were analyzed. The relationship between the position of the CRA in the MIS and the OphA type was analyzed. RESULTS The OphA type 2 was present in 20% of specimens. The site of origin of the CRA from the OphA was found on the medial surface in type 1 and on the lateral surface of type 2. The PP of the CRA was found in 87% of the specimens on the inferomedial surface, just anterior to the inferior muscular trunk, at an average distance of 9.5mm ± 1 from the globe and 17mm ± 1.5 from the AZ. The presence of the CRA in Zone C was associated only with OphA type 1. CONCLUSION OphA type 2 is a common finding and can compromise the feasibility of an EEA to the MIS. A detailed preoperative analysis of the OphA and CRA should be conducted prior to approaching the MIS due to the implications of the anatomical variations that can compromise safe intraconal maneuverability during an EEA.
Collapse
Affiliation(s)
- Viola Bartoletti
- Neurosurgery, Department of Neuroscience, University of Padua, Padua, Italy; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Jorge Rios-Zermeno
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Neurological Surgery, Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | - Ivan El-Sayed
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Adib A Abla
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| |
Collapse
|
18
|
Raper DMS, Abla AA. In Reply: Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. Neurosurgery 2023; 92:e58. [PMID: 36729775 DOI: 10.1227/neu.0000000000002300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | | |
Collapse
|
19
|
Lu AY, Winkler EA, Garcia JH, Raygor KP, Fullerton HJ, Fox CK, Kim H, Auguste KI, Sun PP, Hetts SW, Lawton MT, Abla AA, Gupta N. A comparison of incidental and symptomatic unruptured brain arteriovenous malformations in children. J Neurosurg Pediatr 2023; 31:463-468. [PMID: 36805316 DOI: 10.3171/2023.1.peds22541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 01/12/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE Patients with unruptured brain arteriovenous malformations (AVMs) may present with headaches, seizures, and/or neurological deficits. A smaller number of cases may be discovered incidentally. These lesions remain incompletely understood due to their sparse reporting. Herein, the authors describe the largest series to date comparing the presentation, angioarchitecture, and management of incidental versus symptomatic unruptured AVMs in children. METHODS The authors performed a retrospective analysis of patients who presented with brain AVMs from 1998 to 2022 at the University of California, San Francisco. Inclusion criteria were age ≤ 18 years at the time of presentation and an angiographically proven unruptured AVM that had been diagnosed postnatally. RESULTS Of 76 children with unruptured AVMs, 66 (86.8%) presented with headaches, seizures, and/or neurological deficit. Ten AVMs (13.1%) were incidentally discovered through unrelated disease workup (50%), cranial trauma (40%), or research study participation (10%). Compared with patients with symptomatic unruptured AVMs, patients with incidental unruptured AVMs had a smaller mean ± SD maximum nidus diameter (2.82 ± 1.1 vs 3.98 ± 1.52 cm, p = 0.025) and fewer had deep venous drainage (20% of patients vs 61%, p = 0.036). They also presented at an earlier age (10 ± 5.2 vs 13.5 ± 4 years, p = 0.043) and with longer duration to first treatment (541 ± 922 vs 196 ± 448 days, p = 0.005). During the observation period, 1 patient developed recurring headaches and demonstrated AVM nidus growth. Four AVMs greater than 3 cm in size or in a deep location were treated with radiosurgery. Six other AVMs were treated with resection, with 2 receiving preoperative embolization. Eight AVMs (80%) were obliterated on last follow-up. Postprocedural complications included 2 transient neurological deficits after resection and 1 case of delayed seizure development after radiosurgery. The mean follow-up period was 5.7 ± 5.7 years without any hemorrhage episodes. CONCLUSIONS A substantial proportion of pediatric patients with unruptured AVMs are discovered incidentally. With earlier presentation and more elementary angioarchitecture than symptomatic unruptured AVMs, these incidental lesions provide a snapshot into the natural history of AVM before symptom development or rupture.
Collapse
Affiliation(s)
| | - Ethan A Winkler
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | | | - Heather J Fullerton
- 3Department of Neurology, Pediatric Stroke and Cerebrovascular Disease Center, University of California, San Francisco, California; and
| | - Christine K Fox
- 3Department of Neurology, Pediatric Stroke and Cerebrovascular Disease Center, University of California, San Francisco, California; and
| | - Helen Kim
- 4Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | | | | | | | - Michael T Lawton
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Nalin Gupta
- Departments of1Neurological Surgery.,6Pediatrics, University of California, San Francisco, California
| |
Collapse
|
20
|
Weinsheimer S, Nelson J, Abla AA, Ko NU, Tsang C, Okoye O, Zabramski JM, Akers A, Zafar A, Mabray MC, Hart BL, Morrison L, McCulloch CE, Kim H. Intracranial Hemorrhage Rate and Lesion Burden in Patients With Familial Cerebral Cavernous Malformation. J Am Heart Assoc 2023; 12:e027572. [PMID: 36695309 PMCID: PMC9973654 DOI: 10.1161/jaha.122.027572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Abstract
Background Familial cerebral cavernous alformation (CCM) is an autosomal dominant disease caused by mutations in KRIT1, CCM2, or PDCD10. Cases typically present with multiple lesions, strong family history, and neurological symptoms, including seizures, headaches, or other deficits. Intracranial hemorrhage (ICH) is a severe manifestation of CCM, which can lead to death or long-term neurological deficits. Few studies have reported ICH rates and risk factors in familial CCM. We report ICH rates and assess whether CCM lesion burden, a disease severity marker, is associated with risk of symptomatic ICH during follow-up in a well-characterized cohort of familial CCM cases. Methods and Results We studied 386 patients with familial CCM with follow-up data enrolled in the Brain Vascular Malformation Consortium CCM Project. We estimated symptomatic ICH rates overall and stratified by history of ICH before enrollment. CCM lesion burden (total lesion count and large lesion size) assessed at baseline enrollment was tested for association with increased risk of subsequent ICH during follow-up using Cox regression models adjusted for history of ICH before enrollment, age, sex, and family structure and stratified on recruitment site. The symptomatic ICH rate for familial CCM cases was 2.8 per 100 patient-years (95% CI, 1.9-4.1). Those with ICH before enrollment had a follow-up ICH rate of 4.5 per 100 patient-years (95% CI, 2.6-8.1) compared with 2.0 per 100 patient-years (95% CI, 1.3-3.5) in those without (P=0.042). Total lesion count was associated with increased risk of ICH during follow-up (hazard ratio [HR], 1.37 per doubling of total lesion count [95% CI, 1.10-1.71], P=0.006). The symptomatic ICH rate for familial CCM cases was 2.8 per 100 patient-years (95% CI, 1.9-4.1). Those with ICH before enrollment had a follow-up ICH rate of 4.5 per 100 patient-years (95% CI, 2.6-8.1) compared with 2.0 per 100 patient-years (95% CI, 1.3-3.5) in those without (P=0.042). Total lesion count was associated with increased risk of ICH during follow-up (hazard ratio [HR], 1.37 per doubling of total lesion count [95% CI, 1.10-1.71], P=0.006). Conclusions Patients with familial CCM with prior history of an ICH event are at higher risk for rehemorrhage during follow-up. In addition, total CCM lesion burden is significantly associated with increased risk of subsequent symptomatic ICH; hence lesion burden may be an important predictor of patient outcome and aid patient risk stratification.
Collapse
Affiliation(s)
- Shantel Weinsheimer
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular ResearchUniversity of California San FranciscoCA
- Institute for Human Genetics, University of California San FranciscoCA
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular ResearchUniversity of California San FranciscoCA
| | - Adib A. Abla
- Department of Neurological SurgeryUniversity of California San FranciscoCA
| | - Nerissa U. Ko
- Department of NeurologyUniversity of California San FranciscoCA
| | - Cynthia Tsang
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular ResearchUniversity of California San FranciscoCA
| | - Obiora Okoye
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular ResearchUniversity of California San FranciscoCA
- Global Brain Health Institute, University of California San FranciscoCA
| | | | - Amy Akers
- Alliance to Cure Cavernous MalformationCharlottesvilleVA
| | - Atif Zafar
- Department of NeurologyUniversity of New MexicoAlbuquerqueNM
| | - Marc C. Mabray
- Department of RadiologyUniversity of New MexicoAlbuquerqueNM
| | - Blaine L. Hart
- Department of RadiologyUniversity of New MexicoAlbuquerqueNM
| | - Leslie Morrison
- Department of NeurologyUniversity of New MexicoAlbuquerqueNM
| | - Charles E. McCulloch
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoCA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular ResearchUniversity of California San FranciscoCA
- Institute for Human Genetics, University of California San FranciscoCA
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoCA
| |
Collapse
|
21
|
Tonetti DA, Raygor KP, Dubnicoff T, Abla AA. Side-to-Side M2-M2 Bypass for Revascularization and Trapping of Left M2 Origin Fusiform Aneurysm Presenting With Subarachnoid Hemorrhage: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e123. [PMID: 36637321 DOI: 10.1227/ons.0000000000000494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/06/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Daniel A Tonetti
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | | | | | | |
Collapse
|
22
|
Raper DMS, Rutledge C, Abla AA. Treatment of an infundibular aneurysm by posterior communicating origin disconnection, induced flow reversal and flow diversion after attempted surgical clipping: Case report. Interv Neuroradiol 2023; 29:5-9. [PMID: 35128960 PMCID: PMC9893243 DOI: 10.1177/15910199221079142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/22/2021] [Accepted: 01/21/2022] [Indexed: 02/05/2023] Open
Abstract
Infundibular aneurysms are rare lesions that present unique challenges for both surgical and endovascular approaches. We present a case of a 58-year old man with an incidental 7.5 × 3 mm infundibular aneurysm that incorporated the origin of the posterior communicating artery (PCoA). The fusiform aneurysm incorporated the supraclinoid ICA to the terminus. An attempt at surgical clip reconstruction of the aneurysm to preserve the PCoA was not technically possible due to atherosclerosis at the aneurysm neck. The aneurysm was treated with disconnection of the PCoA origin, induced flow reversal and placement of a flow diverter, after confirmation of adequate collateral flow to the PCoA perforators from the posterior circulation. The case illustrates important concepts in the evaluation and management of infundibular aneurysms, including both reconstructive and deconstructive strategies.
Collapse
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Caleb Rutledge
- Department of Neurosurgery, New York University, New York, NY, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| |
Collapse
|
23
|
Salem MM, Srinivasan VM, Tonetti DA, Ravindran K, Taussky P, Yang K, Karahalios K, Raygor KP, Naylor RM, Catapano JS, Tavakoli-Sabour S, Abdelsalam A, Chen SH, Grandhi R, Jankowitz BT, Baskaya MK, Mascitelli JR, Van Gompel JJ, Cherian J, Couldwell WT, Kim LJ, Cohen-Gadol AA, Starke RM, Kan P, Dehdashti AR, Abla AA, Lawton MT, Burkhardt JK. Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience. Neurosurgery 2023; 92:205-212. [PMID: 36519864 DOI: 10.1227/neu.0000000000002196] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/15/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports. OBJECTIVE To report a multicenter experience assessing microsurgery safety/efficacy. METHODS Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021). RESULTS Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%. CONCLUSION Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.
Collapse
Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Krishnan Ravindran
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Kaiyun Yang
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kunal P Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Samon Tavakoli-Sabour
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Jacob Cherian
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | | | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Aaron A Cohen-Gadol
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
24
|
Hartke JN, Srinivasan VM, Rahmani R, Catapano JS, Labib MA, Rumalla K, Garcia JH, McDougall CM, Abla AA, Lawton MT. Sphenoparietal Sinus Dural Arteriovenous Fistulas: A Series of 10 Patients. Oper Neurosurg (Hagerstown) 2022; 23:139-147. [PMID: 35838453 DOI: 10.1227/ons.0000000000000269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/06/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVFs) of the sphenoparietal sinus or sphenoid wing region are uncommon lesions with unique and interesting angioarchitecture. Understanding appropriate anatomy and recognizing patterns provide important treatment implications. OBJECTIVE To describe a single surgeon's experience with open surgical treatment of sphenoparietal sinus DAVFs, the surgical indications for this uncommon lesion, and the microsurgical techniques related to its treatment and to review the literature on its surgical treatment. METHODS Consecutive cases of sphenoparietal sinus DAVF treatment conducted by a single surgeon over 24 years (1997-2020) were retrospectively reviewed. Published reports of similar cases were reviewed. RESULTS Of 202 surgically treated DAVFs, 10 lesions in 10 patients were sphenoparietal sinus DAVFs. Four patients presented with intracranial hemorrhage, 3 with headache, and 2 with pulsatile tinnitus; 1 patient was incidentally identified as having a DAVF during treatment for a ruptured aneurysm. Most patients (7 of 10) had undergone endovascular embolization previously. Nine patients had Borden type III DAVFs and one had a Borden type II fistula. Surgery in all 10 patients resulted in angiographically confirmed fistula obliteration. Clinical outcomes at the last follow-up, measured by a modified Rankin Scale (mRS) score, were excellent in 6 patients (mRS ≤ 2) and poor in 1 patient (mRS ≥ 3); late outcomes were not available for 3 patients. CONCLUSION Sphenoparietal sinus DAVFs are an uncommon anatomic subtype. Careful attention to angiographic detail leads to identification of the site of venous interruption and results in a high rate of surgical cure with excellent clinical outcomes.
Collapse
Affiliation(s)
- Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joseph H Garcia
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Cameron M McDougall
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| |
Collapse
|
25
|
Budohoski KP, Raygor K, Tonetti DA, Narsinh KH, Winkler EA, Dowd C, Abla AA. Intraoperative Angiogram Using C-Arm Fluoroscopy and Direct Common Carotid Artery Puncture During Surgical Treatment of Paraclinoid Aneurysms. World Neurosurg 2022; 165:95-99. [PMID: 35779758 DOI: 10.1016/j.wneu.2022.06.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intraoperative angiography (IOA) has been shown to be a useful adjunct in surgical treatment of cerebral aneurysms. However, its use can be limited by hybrid operating room availability. On the other hand, the use of C-arm fluoroscopy can add challenges to IOA during navigation of the aortic arch and selection of the great vessels. We aimed to describe a simple method of IOA that can be applied during surgery of paraclinoid aneurysms and can be performed in a normal operating room without the need to navigate the aortic arch. METHODS In patients undergoing surgery for paraclinoid aneurysms with need for cervical carotid artery exposure, IOA was performed using a single plane C-arm fluoroscopy unit after direct puncture of the carotid artery. RESULTS Five patients were included: 2 with subarachnoid hemorrhage, 2 with unruptured aneurysm and history of subarachnoid hemorrhage, and 1 with unruptured aneurysm. There were 2 internal carotid blister aneurysms, 2 ophthalmic artery aneurysms, and 1 superior hypophyseal artery aneurysm. IOA was performed using direct carotid puncture through the neck incision required for proximal control. In all cases, intraoperative images were of sufficient quality to determine the completeness of aneurysm occlusion as well as parent and branching vessel patency. There were no postoperative infarctions and no complications related to IOA. CONCLUSIONS IOA using direct carotid puncture can be performed in a standard operating room with the use of a C-arm, eliminating the need to catheterize the great vessels of the aortic arch.
Collapse
Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher Dowd
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
26
|
Budohoski KP, Raygor K, Cook D, Henrich T, Abla AA. Rapid sequential development and rupture of mycotic aneurysms within a period of days in a patient with graft-versus-host disease and angiotropic Scedosporium apiospermum infection. Surg Neurol Int 2022; 13:242. [PMID: 35855168 PMCID: PMC9282729 DOI: 10.25259/sni_970_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Fungal origin mycotic aneurysms are rare and carry a high mortality rate. Scedosporium apiospermum is an ubiquitous fungus which has been described to cause devastating infections in immunocompromised hosts. Case Description: We report a case of a 23-year-old patient with Burkitt’s lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis. Conclusion: We highlight the difficulties in treating fungal mycotic aneurysms and the associated high mortality. While a less aggressive approach might have been appropriate given the known poor outcomes, the age of the patients as well as the family wishes dictated the treatment decisions.
Collapse
Affiliation(s)
- Karol P. Budohoski
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, Unites States
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, Unites States
| | - Dan Cook
- Department of Radiology, University of California San Francisco, San Francisco, California, Unites States
| | - Timothy Henrich
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, California, Unites States
| | - Adib A. Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, Unites States
| |
Collapse
|
27
|
Baker A, Raygor K, Caton MT, Narsinh KH, Smith E, Dowd CF, Cooke DL, Higashida RT, Amans MR, Abla AA, Hetts SW. Pharyngo-tympano-stapedial middle meningeal artery variant supply to a falcotentorial dural arteriovenous fistula. J Neurointerv Surg 2022; 14:neurintsurg-2022-018817. [PMID: 35545428 DOI: 10.1136/neurintsurg-2022-018817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/29/2022] [Indexed: 11/03/2022]
Abstract
The pharyngo-tympano-stapedial middle meningeal artery (PTS-MMA) variant has been described in one case report and never in the setting of arterial supply to a dural arteriovenous fistula, to our knowledge. We report the case of a middle-aged patient with severe, daily headache who presented to our institution for angiography and treatment. CT angiography and MRI demonstrated an enlarged left middle meningeal artery coursing to a large venous varix in the falcotentorial region. Dural arteriovenous fistula was confirmed by subsequent cerebral angiography. Endovascular treatment was performed but without complete obliteration of the fistula. Follow-up angiography demonstrated parasitized arterial supply from a right middle meningeal artery arising from the proximal cervical internal carotid artery coursing through the middle ear consistent with a PTS-MMA variant. The fistula was then treated surgically without recurrence at the 6-month follow-up.
Collapse
Affiliation(s)
- Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Eric Smith
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
28
|
Raper DMS, Abla AA. Commentary: Modern Appraisal of Patency and Complications in Cerebral Bypass Surgery: A Single Institution Experience. Oper Neurosurg (Hagerstown) 2022; 22:e237-e238. [DOI: 10.1227/ons.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
|
29
|
Osorio RC, Raygor KP, Abla AA. Development of a customised programme to standardise comorbidity diagnosis codes in a large-scale database. BMJ Health Care Inform 2022; 29:bmjhci-2021-100532. [PMID: 35477690 PMCID: PMC9047883 DOI: 10.1136/bmjhci-2021-100532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/09/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectivesThe transition from ICD-9 to ICD-10 coding creates a data standardisation challenge for large-scale longitudinal research. We sought to develop a programme that automated this standardisation process.MethodsA programme was developed to standardise ICD-9 and ICD-10 terminology into one system. Code was improved to reduce runtime, and two iterations were tested on a joint ICD-9/ICD-10 database of 15.8 million patients.ResultsBoth programmes successfully standardised diagnostic terminology in the database. While the original programme updated 100 000 cells in 12.5 hours, the improved programme translated 3.1 million cells in 38 min.DiscussionWhile both programmes successfully translated ICD-related data into a standardised format, the original programme suffered from excessive runtimes. Code improvement with hash tables and parallelisation exponentially reduced these runtimes.ConclusionDatabases with ICD-9 and ICD-10 codes require terminology standardisation for analysis. By sharing our programme’s implementation, we hope to assist other researchers in standardising their own databases.
Collapse
Affiliation(s)
- Robert C Osorio
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
30
|
Raygor KP, Phelps RRL, Rutledge C, Raper DMS, Molinaro A, Fox CK, Gupta N, Abla AA. Socioeconomic factors associated with pediatric moyamoya disease hospitalizations: a nationwide cross-sectional study. J Neurosurg Pediatr 2022:1-10. [PMID: 35334457 DOI: 10.3171/2022.1.peds21339] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 01/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Healthcare disparities are widely described in adults, but barriers affecting access to care for pediatric patients with moyamoya disease (MMD) are unknown. Understanding socioeconomic factors impacting hospital access and outcomes is necessary to address pediatric healthcare disparities. METHODS In this cross-sectional observational study, the Kids' Inpatient Database was used to identify patients admitted with a primary diagnosis of MMD from 2003 to 2016. Patients ≤ 18 years with a primary diagnosis of MMD based on International Classification of Diseases (ICD) codes were included. Hospital admissions were queried for use of cerebral revascularization based on ICD procedure codes. RESULTS Query of the KID yielded 1449 MMD hospitalizations. After multivariable regression, Hispanic ethnicity (OR 0.52 [95% CI 0.33-0.81], p = 0.004) was associated with lack of surgical revascularization. Private insurance (OR 1.56 [95% CI 1.15-2.13], p = 0.004), admissions at medium- and high-volume centers (OR 2.01 [95% CI 1.42-2.83], p < 0.001 and OR 2.84 [95% CI 1.95-4.14], p < 0.001, respectively), and elective hospitalization (OR 3.37 [95% CI 2.46-4.64], p < 0.001) were positively associated with revascularization. Compared with Caucasian race, Hispanic ethnicity was associated with increased mean (± SEM) length of stay by 2.01 ± 0.70 days (p = 0.004) and increased hospital charges by $24,333.61 ± $7918.20 (p = 0.002), despite the decreased utilization of surgical revascularization. Private insurance was associated with elective admission (OR 1.50 [95% CI 1.10-2.05], p = 0.01) and admission to high-volume centers (OR 1.90 [95% CI 1.26-2.88], p = 0.002). African American race was associated with the development of in-hospital complications (OR 2.52 [95% CI 1.38-4.59], p = 0.003). CONCLUSIONS Among pediatric MMD hospitalizations, multiple socioeconomic factors were associated with access to care, whether surgical treatment is provided, and whether in-hospital complications occur. These results suggest that socioeconomic factors are important drivers of healthcare disparities in children with MMD and warrant further study.
Collapse
Affiliation(s)
- Kunal P Raygor
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Ryan R L Phelps
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Caleb Rutledge
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Daniel M S Raper
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Annette Molinaro
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Christine K Fox
- 2Department of Neurology, University of California, San Francisco, California
| | - Nalin Gupta
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Adib A Abla
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| |
Collapse
|
31
|
Garcia JH, Rutledge C, Winkler EA, Carrete L, Morshed RA, Lu AY, Saggi S, Fox CK, Fullerton HJ, Kim H, Cooke DL, Hetts SW, Lawton MT, Gupta N, Abla AA. Validation of the Ruptured Arteriovenous Malformation Grading Scale in a pediatric cohort. J Neurosurg Pediatr 2022; 29:575-579. [PMID: 35213838 DOI: 10.3171/2022.1.peds21466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric brain arteriovenous malformations (AVMs) are the leading cause of spontaneous intracranial hemorrhage (SICH) in children. Although the incidence of SICH is low in pediatric populations, such events cause substantial morbidity. The recently created Ruptured Arteriovenous Malformation Grading Scale (RAGS) is proposed as a reliable and novel grading system to specifically serve as a predictor of clinical outcomes in patients following AVM rupture, similar to the Hunt and Hess (HH) grade for ruptured aneurysms. While these data are promising, pediatric patients were notably absent from the original study validating the RAGS. Therefore, correlation of the RAGS score with clinical outcomes following AVM rupture in individuals younger than 18 years of age using the RAGS score is needed. The objective of this study was to validate the RAGS in a cohort of pediatric patients with AVMs who presented with hemorrhage, thereby demonstrating the score's generalizability, and expanding its external validity. METHODS A cohort of children with ruptured AVMs were retrospectively reviewed. Using disability, measured by the modified Rankin Scale (mRS), as the response variable, the area under the receiver operating characteristic curve (AUROC) was calculated for patients based on their RAGS scores for three time periods. The AUROC values were then compared with those generated by two commonly used clinical grading systems, the HH classification and Glasgow Coma Scale. RESULTS A total of 81 children who presented with ruptured AVMs were included in the study, with a mean follow-up duration of 4 years. The RAGS score outperformed other clinical grading scales in predicting mRS scores, with AUROC values of 0.81, 0.82, and 0.81 at three distinct follow-up periods. CONCLUSIONS The RAGS score correlated well with the clinical outcome after AVM rupture in pediatric patients. Additional validation studies across multiple treatment centers are needed to further demonstrate the generalizability of the scoring system.
Collapse
Affiliation(s)
- Joseph H Garcia
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Caleb Rutledge
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ethan A Winkler
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Luis Carrete
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Alex Y Lu
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Satvir Saggi
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Christine K Fox
- 2Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California, San Francisco
| | - Heather J Fullerton
- 2Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California, San Francisco
| | - Helen Kim
- 3Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Daniel L Cooke
- 4Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Steven W Hetts
- 4Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Michael T Lawton
- 1Department of Neurological Surgery, University of California, San Francisco.,5Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Nalin Gupta
- 1Department of Neurological Surgery, University of California, San Francisco.,6Department of Pediatrics, University of California, San Francisco, California; and
| | - Adib A Abla
- 1Department of Neurological Surgery, University of California, San Francisco
| |
Collapse
|
32
|
Raper DMS, Abla AA. Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. Neurosurgery 2022; 90:e84-e85. [PMID: 35118997 DOI: 10.1227/neu.0000000000001870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
33
|
Winkler EA, Kim CN, Ross JM, Garcia JH, Gil E, Oh I, Chen LQ, Wu D, Catapano JS, Raygor K, Narsinh K, Kim H, Weinsheimer S, Cooke DL, Walcott BP, Lawton MT, Gupta N, Zlokovic BV, Chang EF, Abla AA, Lim DA, Nowakowski TJ. A single-cell atlas of the normal and malformed human brain vasculature. Science 2022; 375:eabi7377. [PMID: 35084939 DOI: 10.1126/science.abi7377] [Citation(s) in RCA: 105] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cerebrovascular diseases are a leading cause of death and neurologic disability. Further understanding of disease mechanisms and therapeutic strategies requires a deeper knowledge of cerebrovascular cells in humans. We profiled transcriptomes of 181,388 cells to define a cell atlas of the adult human cerebrovasculature, including endothelial cell molecular signatures with arteriovenous segmentation and expanded perivascular cell diversity. By leveraging this reference, we investigated cellular and molecular perturbations in brain arteriovenous malformations, a leading cause of stroke in young people, and identified pathologic endothelial transformations with abnormal vascular patterning and the ontology of vascularly derived inflammation. Here, we illustrate the interplay between vascular and immune cells that contributes to brain hemorrhage and catalog opportunities for targeting angiogenic and inflammatory programs in vascular malformations.
Collapse
Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Chang N Kim
- Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Anatomy, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Jayden M Ross
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Anatomy, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Joseph H Garcia
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Eugene Gil
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA
| | - Irene Oh
- Rebus Biosystems, Santa Clara, CA, USA
| | | | - David Wu
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kazim Narsinh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Shantel Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Daniel L Cooke
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Brian P Walcott
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Berislav V Zlokovic
- Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Daniel A Lim
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Tomasz J Nowakowski
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Anatomy, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Chan Zuckerberg Biohub, San Francisco, CA, USA
| |
Collapse
|
34
|
Yue JK, Chang D, Caton MT, Haddad AF, Dalle Ore CL, Wozny TA, Oh T, Wang AS, Tonetti DA, Auguste KI, Sun PP, Cooke DL, Hetts SW, Abla AA, Gupta N, Roland JL. The Hybrid Operative Suite with Intraoperative Biplane Rotational Angiography in Pediatric Cerebrovascular Neurosurgery: Utility and Lessons Learned. Pediatr Neurosurg 2022; 57:245-259. [PMID: 35508115 DOI: 10.1159/000524875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/26/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The benefits of performing open and endovascular procedures in a hybrid neuroangiography surgical suite include confirmation of treatment results and reduction in number of procedures, leading to improved efficiency of care. Combined procedural suites are infrequently used in pediatric facilities due to technical and logistical limitations. We report the safety, utility, and lessons learned from a single-institution experience using a hybrid suite equipped with biplane rotational digital subtraction angiography and pan-surgical capabilities. METHODS We conducted a retrospective review of consecutive cases performed at our institution that utilized the hybrid neuroangiography surgical suite from February 2020 to August 2021. Demographics, surgical metrics, and imaging results were collected from the electronic medical record. Outcomes, interventions, and nuances for optimizing preoperative/intraoperative setup and postoperative care were presented. RESULTS Eighteen procedures were performed in 17 patients (mean age 13.4 years, range 6-19). Cases included 14 arteriovenous malformations (AVM; 85.7% ruptured), one dural arteriovenous fistula, one mycotic aneurysm, and one hemangioblastoma. The average operative time was 416 min (range 321-745). There were no intraoperative or postoperative complications. All patients were alive at follow-up (range 0.1-14.7 months). Five patients had anticipated postoperative deficits arising from their hemorrhage, and 12 returned to baseline neurological status. Four illustrative cases demonstrating specific, unique applications of the hybrid angiography suite are presented. CONCLUSION The hybrid neuroangiography surgical suite is a safe option for pediatric cerebrovascular pathologies requiring combined surgical and endovascular intervention. Hybrid cases can be completed within the same anesthesia session and reduce the need for return to the operating room for resection or surveillance angiography. High-quality intraoperative angiography enables diagnostic confirmation under a single procedure, mitigating risk of morbidity and accelerating recovery. Effective multidisciplinary planning enables preoperative angiograms to be completed to inform the operative plan immediately prior to definitive resection.
Collapse
Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael Travis Caton
- Department of Neurointerventional Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Cecilia L Dalle Ore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Thomas A Wozny
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Albert S Wang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kurtis I Auguste
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Peter P Sun
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Neurointerventional Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Neurointerventional Radiology, University of California, San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Jarod L Roland
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
35
|
Narsinh KH, Narsinh K, McCoy DB, Sun Z, Halabi C, Meisel K, Tihan T, Chaganti K, Amans MR, Halbach VV, Higashida RT, Hetts SW, Dowd CF, Winkler EA, Abla AA, Nowakowski TJ, Cooke DL. Endovascular Biopsy of Vertebrobasilar Aneurysm in Patient With Polyarteritis Nodosa. Front Neurol 2021; 12:697105. [PMID: 34887823 PMCID: PMC8650719 DOI: 10.3389/fneur.2021.697105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022] Open
Abstract
Background and Purpose: The management of unruptured intracranial aneurysms remains controversial. The decisions to treat are heavily informed by estimated risk of bleeding. However, these estimates are imprecise, and better methods for stratifying the risk or tailoring treatment strategy are badly needed. Here, we demonstrate an initial proof-of-principle concept for endovascular biopsy to identify the key molecular pathways and gene expression changes associated with aneurysm formation. We couple this technique with single cell RNA sequencing (scRNAseq) to develop a roadmap of the pathogenic changes of a dolichoectatic vertebrobasilar aneurysm in a patient with polyarteritis nodosa. Methods: Endovascular biopsy and fluorescence activated cell sorting was used to isolate the viable endothelial cells (ECs) using the established techniques. A single cell RNA sequencing (scRNAseq) was then performed on 24 aneurysmal ECs and 23 patient-matched non-aneurysmal ECs. An integrated panel of bioinformatic tools was applied to determine the differential gene expression, enriched signaling pathways, and cell subpopulations hypothesized to drive disease pathogenesis. Results: We identify a subset of 7 (29%) aneurysm-specific ECs with a distinct gene expression signature not found in the patient-matched control ECs. A gene set enrichment analysis identified these ECs to have increased the expression of genes regulating the leukocyte-endothelial cell adhesion, major histocompatibility complex (MHC) class I, T cell receptor recycling, tumor necrosis factor alpha (TNFα) response, and interferon gamma signaling. A histopathologic analysis of a different intracranial aneurysm that was later resected yielded a diagnosis of polyarteritis nodosa and positive staining for TNFα. Conclusions: We demonstrate feasibility of applying scRNAseq to the endovascular biopsy samples and identify a subpopulation of ECs associated with cerebral aneurysm in polyarteritis nodosa. Endovascular biopsy may be a safe method for deriving insight into the disease pathogenesis and tailoring the personalized treatment approaches to intracranial aneurysms.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Kamileh Narsinh
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - David B McCoy
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Zhengda Sun
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Cathra Halabi
- Division of Neurovascular Neurology, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States.,Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Karl Meisel
- Division of Neurovascular Neurology, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Tarik Tihan
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, San Francisco, CA, United States
| | - Krishna Chaganti
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Matthew R Amans
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Van V Halbach
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Randall T Higashida
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Steven W Hetts
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher F Dowd
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Ethan A Winkler
- Cerebrovascular Disorders Program, Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Adib A Abla
- Cerebrovascular Disorders Program, Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Tomasz J Nowakowski
- Department of Anatomy, Chan Zuckerberg Biohub, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel L Cooke
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
36
|
Dammann P, Abla AA, Al-Shahi Salman R, Andrade-Barazarte H, Benes V, Cenzato M, Connolly ES, Cornelius JF, Couldwell WT, Sola RG, Gomez-Paz S, Hauck E, Hernesniemi J, Kivelev J, Lanzino G, Macdonald RL, Morcos JJ, Ogilvy CS, Steiger HJ, Steinberg GK, Santos AN, Rauschenbach L, Darkwah Oppong M, Schmidt B, Spetzler RF, Schaller K, Lawton MT, Sure U. Surgical treatment of brainstem cavernous malformations: an international Delphi consensus. J Neurosurg 2021:1-11. [PMID: 34598135 DOI: 10.3171/2021.3.jns2156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Indication for surgery in brainstem cavernous malformations (BSCMs) is based on many case series, few comparative studies, and no randomized controlled trials. The objective of this study was to seek consensus about surgical management aspects of BSCM. METHODS A total of 29 experts were invited to participate in a multistep Delphi consensus process on the surgical treatment of BSCM. RESULTS Twenty-two (76%) of 29 experts participated in the consensus. Qualitative analysis (content analysis) of an initial open-ended question survey resulted in 99 statements regarding surgical treatment of BSCM. By using a multistep survey with 100% participation in each round, consensus was reached on 52 (53%) of 99 statements. These were grouped into 4 categories: 1) definitions and reporting standards (7/14, 50%); 2) general and patient-related aspects (11/16, 69%); 3) anatomical-, timing of surgery-, and BSCM-related aspects (22/37, 59%); and 4) clinical situation-based decision-making (12/32, 38%). Among other things, a consensus was reached for surgical timing, handling of associated developmental venous anomalies, handling of postoperative BSCM remnants, assessment of specific anatomical BSCM localizations, and treatment decisions in typical clinical BSCM scenarios. CONCLUSIONS A summary of typical clinical scenarios and a catalog of various BSCM- and patient-related aspects that influence the surgical treatment decision have been defined, rated, and interpreted.
Collapse
Affiliation(s)
- Philipp Dammann
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany
| | - Adib A Abla
- 9Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Hugo Andrade-Barazarte
- 5Department of Neurosurgery, Juha Hernesniemi International Center, Henan Provincial People's Hospital, University of Zhengzhou, China
| | - Vladimir Benes
- 13Department of Neurosurgery and Neuro-oncology, Military University Hospital and Charles University, First Medical Faculty, Prague, Czech Republic
| | - Marco Cenzato
- 20Department of Neurosurgery, Niguarda Metropolitan Hospital, Milan, Italy
| | - E Sander Connolly
- 3Columbia University Medical Center Department of Neurological Surgery, New York, New York
| | - Jan F Cornelius
- 16Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | | | - Rafael G Sola
- 2UAM Chair "Innovation in Neurosurgery," Universidad Autónoma de Madrid, Spain
| | - Santiago Gomez-Paz
- 10Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Erik Hauck
- 17Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Juha Hernesniemi
- 5Department of Neurosurgery, Juha Hernesniemi International Center, Henan Provincial People's Hospital, University of Zhengzhou, China
| | - Juri Kivelev
- 4Department of Neurosurgery, Turku University Hospital, Turku, Finland
| | | | - R Loch Macdonald
- 8Department of Neurological Surgery, University of California, San Francisco, Fresno Campus, Fresno, California
| | - Jacques J Morcos
- 12Department of Neurological Surgery, University of Miami, Florida
| | - Christopher S Ogilvy
- 10Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Hans-Jakob Steiger
- 16Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Gary K Steinberg
- 7Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California
| | - Alejandro N Santos
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany
| | - Laurèl Rauschenbach
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany
| | | | - Börge Schmidt
- 19Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany; and
| | - Robert F Spetzler
- 6Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Karl Schaller
- 18Department of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospital, Geneva, Switzerland
| | - Michael T Lawton
- 6Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ulrich Sure
- 1Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany
| |
Collapse
|
37
|
Narsinh KH, Mirza MH, Duvvuri M, Caton MT, Baker A, Winkler EA, Higashida RT, Halbach VV, Amans MR, Cooke DL, Hetts SW, Abla AA, Dowd CF. Radial artery access anatomy: considerations for neuroendovascular procedures. J Neurointerv Surg 2021; 13:1139-1144. [PMID: 34551992 DOI: 10.1136/neurintsurg-2021-017871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023]
Abstract
Although enthusiasm for transradial access for neurointerventional procedures has grown, a unique set of considerations bear emphasis to preserve safety and minimize complications. In the first part of this review series, we will review important anatomical considerations for safe and easy neuroendovascular procedures from a transradial approach. These include normal and variant radial artery anatomy, the anatomic snuffbox, as well as axillary, brachial, and great vessel arterial anatomy that is imperative for the neuroendovascular surgeon to be intimately familiar prior to pursuing transradial access procedures. In the next part of the review series, we will focus on safety and complications specific to a transradial approach.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Mohammed H Mirza
- Department of Radiology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Madhavi Duvvuri
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Van V Halbach
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
38
|
Narsinh KH, Mirza MH, Caton MT, Baker A, Winkler E, Higashida RT, Halbach VV, Amans MR, Cooke DL, Hetts SW, Abla AA, Dowd CF. Radial artery access for neuroendovascular procedures: safety review and complications. J Neurointerv Surg 2021; 13:1132-1138. [PMID: 34551991 DOI: 10.1136/neurintsurg-2021-017325] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/16/2021] [Indexed: 01/01/2023]
Abstract
Although enthusiasm for transradial access for neurointerventional procedures has grown, a unique set of considerations bear emphasis to preserve safety and minimize complications. In the first part of this review series, we reviewed anatomical considerations for safe and easy neuroendovascular procedures from a transradial approach. In this second part of the review series, we aim to (1) summarize evidence for safety of the transradial approach, and (2) explain complications and their management.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Mohammed H Mirza
- Radiology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - M Travis Caton
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Ethan Winkler
- Neurological Surgery, University California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Van V Halbach
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Neurological Surgery, University California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| |
Collapse
|
39
|
Garcia JH, Winkler EA, Morshed RA, Lu A, Ammanuel SG, Saggi S, Wang EJ, Braunstein S, Fox CK, Fullerton HJ, Kim H, Cooke DL, Hetts SW, Lawton MT, Abla AA, Gupta N. Factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations. J Neurosurg Pediatr 2021:1-6. [PMID: 34560640 DOI: 10.3171/2021.6.peds21126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with cerebral arteriovenous malformations (AVMs) can present with seizures, potentially increasing morbidity and impacting clinical management. However, the factors that lead to seizures as a presenting sign are not well defined. While AVM-related seizures have been described in case series, most studies have focused on adults and have included patients who developed seizures after an AVM rupture. To address this, the authors sought to analyze demographic and morphological characteristics of AVMs in a large cohort of children. METHODS The demographic, clinical, and AVM morphological characteristics of 189 pediatric patients from a single-center database were studied. Univariate and multivariate logistic regression models were used to test the effect of these characteristics on seizures as an initial presenting symptom in patients with unruptured brain AVMs. RESULTS Overall, 28 of 189 patients initially presented with seizures (14.8%). By univariate comparison, frontal lobe location (p = 0.02), larger AVM size (p = 0.003), older patient age (p = 0.04), and the Supplemented Spetzler-Martin (Supp-SM) grade (0.0006) were associated with seizure presentation. Multivariate analysis confirmed an independent effect of frontal lobe AVM location and higher Supp-SM grade. All patients presenting with seizures had AVMs in the cortex or subcortical white matter. CONCLUSIONS While children and adults share some risk factors for seizure presentation, their risk factor profiles do not entirely overlap. Pediatric patients with cortical AVMs in the frontal lobe were more likely to present with seizures. Additionally, the Supp-SM grade was highly associated with seizure presentation. Future clinical research should focus on the effect of therapeutic interventions targeting AVMs on seizure control in these patients.
Collapse
Affiliation(s)
- Joseph H Garcia
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Ethan A Winkler
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Alex Lu
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Simon G Ammanuel
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Satvir Saggi
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Elaina J Wang
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Steve Braunstein
- 2Department of Radiation Oncology, University of California San Francisco, San Francisco
| | - Christine K Fox
- 3Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California San Francisco, San Francisco
| | - Heather J Fullerton
- 3Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California San Francisco, San Francisco
| | - Helen Kim
- 4Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco
| | - Daniel L Cooke
- 5Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco
| | - Steven W Hetts
- 5Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco
| | - Michael T Lawton
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco.,6Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adib A Abla
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Nalin Gupta
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco.,7Department of Pediatrics, University of California San Francisco, San Francisco, California; and
| |
Collapse
|
40
|
Chen CJ, Buell TJ, Ding D, Guniganti R, Kansagra AP, Lanzino G, Giordan E, Kim LJ, Levitt MR, Abecassis IJ, Bulters D, Durnford A, Fox WC, Polifka AJ, Gross BA, Hayakawa M, Derdeyn CP, Samaniego EA, Amin-Hanjani S, Alaraj A, Kwasnicki A, van Dijk JMC, Potgieser ARE, Starke RM, Sur S, Satomi J, Tada Y, Abla AA, Winkler EA, Du R, Lai PMR, Zipfel GJ, Sheehan JP. Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study. J Neurosurg 2021; 136:962-970. [PMID: 34608140 DOI: 10.3171/2021.1.jns202799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The risk-to-benefit profile of treating an unruptured high-grade dural arteriovenous fistula (dAVF) is not clearly defined. The aim of this multicenter retrospective cohort study was to compare the outcomes of different interventions with observation for unruptured high-grade dAVFs. METHODS The authors retrospectively reviewed dAVF patients from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with unruptured high-grade (Borden type II or III) dAVFs were included and categorized into four groups (observation, embolization, surgery, and stereotactic radiosurgery [SRS]) based on the initial management. The primary outcome was defined as the modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were good outcome (mRS scores 0-2) at final follow-up, symptomatic improvement, all-cause mortality, and dAVF obliteration. The outcomes of each intervention group were compared against those of the observation group as a reference, with adjustment for differences in baseline characteristics. RESULTS The study included 415 dAVF patients, accounting for 29, 324, 43, and 19 in the observation, embolization, surgery, and SRS groups, respectively. The mean radiological and clinical follow-up durations were 21 and 25 months, respectively. Functional outcomes were similar for embolization, surgery, and SRS compared with observation. With observation as a reference, obliteration rates were higher after embolization (adjusted OR [aOR] 7.147, p = 0.010) and surgery (aOR 33.803, p < 0.001) and all-cause mortality was lower after embolization (imputed, aOR 0.171, p = 0.040). Hemorrhage rates per 1000 patient-years were 101 for observation versus 9, 22, and 0 for embolization (p = 0.022), surgery (p = 0.245), and SRS (p = 0.077), respectively. Nonhemorrhagic neurological deficit rates were similar between each intervention group versus observation. CONCLUSIONS Embolization and surgery for unruptured high-grade dAVFs afforded a greater likelihood of obliteration than did observation. Embolization also reduced the risk of death and dAVF-associated hemorrhage compared with conservative management over a modest follow-up period. These findings support embolization as the first-line treatment of choice for appropriately selected unruptured Borden type II and III dAVFs.
Collapse
Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 18Department of Neurosurgery, University of Louisville, Kentucky
| | - Ridhima Guniganti
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri.,15Mallinckrodt Institute of Radiology and.,16Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Enrico Giordan
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Louis J Kim
- 4Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- 4Department of Neurosurgery, University of Washington, Seattle, Washington
| | | | - Diederik Bulters
- 5Department of Neurosurgery, University of Southampton, United Kingdom
| | - Andrew Durnford
- 5Department of Neurosurgery, University of Southampton, United Kingdom
| | - W Christopher Fox
- 6Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Adam J Polifka
- 6Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Bradley A Gross
- 7Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Minako Hayakawa
- 8Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Colin P Derdeyn
- 8Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | | | - Ali Alaraj
- 9Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Amanda Kwasnicki
- 9Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - J Marc C van Dijk
- 10Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Adriaan R E Potgieser
- 10Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Robert M Starke
- 11Department of Neurosurgery, University of Miami, Florida.,17Department of Radiology, University of Miami, Florida; and
| | - Samir Sur
- 11Department of Neurosurgery, University of Miami, Florida
| | - Junichiro Satomi
- 12Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 12Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Adib A Abla
- 13Department of Neurosurgery, University of California, San Francisco, California
| | - Ethan A Winkler
- 13Department of Neurosurgery, University of California, San Francisco, California
| | - Rose Du
- 14Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pui Man Rosalind Lai
- 14Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregory J Zipfel
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
41
|
Garcia JH, Morshed RA, Winkler EA, Li Y, Fox CK, Fullerton HJ, Rutledge C, Beniwal AS, Lawton MT, Abla AA, Gupta N, Hetts SW. Pediatric moyamoya MRI score: an imaging-based scale to predict outcomes in surgically treated pediatric patients with moyamoya. Neurosurg Focus 2021; 51:E8. [PMID: 34469869 DOI: 10.3171/2021.6.focus21283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Moyamoya is a progressive arteriopathy that predisposes patients to stroke due to stenosis of the intracranial internal carotid arteries and their proximal branches. Despite the morbidity caused by this condition, the ability to accurately predict prognosis for individual patients remains challenging. The goal of this study was to develop a systematic scoring method based on parenchymal findings on preoperative brain MRI to predict long-term outcomes for surgically treated pediatric patients with moyamoya. METHODS A retrospective surgical cohort of pediatric patients (≤ 18 years of age at the time of the initial surgery) with moyamoya from a single center were studied. Radiological variables with existing correlations between outcomes in moyamoya or other vascular diseases were chosen to score preoperative MRI based on easily defined parenchymal findings that could be rapidly assessed and used to make a numeric score. Calculated scores were correlated with clinical outcome measures using the Pearson correlation coefficient and area under the receiver operating characteristic curve (AUROC). RESULTS A total of 35 children with moyamoya disease or moyamoya syndrome were included in the study, with a median follow-up time of 2.6 years from the time of surgery. The pediatric moyamoya MRI score (PMMS) consists of ischemic changes (0-2; 0 = none, 1 = focal, 2 = diffuse), encephalomalacia (0-2; 0 = none, 1 = focal, 2 = diffuse), and hemorrhage (0-1; 0 = not present, 1 = present). PMMSs were highly correlated with pediatric modified Rankin Scale scores at the last follow-up (r = 0.7, 95% CI 0.44-0.84; p < 0.001) as a six-point scale, and when dichotomized (AUROC = 0.85). CONCLUSIONS The PMMS was found to be a simple tool based on preoperative MRI data that could be quickly and easily calculated and correlated with disability. This scoring method may aid future development of predictive models of outcomes for children with moyamoya disease and moyamoya syndrome.
Collapse
Affiliation(s)
- Joseph H Garcia
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ethan A Winkler
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Yi Li
- 2Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Christine K Fox
- 3Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California, San Francisco; and
| | - Heather J Fullerton
- 3Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California, San Francisco; and
| | - Caleb Rutledge
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Angad S Beniwal
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Michael T Lawton
- 1Department of Neurological Surgery, University of California, San Francisco.,4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adib A Abla
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Nalin Gupta
- 1Department of Neurological Surgery, University of California, San Francisco.,5Department of Pediatrics, University of California, San Francisco, California; and
| | - Steven W Hetts
- 2Department of Radiology and Biomedical Imaging, University of California, San Francisco
| |
Collapse
|
42
|
Zhu H, Vigo V, Ahluwalia A, El-Sayed I, Abla AA, Rubio RR. Assessment of Arterial Configurations of the Suprachiasmatic Region from the Endoscopic Endonasal Perspective: A Cadaveric Anatomical Study. World Neurosurg 2021; 155:e460-e471. [PMID: 34454071 DOI: 10.1016/j.wneu.2021.08.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endoscopic endonasal surgery has proved to offer a practical route to treat suprasellar lesions, including tumors and vascular pathologies. Understanding the different configurations of the anterior cerebral communicating artery (ACoA) complex (ACoA-C) is crucial to properly navigate the suprachiasmatic space and decrease any vascular injury while approaching this region through an endonasal approach. METHODS An endoscopic endonasal transplanum-transtubercular approach was performed on 36 cadaveric heads (72 sides). The variations of the ACoA-C and feasibility of reaching its different components were analyzed. The surgical area exposure of the lamina terminalis was also quantified before and after mobilization of the ACoA-C. RESULTS The typical ACoA-C configuration was found in 41.6% of specimens. The following 2 main variations were identified: accessory anterior cerebral artery segment 2 (5, 13.9%) and common trunk of anterior cerebral artery with absence of ACoA (5, 13.9%). Of 101 recurrent arteries of Heubner, 96 (95.0%) were identified within 4 mm proximal or distal to the ACoA. The mean lamina terminalis exposure area was 33.1 ± 16.7 mm2, which increased to 59.9 ± 11.9 mm2 after elevating the ACoA. CONCLUSIONS A considerable amount of variation of the ACoA-C can be found through an endoscopic endonasal transplanum-transtubercular approach. These configurations determine the feasibility of lamina terminalis exposure and the complexity of reaching the ACoA. Assessment of ACoA morphology and its adjacent structures is crucial while approaching the suprachiasmatic through a transnasal corridor.
Collapse
Affiliation(s)
- Hongwei Zhu
- Department of Neurological Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China; Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Vera Vigo
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Amandeep Ahluwalia
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Ivan El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA.
| |
Collapse
|
43
|
Raper DMS, Abla AA. Letter: Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms. Neurosurgery 2021; 89:E272-E273. [PMID: 34332509 DOI: 10.1093/neuros/nyab285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/27/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery Baylor College of Medicine Houston, Texas, USA
| | - Adib A Abla
- Department of Neurological Surgery University of California, San Francisco San Francisco, California, USA
| |
Collapse
|
44
|
Gao S, Nelson J, Weinsheimer S, Winkler EA, Rutledge C, Abla AA, Gupta N, Shieh JT, Cooke DL, Hetts SW, Tihan T, Hess CP, Ko N, Walcott BP, McCulloch CE, Lawton MT, Su H, Pawlikowska L, Kim H. Somatic mosaicism in the MAPK pathway in sporadic brain arteriovenous malformation and association with phenotype. J Neurosurg 2021; 136:148-155. [PMID: 34214981 DOI: 10.3171/2020.11.jns202031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sporadic brain arteriovenous malformation (BAVM) is a tangled vascular lesion characterized by direct artery-to-vein connections that can cause life-threatening intracerebral hemorrhage (ICH). Recently, somatic mutations in KRAS have been reported in sporadic BAVM, and mutations in other mitogen-activated protein kinase (MAPK) signaling pathway genes have been identified in other vascular malformations. The objectives of this study were to systematically evaluate somatic mutations in MAPK pathway genes in patients with sporadic BAVM lesions and to evaluate the association of somatic mutations with phenotypes of sporadic BAVM severity. METHODS The authors performed whole-exome sequencing on paired lesion and blood DNA samples from 14 patients with sporadic BAVM, and 295 genes in the MAPK signaling pathway were evaluated to identify genes with somatic mutations in multiple patients with BAVM. Digital droplet polymerase chain reaction was used to validate KRAS G12V and G12D mutations and to assay an additional 56 BAVM samples. RESULTS The authors identified a total of 24 candidate BAVM-associated somatic variants in 11 MAPK pathway genes. The previously identified KRAS G12V and G12D mutations were the only recurrent mutations. Overall, somatic KRAS G12V was present in 14.5% of BAVM lesions and G12D was present in 31.9%. The authors did not detect a significant association between the presence or allelic burden of KRAS mutation and three BAVM phenotypes: lesion size (maximum diameter), age at diagnosis, and age at ICH. CONCLUSIONS The authors confirmed the high prevalence of somatic KRAS mutations in sporadic BAVM lesions and identified several candidate somatic variants in other MAPK pathway genes. These somatic variants may contribute to understanding of the etiology of sporadic BAVM and the clinical characteristics of patients with this condition.
Collapse
Affiliation(s)
- Sen Gao
- Departments of1Anesthesia and Perioperative Care.,2Center for Cerebrovascular Research, and
| | - Jeffrey Nelson
- Departments of1Anesthesia and Perioperative Care.,2Center for Cerebrovascular Research, and
| | - Shantel Weinsheimer
- Departments of1Anesthesia and Perioperative Care.,2Center for Cerebrovascular Research, and.,4Institute for Human Genetics, University of California, San Francisco, California
| | | | | | | | | | - Joseph T Shieh
- 4Institute for Human Genetics, University of California, San Francisco, California.,11Pediatrics, and
| | | | | | | | | | | | - Brian P Walcott
- 3Neurological Surgery.,8NorthShore University Health System, Evanston, Illinois; and
| | | | - Michael T Lawton
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Hua Su
- Departments of1Anesthesia and Perioperative Care.,2Center for Cerebrovascular Research, and
| | - Ludmila Pawlikowska
- Departments of1Anesthesia and Perioperative Care.,2Center for Cerebrovascular Research, and.,4Institute for Human Genetics, University of California, San Francisco, California
| | - Helen Kim
- Departments of1Anesthesia and Perioperative Care.,2Center for Cerebrovascular Research, and.,4Institute for Human Genetics, University of California, San Francisco, California
| |
Collapse
|
45
|
Raper DMS, Rutledge WC, Winkler EA, Meisel K, Callen AL, Cooke DL, Abla AA. Controversies and Advances in Adult Intracranial Bypass Surgery in 2020. Oper Neurosurg (Hagerstown) 2021; 20:1-7. [PMID: 32895706 DOI: 10.1093/ons/opaa276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/11/2020] [Indexed: 02/02/2023] Open
Abstract
Cerebral revascularization utilizing a variety of bypass techniques can provide either flow augmentation or flow replacement in the treatment of a range of intracranial pathologies, including moyamoya disease, intracranial atherosclerotic disease, and complex aneurysms that are not amenable to endovascular or simple surgical techniques. Though once routine, the publication of high-quality prospective evidence, along with the development of flow-diverting stents, has limited the indications for extracranial-to-intracranial (EC-IC) bypass. Nevertheless, advances in imaging, assessment of cerebral hemodynamics, and surgical technique have changed the risk-benefit calculus for EC-IC bypass. New variations of revascularization surgery involving multiple anastomoses, flow preserving solutions, IC-IC constructs, and posterior circulation bypasses have been pioneered for otherwise difficult to treat pathology including giant aneurysms, dolichoectasia, and medically refractory intracranial atherosclerosis. This review provides a practical update on recent advances in adult intracranial bypass surgery.
Collapse
Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Karl Meisel
- Department of Neurology, University of California, San Francisco, California
| | - Andrew L Callen
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
| |
Collapse
|
46
|
Rutledge C, Raper DMS, Rodriguez Rubio R, Winkler EA, Abla AA. Supracerebellar Infratentorial Infratrochlear Trans-Quadrangular Lobule Approach to Pontine Cavernous Malformations. Oper Neurosurg (Hagerstown) 2021; 20:268-275. [PMID: 33432968 DOI: 10.1093/ons/opaa373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Brainstem cavernous malformations with symptomatic hemorrhage have a poor natural history. Those without a pial or ependymal presentation are often observed given the morbidity of resection. Surgical removal is considered only in patients with accessible lesions that have repeated symptomatic hemorrhagic. OBJECTIVE To describe a novel supracerebellar infratentorial infratrochlear trans-quadrangular lobule approach to safely resect lesions in the upper pons. METHODS We use a hybrid paramedian/lateral suboccipital craniotomy in the gravity-dependent supine position. Opening the cerebellomesencephalic fissure over the tentorial surface of the cerebellum brings the trochlear nerve, branches of the superior cerebellar artery, and the quadrangular lobule of the cerebellum into view. Removal of small a portion of the quadrangular lobule defines an entry point on the superomedial aspect of the middle cerebellar peduncle, and a surgical trajectory aimed superior to inferior. RESULTS A total of 6 patients underwent this approach. All presented with symptomatic hemorrhage and all cavernous malformations were completely resected. Five patients were improved or unchanged with modified Rankin scale scores of 1 or 2. CONCLUSION The trans-quadrangular lobule approach allows safe resection of upper pontine cavernous malformations along a superior to inferior trajectory.
Collapse
Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| |
Collapse
|
47
|
Raper DMS, Abla AA. In Reply: Controversies and Advances in Adult Intracranial Bypass Surgery in 2020. Oper Neurosurg (Hagerstown) 2021; 20:E257. [PMID: 33373448 DOI: 10.1093/ons/opaa436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery Baylor College of Medicine Houston, Texas
| | - Adib A Abla
- Department of Neurological Surgery University of California, San Francisco San Francisco, California
| |
Collapse
|
48
|
Rutledge C, Raper DMS, Jonzzon S, Raygor KP, Pereira MP, Winkler EA, Zhang L, Lawton MT, Abla AA. Sensitivity of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) in the Elderly: Retrospective Analysis of Ruptured Aneurysms. World Neurosurg 2021; 152:e673-e677. [PMID: 34129975 DOI: 10.1016/j.wneu.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE The prevalence of intracranial aneurysms, as well as the incidence of subarachnoid hemorrhage (SAH), increase with age, and the elderly have poor outcomes after SAH. Age is a key factor in the unruptured intracranial aneurysm treatment score (UIATS),but the sensitivity of the UIATS model in detecting risk of SAH among the elderly is unknown. METHODS We retrospectively analyzed 153 consecutive cases of ruptured aneurysms between 2012 and 2018. We used Fisher's exact test, analysis of variance, and multivariate logistic regression to compare outcomes between those >65 years of age and those younger. We then applied the UIATS model and evaluated the sensitivity of the model as a predictor of SAH in the elderly compared with younger patients. RESULTS Elderly patients made up 32% (n = 49 of 153) of our cohort. They had significantly higher in-hospital mortality (19 of 49, 39%) than younger patients (14 of 104, 13%) (P < 0.01). In a multivariate logistic regression, controlling for Hunt-Hess grade and comorbidities, age >65 years remained a significant predictor of unfavorable outcome at discharge (P = 0.03). The UIATS model had low sensitivity in the elderly compared with younger patients: 63% (59 of 136) of younger patients would have been recommended aneurysm repair had their aneurysm been detected unruptured, compared with only 12% (5 of 42) of elderly patients >65 years (P < 0.01). CONCLUSIONS Elderly patients >65 years in age have far worse outcomes after SAH. The sensitivity of the UIATS model for detecting those at risk of SAH was significantly lower in elderly patients. The UIATS model may lead to undertreatment of elderly patients at risk of SAH.
Collapse
Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Soren Jonzzon
- School of Medicine, University of California, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | | | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
| |
Collapse
|
49
|
Halabi C, Williams EK, Morshed RA, Caffarelli M, Anastasiou C, Tihan T, Cooke D, Abla AA, Dowd CF, Shah V, Chung S, Richie MB. Neurological manifestations of polyarteritis nodosa: a tour of the neuroaxis by case series. BMC Neurol 2021; 21:205. [PMID: 34020612 PMCID: PMC8138997 DOI: 10.1186/s12883-021-02228-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/06/2021] [Indexed: 11/30/2022] Open
Abstract
Background Heterogenous central nervous system (CNS) neurologic manifestations of polyarteritis nodosa (PAN) are underrecognized. We review three cases of patients with PAN that illustrate a range of nervous system pathology, including the classical mononeuritis multiplex as well as uncommon brain and spinal cord vascular manifestations. Case presentation Case 1 presented with mononeuritis multiplex and characteristic skin findings. Case 2 presented with thunderclap headache and myelopathy due to spinal artery aneurysm rupture. Both patients experienced disease remission upon treatment. Case 3 presented with headache and bulbar symptoms due to partially thrombosed intracranial aneurysms, followed by systemic manifestations related to visceral aneurysms. She demonstrated clinical improvement with treatment, was lost to follow-up, then clinically deteriorated and entered hospice care. Conclusions Although the peripheral manifestations of PAN are well-known, PAN association with CNS neurovascular disease is relatively underappreciated. Clinician awareness of the spectrum of neurologic disease is required to reduce diagnostic delay and promote prompt diagnosis and treatment with immunosuppressants.
Collapse
Affiliation(s)
- Cathra Halabi
- Department of Neurology, Neurovascular Division, University of California, 505 Parnassus Avenue, Box 0114, San Francisco, California, 94143, USA. .,Weill Institute for Neurosciences, University of California, San Francisco, California, USA.
| | | | - Ramin A Morshed
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Mauro Caffarelli
- Department of Neurology, University of California, San Francisco, California, USA
| | - Christine Anastasiou
- Russell/Engleman Rheumatology Research Center, University of California, San Francisco, California, USA
| | - Tarik Tihan
- Department of Pathology, Neuropathology Division, University of California, San Francisco, California, USA
| | - Daniel Cooke
- Department of Neurointerventional Radiology, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Neurointerventional Radiology, University of California, San Francisco, California, USA
| | - Vinil Shah
- Department of Neuroradiology, University of California, San Francisco, California, USA
| | - Sharon Chung
- Russell/Engleman Rheumatology Research Center, University of California, San Francisco, California, USA
| | - Megan B Richie
- Weill Institute for Neurosciences, University of California, San Francisco, California, USA.,Department of Neurology, Neurohospitalist Division, University of California, San Francisco, California, USA
| |
Collapse
|
50
|
Amans MR, Smith E, Narsinh KH, Dowd CF, Higashida RT, Halbach VV, Hetts SW, Cooke DL, Nelson J, Mccoy D, Ciano M, Dillon WP, Copelan AZ, Drocton GT, Khangura RS, Murph D, Hartley ZJ, Abla AA. Reply. AJNR Am J Neuroradiol 2021; 42:E58-E59. [PMID: 33985958 DOI: 10.3174/ajnr.a7160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- M R Amans
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - E Smith
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - K H Narsinh
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - C F Dowd
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - R T Higashida
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - V V Halbach
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - S W Hetts
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - D L Cooke
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - J Nelson
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - D Mccoy
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - M Ciano
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - W P Dillon
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - A Z Copelan
- Neurointerventional RadiologyConsulting Radiologists, LtdMinneapolis, Minnesota
| | - G T Drocton
- Neurointerventional RadiologySutter HealthSacramento, California
| | - R S Khangura
- Neurointerventional RadiologySutter HealthSacramento, California
| | - D Murph
- Interventional NeuroradiologyAsheville Radiology AssociatesAsheville, North Carolina
| | - Z J Hartley
- Diagnostic RadiologyBrown UniversityProvidence, Rhode Island
| | - A A Abla
- NeurosurgeryUniversity of California, San FranciscoSan Francisco, California
| |
Collapse
|