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Sanchez S, Raghuram A, Wendt L, Hayakawa M, Chen CJ, Sheehan JP, Kim LJ, Abecassis IJ, Levitt MR, Meyer RM, Guniganti R, Kansagra AP, Lanzino G, Giordan E, Brinjikji W, Bulters DO, Durnford A, Fox WC, Smith J, Polifka AJ, Gross B, Amin-Hanjani S, Alaraj A, Kwasnicki A, Starke RM, Chen SH, van Dijk JMC, Potgieser ARE, Satomi J, Tada Y, Phelps R, Abla A, Winkler E, Du R, Lai PMR, Zipfel GJ, Derdeyn C, Samaniego EA. Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas. J Neurointerv Surg 2023; 15:903-908. [PMID: 35944975 DOI: 10.1136/jnis-2022-019160] [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: 05/14/2022] [Accepted: 07/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs. METHODS The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990-2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed. RESULTS 60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs. CONCLUSION Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.
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Affiliation(s)
- Sebastian Sanchez
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ashrita Raghuram
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Linder Wendt
- Institute for Clinical and Translational Science, The University of Iowa, Iowa City, Iowa, USA
| | - Minako Hayakawa
- Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Louis J Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - R Michael Meyer
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Ridhima Guniganti
- Department of Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Enrico Giordan
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Diederik O Bulters
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Andrew Durnford
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - W Christopher Fox
- Department of Neurosurgery, Mayo Clinic Jacksonville Campus, Jacksonville, Florida, USA
| | - Jessica Smith
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Bradley Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Coral Gables, Florida, USA
| | - Stephanie H Chen
- Department of Neurosurgery, University of Miami, Coral Gables, Florida, USA
| | - J Marc C van Dijk
- Department of Neurosurgery, University of Groningen, Groningen, Groningen, Netherlands
| | - Adriaan R E Potgieser
- Department of Neurosurgery, University of Groningen, Groningen, Groningen, Netherlands
| | - Junichiro Satomi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yoshiteru Tada
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Ryan Phelps
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Colin Derdeyn
- Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Departments of Neurology, Radiology and Neurosurgery, The University of Iowa, Iowa City, Iowa, USA
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2
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Durnford AJ, Akarca D, Culliford D, Millar J, Guniganti R, Giordan E, Brinjikji W, Chen CJ, Abecassis IJ, Levitt M, Polifka AJ, Derdeyn CP, Samaniego EA, Kwasnicki A, Alaraj A, Potgieser ARE, Chen S, Tada Y, Phelps R, Abla A, Satomi J, Starke RM, van Dijk JMC, Amin-Hanjani S, Hayakawa M, Gross B, Fox WC, Kim L, Sheehan J, Lanzino G, Kansagra AP, Du R, Lai R, Zipfel GJ, Bulters DO. Risk of Early Versus Later Rebleeding From Dural Arteriovenous Fistulas With Cortical Venous Drainage. Stroke 2022; 53:2340-2345. [PMID: 35420453 PMCID: PMC9232241 DOI: 10.1161/strokeaha.121.036450] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cranial dural arteriovenous fistulas with cortical venous drainage are rare lesions that can present with hemorrhage. A high rate of rebleeding in the early period following hemorrhage has been reported, but published long-term rates are much lower. No study has examined how risk of rebleeding changes over time. Our objective was to quantify the relative incidence of rebleeding in the early and later periods following hemorrhage. METHODS Patients with dural arteriovenous fistula and cortical venous drainage presenting with hemorrhage were identified from the multinational CONDOR (Consortium for Dural Fistula Outcomes Research) database. Natural history follow-up was defined as time from hemorrhage to first treatment, rebleed, or last follow-up. Rebleeding in the first 2 weeks and first year were compared using incidence rate ratio and difference. RESULTS Of 1077 patients, 250 met the inclusion criteria and had 95 cumulative person-years natural history follow-up. The overall annualized rebleed rate was 7.3% (95% CI, 3.2-14.5). The incidence rate of rebleeding in the first 2 weeks was 0.0011 per person-day; an early rebleed risk of 1.6% in the first 14 days (95% CI, 0.3-5.1). For the remainder of the first year, the incidence rate was 0.00015 per person-day; a rebleed rate of 5.3% (CI, 1.7-12.4) over 1 year. The incidence rate ratio was 7.3 (95% CI, 1.4-37.7; P, 0.026). CONCLUSIONS The risk of rebleeding of a dural arteriovenous fistula with cortical venous drainage presenting with hemorrhage is increased in the first 2 weeks justifying early treatment. However, the magnitude of this increase may be considerably lower than previously thought. Treatment within 5 days was associated with a low rate of rebleeding and appears an appropriate timeframe.
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Affiliation(s)
- Andrew J Durnford
- Wessex Neurological Center (A.J.D., D.A., J.M.), University Hospital Southampton, United Kingdom
| | - Danyal Akarca
- MRC Cognition and Brain Sciences Unit, University of Cambridge, United Kingdom (D.A.)
| | - David Culliford
- University of Southampton (D.C.), University Hospital Southampton, United Kingdom
| | - John Millar
- Wessex Neurological Center (A.J.D., D.A., J.M.), University Hospital Southampton, United Kingdom
| | - Ridhima Guniganti
- Department of Neurological Surgery, Washington University, St. Louis, MO (R.G., G.J.Z.)
| | - Enrico Giordan
- Department of Neurological Surgery (E.G., W.B., G.L.), Mayo Clinic, Rochester, MN.,Department of Radiology (E.G., W.B., G.L.), Mayo Clinic, Rochester, MN
| | - Waleed Brinjikji
- Department of Neurological Surgery (E.G., W.B., G.L.), Mayo Clinic, Rochester, MN.,Department of Radiology (E.G., W.B., G.L.), Mayo Clinic, Rochester, MN
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville (C.-J.C., J.S.)
| | - Isaac Josh Abecassis
- Department of Neurological Surgery (I.J.A., M.L., L.K.), University of Washington, Seattle
| | - Michael Levitt
- Department of Neurological Surgery (I.J.A., M.L., L.K.), University of Washington, Seattle.,Stroke and Applied Neuroscience Center (M.L., L.K.), University of Washington, Seattle
| | - Adam J Polifka
- Department of Neurological Surgery, University of Florida, Gainesville (A.J.P., W.C.F.)
| | - Colin P Derdeyn
- Department of Neurology (C.P.D., E.A.S., M.H.), University of Iowa, Iowa City.,Department of Radiology (C.P.D., E.A.S., M.H.), University of Iowa, Iowa City
| | - Edgar A Samaniego
- Department of Neurology (C.P.D., E.A.S., M.H.), University of Iowa, Iowa City.,Department of Radiology (C.P.D., E.A.S., M.H.), University of Iowa, Iowa City
| | - Amanda Kwasnicki
- Department of Neurological Surgery, University of Illinois at Chicago (A.K., A.A., S.A.-H.)
| | - Ali Alaraj
- Department of Neurological Surgery, University of Illinois at Chicago (A.K., A.A., S.A.-H.).,Department of Neurological Surgery, University of Pittsburgh, PA (A.A., B.G.)
| | - Adriaan R E Potgieser
- Department of Neurological Surgery, University Medical Center Groningen, Netherlands (A.R.E.P., J.M.C.v.D.)
| | - Stephanie Chen
- Department of Neurological Surgery, University of Miami, FL (S.C., R.M.S.)
| | - Yoshiteru Tada
- Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School, Japan (Y.T., J.S.)
| | - Ryan Phelps
- Weill Institute for Neurosciences, Department of Neurosurgery, University of California San Francisco (R.P.)
| | | | - Junichiro Satomi
- Department of Neurological Surgery, University of Virginia, Charlottesville (C.-J.C., J.S.).,Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School, Japan (Y.T., J.S.)
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, FL (S.C., R.M.S.)
| | - J Marc C van Dijk
- Department of Neurological Surgery, University Medical Center Groningen, Netherlands (A.R.E.P., J.M.C.v.D.)
| | - Sepideh Amin-Hanjani
- Department of Neurological Surgery, University of Illinois at Chicago (A.K., A.A., S.A.-H.)
| | - Minako Hayakawa
- Department of Neurology (C.P.D., E.A.S., M.H.), University of Iowa, Iowa City.,Department of Radiology (C.P.D., E.A.S., M.H.), University of Iowa, Iowa City
| | - Bradley Gross
- Department of Neurological Surgery, University of Pittsburgh, PA (A.A., B.G.)
| | - W Christopher Fox
- Department of Neurological Surgery, University of Florida, Gainesville (A.J.P., W.C.F.)
| | - Louis Kim
- Department of Neurological Surgery (I.J.A., M.L., L.K.), University of Washington, Seattle.,Stroke and Applied Neuroscience Center (M.L., L.K.), University of Washington, Seattle
| | | | - Giuseppe Lanzino
- Wessex Neurological Center (A.J.D., D.A., J.M.), University Hospital Southampton, United Kingdom.,Department of Radiology (E.G., W.B., G.L.), Mayo Clinic, Rochester, MN
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO (A.P.K.)
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA (R.D., R.L.)
| | - Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA (R.D., R.L.)
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University, St. Louis, MO (R.G., G.J.Z.)
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3
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Abecassis IJ, Meyer RM, Levitt MR, Sheehan JP, Chen CJ, Gross BA, Smith J, Fox WC, Giordan E, Lanzino G, Starke RM, Sur S, Potgieser ARE, van Dijk JMC, Durnford A, Bulters D, Satomi J, Tada Y, Kwasnicki A, Amin-Hanjani S, Alaraj A, Samaniego EA, Hayakawa M, Derdeyn CP, Winkler E, Abla A, Lai PMR, Du R, Guniganti R, Kansagra AP, Zipfel GJ, Kim LJ. Recurrence after cure in cranial dural arteriovenous fistulas: a collaborative effort by the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). J Neurosurg 2022; 136:981-989. [PMID: 34507283 DOI: 10.3171/2021.1.jns202033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 07/24/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranial dural arteriovenous fistulas (dAVFs) are often treated with endovascular therapy, but occasionally a multimodality approach including surgery and/or radiosurgery is utilized. Recurrence after an initial angiographic cure has been reported, with estimated rates ranging from 2% to 14.3%, but few risk factors have been identified. The objective of this study was to identify risk factors associated with recurrence of dAVF after putative cure. METHODS The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) data were retrospectively reviewed. All patients with angiographic cure after treatment and subsequent angiographic follow-up were included. The primary outcome was recurrence, with risk factor analysis. Secondary outcomes included clinical outcomes, morbidity, and mortality associated with recurrence. Risk factor analysis was performed comparing the group of patients who experienced recurrence with those with durable cure (regardless of multiple recurrences). Time-to-event analysis was performed using all collective recurrence events (multiple per patients in some cases). RESULTS Of the 1077 patients included in the primary CONDOR data set, 457 met inclusion criteria. A total of 32 patients (7%) experienced 34 events of recurrence at a mean of 368.7 days (median 192 days). The recurrence rate was 4.5% overall. Kaplan-Meier analysis predicted long-term recurrence rates approaching 11% at 3 years. Grade III dAVFs treated with endovascular therapy were statistically significantly more likely to experience recurrence than those treated surgically (13.3% vs 0%, p = 0.0001). Tentorial location, cortical venous drainage, and deep cerebral venous drainage were all risk factors for recurrence. Endovascular intervention and radiosurgery were associated with recurrence. Six recurrences were symptomatic, including 2 with hemorrhage, 3 with nonhemorrhagic neurological deficit, and 1 with progressive flow-related symptoms (decreased vision). CONCLUSIONS Recurrence of dAVFs after putative cure can occur after endovascular treatment. Risk factors include tentorial location, cortical venous drainage, and deep cerebral drainage. Multimodality therapy can be used to achieve cure after recurrence. A delayed long-term angiographic evaluation (at least 1 year from cure) may be warranted, especially in cases with risk factors for recurrence.
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Affiliation(s)
| | | | - Michael R Levitt
- Departments of1Neurological Surgery
- 4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Jason P Sheehan
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bradley A Gross
- 6Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Jessica Smith
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - W Christopher Fox
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Giuseppe Lanzino
- Departments of8Neurosurgery and
- 9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert M Starke
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Samir Sur
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Adriaan R E Potgieser
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - J Marc C van Dijk
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Andrew Durnford
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Diederik Bulters
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Junichiro Satomi
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Amanda Kwasnicki
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | | | - Ali Alaraj
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Edgar A Samaniego
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Minako Hayakawa
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Ethan Winkler
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Adib Abla
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Pui Man Rosalind Lai
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Rose Du
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | | | - Akash P Kansagra
- Departments of18Neurological Surgery
- 20Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Louis J Kim
- Departments of1Neurological Surgery
- 2Radiology, and
- 4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
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4
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Kwasnicki A, Calandriello A, Nikas D. Spontaneous spinal epidural hematoma in an infant presenting with Horner syndrome. Childs Nerv Syst 2022; 38:827-830. [PMID: 34228175 DOI: 10.1007/s00381-021-05252-2] [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: 02/19/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic entity, especially in infants, that develops in the absence of underlying coagulopathy, bleeding diathesis, infection, vascular malformation, trauma, iatrogenic, or other identifiable cause. In contrast to adults, diagnosis is frequently delayed or missed in infants due to non-specific symptoms and limited clinical examination. CASE ILLUSTRATION An 11-month-old female demonstrated symptoms of irritability, intermittent diarrhea, lethargy, decreased oral intake, and difficulties crawling before presenting to the emergency room. At time of presentation, she was noted to have minimal spontaneous movement of the lower extremities and anisocoria with ptosis of the right eye. Given her clinical presentation, a magnetic resonance image (MRI) of the spine was obtained which revealed an epidural hematoma with compression extending from C7-T3. She underwent C7-T3 laminoplasty and hematoma evacuation. Following surgical intervention, she demonstrated significant improvements in her lower extremity strength and resolution of Horner syndrome. CONCLUSION SSEH in infants is a rare neurologic condition, with diagnosis often delayed due to nonspecific symptomatology. Prompt diagnosis and intervention are essential in the treatment of SSEH to prevent permanent neurologic dysfunction. Physicians should have a high index of suspicion for SSEH in these instances, and investigation with spinal MRI imaging is recommended.
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Affiliation(s)
- Amanda Kwasnicki
- Department of Neurological Surgery, University of Illinois at Chicago, 912 South Wood Street, 451N - MC 799, Chicago, IL, 60612, USA.
| | - Amy Calandriello
- Department of Pediatric Neurological Surgery, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Dimitrios Nikas
- Department of Neurological Surgery, University of Illinois at Chicago, 912 South Wood Street, 451N - MC 799, Chicago, IL, 60612, USA.,Department of Pediatric Neurological Surgery, Advocate Christ Medical Center, Oak Lawn, IL, USA
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5
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Bram R, Kwasnicki A, Atwal GS. Microsurgical Clipping of a Ruptured Basilar-P1 Junction Aneurysm. World Neurosurg 2021; 159:12. [PMID: 34929364 DOI: 10.1016/j.wneu.2021.12.037] [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: 11/25/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022]
Abstract
In current neurosurgical practice, treatment paradigms for posterior circulation aneurysms have shifted away from microsurgical clip ligation toward endovascular therapy. This is largely due to the results of the International Subarachnoid Aneurysm Trial and International Study of Unruptured Intracranial Aneurysms, which, in part, showed that outcomes in patients with ruptured aneurysms were better with coiling and that a location in the posterior circulation was an independent risk factor for poor outcome, respectively.1,2 Nevertheless, there exist certain anatomic features that highlight the importance of a microsurgical approach. These include small size, wide-neck configuration, and the incorporation of perforators, among other factors. In Video 1, we report a case of a 53-year-old male with a ruptured 2 mm × 2 mm right basilar-P1 junction aneurysm. Endovascular options were deemed less favorable due to the small size of the aneurysm and the hemorrhagic complications associated with dual-antiplatelet therapy in the setting of an acute subarachnoid hemorrhage. A standard right-sided orbitozygomatic approach was performed.3 This video highlights the importance of performing microsurgical clipping for posterior circulation aneurysms in an era with increasing reliance on endovascular treatment.
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Affiliation(s)
- Richard Bram
- Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA.
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
| | - Gursant S Atwal
- Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
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6
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McGuire LS, See AP, Kwasnicki A, Charbel FT. External carotid artery to internal carotid artery transposition to augment flow for a superficial temporal artery to middle cerebral artery bypass associated with severe external carotid artery stenosis. Acta Neurochir (Wien) 2021; 163:3495-3499. [PMID: 34420106 DOI: 10.1007/s00701-021-04974-1] [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: 06/29/2021] [Accepted: 08/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Donor vessel quality can impact the outcome of extracranial-intracranial (EC-IC) bypass. External carotid artery (ECA) disease may produce embolism into the anastomosis and cerebral territory and possibly reduce flow in the superficial temporal artery (STA). Previously reported remedies to ECA stenosis include ECA endarterectomy, stenting, and angioplasty. Clinical presentation A middle-aged patient with chronic left MCA occlusion, progressive ischemic symptoms on maximal medical therapy, and imaging confirmation of compromised hemodynamic reserve was evaluated for EC-IC bypass. Angiography demonstrated severe ECA origin stenosis. An ECA-ICA transposition was performed, primarily to eliminate the risk of emboli and secondarily to possibly improve the STA flow. The patient sustained an excellent radiological and clinical outcome, and the STA donor cut-flow was increased modestly by 22% (45 to 55 mL/min). CONCLUSION This case is the first report of an ECA to internal carotid artery transposition as an option in the management of ECA stenosis in preparation for an STA-MCA bypass for the purpose of flow augmentation.
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Affiliation(s)
- Laura Stone McGuire
- Department of Neurological Surgery, University of Illinois At Chicago, 912 South Wood Street, Chicago, IL, 60612, USA
| | - Alfred P See
- Department of Neurological Surgery, University of Illinois At Chicago, 912 South Wood Street, Chicago, IL, 60612, USA
| | - Amanda Kwasnicki
- Department of Neurological Surgery, University of Illinois At Chicago, 912 South Wood Street, Chicago, IL, 60612, USA
| | - Fady T Charbel
- Department of Neurological Surgery, University of Illinois At Chicago, 912 South Wood Street, Chicago, IL, 60612, USA.
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7
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Guniganti R, Giordan E, Chen CJ, Abecassis IJ, Levitt MR, Durnford A, Smith J, Samaniego EA, Derdeyn CP, Kwasnicki A, Alaraj A, Potgieser ARE, Sur S, Chen SH, Tada Y, Winkler E, Phelps RRL, Lai PMR, Du R, Abla A, Satomi J, Starke RM, van Dijk JMC, Amin-Hanjani S, Hayakawa M, Gross BA, Fox WC, Bulters D, Kim LJ, Sheehan J, Lanzino G, Piccirillo JF, Kansagra AP, Zipfel GJ. Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR): rationale, design, and initial characterization of patient cohort. J Neurosurg 2021; 136:951-961. [PMID: 34507282 DOI: 10.3171/2021.1.jns202790] [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: 07/18/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranial dural arteriovenous fistulas (dAVFs) are rare lesions, hampering efforts to understand them and improve their care. To address this challenge, investigators with an established record of dAVF investigation formed an international, multicenter consortium aimed at better elucidating dAVF pathophysiology, imaging characteristics, natural history, and patient outcomes. This report describes the design of the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) and includes characterization of the 1077-patient cohort. METHODS Potential collaborators with established interest in the field were identified via systematic review of the literature. To ensure uniformity of data collection, a quality control process was instituted. Data were retrospectively obtained. RESULTS CONDOR comprises 14 centers in the United States, the United Kingdom, the Netherlands, and Japan that have pooled their data from 1077 dAVF patients seen between 1990 and 2017. The cohort includes 359 patients (33%) with Borden type I dAVFs, 175 (16%) with Borden type II fistulas, and 529 (49%) with Borden type III fistulas. Overall, 852 patients (79%) presented with fistula-related symptoms: 427 (40%) presented with nonaggressive symptoms such as tinnitus or orbital phenomena, 258 (24%) presented with intracranial hemorrhage, and 167 (16%) presented with nonhemorrhagic neurological deficits. A smaller proportion (224 patients, 21%), whose dAVFs were discovered incidentally, were asymptomatic. Many patients (85%, 911/1077) underwent treatment via endovascular embolization (55%, 587/1077), surgery (10%, 103/1077), radiosurgery (3%, 36/1077), or multimodal therapy (17%, 184/1077). The overall angiographic cure rate was 83% (758/911 treated), and treatment-related permanent neurological morbidity was 2% (27/1467 total procedures). The median time from diagnosis to follow-up was 380 days (IQR 120-1038.5 days). CONCLUSIONS With more than 1000 patients, the CONDOR registry represents the largest registry of cranial dAVF patient data in the world. These unique, well-annotated data will enable multiple future analyses to be performed to better understand dAVFs and their management.
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Affiliation(s)
| | - Enrico Giordan
- Departments of4Neurological Surgery and.,5Radiology, Mayo Clinic, Rochester, Minnesota
| | - Ching-Jen Chen
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Michael R Levitt
- 7Department of Neurological Surgery and.,8Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Andrew Durnford
- 9Department of Neurosurgery, University of Southampton, University Hospital Southampton, United Kingdom
| | - Jessica Smith
- 10Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Edgar A Samaniego
- Departments of12Neurology and.,13Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- Departments of12Neurology and.,13Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amanda Kwasnicki
- 14Department of Neurological Surgery, University of Illinois at Chicago, Illinois
| | - Ali Alaraj
- 14Department of Neurological Surgery, University of Illinois at Chicago, Illinois
| | - Adriaan R E Potgieser
- 15Department of Neurological Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Samir Sur
- 16Department of Neurological Surgery and Radiology, University of Miami, Florida
| | - Stephanie H Chen
- 16Department of Neurological Surgery and Radiology, University of Miami, Florida
| | - Yoshiteru Tada
- 17Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School, Tokushima, Japan
| | - Ethan Winkler
- 18Weill Institute for Neurosciences, Department of Neurosurgery, University of California, San Francisco, California
| | - Ryan R L Phelps
- 18Weill Institute for Neurosciences, Department of Neurosurgery, University of California, San Francisco, California
| | - Pui Man Rosalind Lai
- 19Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rose Du
- 19Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adib Abla
- 18Weill Institute for Neurosciences, Department of Neurosurgery, University of California, San Francisco, California
| | - Junichiro Satomi
- 17Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School, Tokushima, Japan
| | - Robert M Starke
- 16Department of Neurological Surgery and Radiology, University of Miami, Florida
| | - J Marc C van Dijk
- 15Department of Neurological Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Sepideh Amin-Hanjani
- 14Department of Neurological Surgery, University of Illinois at Chicago, Illinois
| | - Minako Hayakawa
- Departments of12Neurology and.,13Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Bradley A Gross
- 11Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - W Christopher Fox
- 10Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Diederik Bulters
- 9Department of Neurosurgery, University of Southampton, University Hospital Southampton, United Kingdom
| | - Louis J Kim
- 7Department of Neurological Surgery and.,8Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Jason Sheehan
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Giuseppe Lanzino
- Departments of4Neurological Surgery and.,5Radiology, Mayo Clinic, Rochester, Minnesota
| | - Jay F Piccirillo
- 3Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 1Department of Neurological Surgery.,2Mallinckrodt Institute of Radiology, and
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8
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Samaniego EA, Roa JA, Hayakawa M, Chen CJ, Sheehan JP, Kim LJ, Abecassis IJ, Levitt MR, Guniganti R, Kansagra AP, Lanzino G, Giordan E, Brinjikji W, Bulters D, Durnford A, Fox WC, Polifka AJ, Gross BA, Amin-Hanjani S, Alaraj A, Kwasnicki A, Starke RM, Sur S, van Dijk JMC, Potgieser ARE, Satomi J, Tada Y, Abla A, Winkler E, Du R, Lai PMR, Zipfel GJ, Derdeyn CP. Dural arteriovenous fistulas without cortical venous drainage: presentation, treatment, and outcomes. J Neurosurg 2021; 136:942-950. [PMID: 34507278 DOI: 10.3171/2021.1.jns202825] [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: 07/21/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current evidence suggests that intracranial dural arteriovenous fistulas (dAVFs) without cortical venous drainage (CVD) have a benign clinical course. However, no large study has evaluated the safety and efficacy of current treatments and their impact over the natural history of dAVFs without CVD. METHODS The authors conducted an analysis of the retrospectively collected multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database. Patient demographics and presenting symptoms, angiographic features of the dAVFs, and treatment outcomes of patients with Borden type I dAVFs were reviewed. Clinical and radiological follow-up information was assessed to determine rates of new intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND), worsening of venous hyperdynamic symptoms (VHSs), angiographic recurrence, and progression or spontaneous regression of dAVFs over time. RESULTS A total of 342 patients/Borden type I dAVFs were identified. The mean patient age was 58.1 ± 15.6 years, and 62% were women. The mean follow-up time was 37.7 ± 54.3 months. Of 230 (67.3%) treated dAVFs, 178 (77%) underwent mainly endovascular embolization, 11 (4.7%) radiosurgery alone, and 4 (1.7%) open surgery as the primary modality. After the first embolization, most dAVFs (47.2%) achieved only partial reduction in early venous filling. Multiple complementary interventions increased complete obliteration rates from 37.9% after first embolization to 46.7% after two or more embolizations, and 55.2% after combined radiosurgery and open surgery. Immediate postprocedural complications occurred in 35 dAVFs (15.2%) and 6 (2.6%) with permanent sequelae. Of 127 completely obliterated dAVFs by any therapeutic modality, 2 (1.6%) showed angiographic recurrence/recanalization at a mean of 34.2 months after treatment. Progression to Borden-Shucart type II or III was documented in 2.2% of patients and subsequent development of a new dAVF in 1.6%. Partial spontaneous regression was found in 22 (21.4%) of 103 nontreated dAVFs. Multivariate Cox regression analysis demonstrated that older age, NHND, or severe venous-hyperdynamic symptoms at presentation and infratentorial location were associated with worse prognosis. Kaplan-Meier curves showed no significant difference for stable/improved symptoms survival probability in treated versus nontreated dAVFs. However, estimated survival times showed better trends for treated dAVFs compared with nontreated dAVFs (288.1 months vs 151.1 months, log-rank p = 0.28). This difference was statistically significant for treated dAVFs with 100% occlusion (394 months, log-rank p < 0.001). CONCLUSIONS Current therapeutic modalities for management of dAVFs without CVD may provide better symptom control when complete angiographic occlusion is achieved.
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Affiliation(s)
- Edgar A Samaniego
- Departments of1Neurology.,3Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jorge A Roa
- Departments of1Neurology.,2Neurosurgery, and
| | - Minako Hayakawa
- 3Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Ching-Jen Chen
- 4Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- 4Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Louis J Kim
- 5Department of Neurosurgery, University of Washington, Seattle, Washington
| | | | - Michael R Levitt
- 5Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Ridhima Guniganti
- 6Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 6Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Enrico Giordan
- 7Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | | | - Diederik Bulters
- 8Department of Neurosurgery, University of Southampton, United Kingdom
| | - Andrew Durnford
- 8Department of Neurosurgery, University of Southampton, United Kingdom
| | - W Christopher Fox
- 9Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Adam J Polifka
- 9Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Bradley A Gross
- 10Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | | | - Ali Alaraj
- 11Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Amanda Kwasnicki
- 11Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | | | - Samir Sur
- 12Department of Neurosurgery, University of Miami, Florida
| | - J Marc C van Dijk
- 13Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Adriaan R E Potgieser
- 13Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Junichiro Satomi
- 14Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 14Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Adib Abla
- 15Department of Neurosurgery, University of California, San Francisco, California; and
| | - Ethan Winkler
- 15Department of Neurosurgery, University of California, San Francisco, California; and
| | - Rose Du
- 16Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pui Man Rosalind Lai
- 16Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregory J Zipfel
- 6Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Colin P Derdeyn
- 3Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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9
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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.
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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
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10
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Abecassis IJ, Meyer RM, Levitt MR, Sheehan JP, Chen CJ, Gross BA, Lockerman A, Fox WC, Brinjikji W, Lanzino G, Starke RM, Chen SH, Potgieser ARE, van Dijk JMC, Durnford A, Bulters D, Satomi J, Tada Y, Kwasnicki A, Amin-Hanjani S, Alaraj A, Samaniego EA, Hayakawa M, Derdeyn CP, Winkler E, Abla A, Lai PMR, Du R, Guniganti R, Kansagra AP, Zipfel GJ, Kim LJ. Assessing the rate, natural history, and treatment trends of intracranial aneurysms in patients with intracranial dural arteriovenous fistulas: a Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) investigation. J Neurosurg 2021; 136:971-980. [PMID: 34507300 DOI: 10.3171/2021.1.jns202861] [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: 07/24/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a reported elevated risk of cerebral aneurysms in patients with intracranial dural arteriovenous fistulas (dAVFs). However, the natural history, rate of spontaneous regression, and ideal treatment regimen are not well characterized. In this study, the authors aimed to describe the characteristics of patients with dAVFs and intracranial aneurysms and propose a classification system. METHODS The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database from 12 centers was retrospectively reviewed. Analysis was performed to compare dAVF patients with (dAVF+ cohort) and without (dAVF-only cohort) concomitant aneurysm. Aneurysms were categorized based on location as a dAVF flow-related aneurysm (FRA) or a dAVF non-flow-related aneurysm (NFRA), with further classification as extra- or intradural. Patients with traumatic pseudoaneurysms or aneurysms with associated arteriovenous malformations were excluded from the analysis. Patient demographics, dAVF anatomical information, aneurysm information, and follow-up data were collected. RESULTS Of the 1077 patients, 1043 were eligible for inclusion, comprising 978 (93.8%) and 65 (6.2%) in the dAVF-only and dAVF+ cohorts, respectively. There were 96 aneurysms in the dAVF+ cohort; 10 patients (1%) harbored 12 FRAs, and 55 patients (5.3%) harbored 84 NFRAs. Dural AVF+ patients had higher rates of smoking (59.3% vs 35.2%, p < 0.001) and illicit drug use (5.8% vs 1.5%, p = 0.02). Sixteen dAVF+ patients (24.6%) presented with aneurysm rupture, which represented 16.7% of the total aneurysms. One patient (1.5%) had aneurysm rupture during follow-up. Patients with dAVF+ were more likely to have a dAVF located in nonconventional locations, less likely to have arterial supply to the dAVF from external carotid artery branches, and more likely to have supply from pial branches. Rates of cortical venous drainage and Borden type distributions were comparable between cohorts. A minority (12.5%) of aneurysms were FRAs. The majority of the aneurysms underwent treatment via either endovascular (36.5%) or microsurgical (15.6%) technique. A small proportion of aneurysms managed conservatively either with or without dAVF treatment spontaneously regressed (6.2%). CONCLUSIONS Patients with dAVF have a similar risk of harboring a concomitant intracranial aneurysm unrelated to the dAVF (5.3%) compared with the general population (approximately 2%-5%) and a rare risk (0.9%) of harboring an FRA. Only 50% of FRAs are intradural. Dural AVF+ patients have differences in dAVF angioarchitecture. A subset of dAVF+ patients harbor FRAs that may regress after dAVF treatment.
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Affiliation(s)
| | | | - Michael R Levitt
- Departments of1Neurological Surgery.,4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Jason P Sheehan
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bradley A Gross
- 6Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ashley Lockerman
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - W Christopher Fox
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Waleed Brinjikji
- Departments of8Neurosurgery and.,9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Giuseppe Lanzino
- Departments of8Neurosurgery and.,9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert M Starke
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Stephanie H Chen
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Adriaan R E Potgieser
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - J Marc C van Dijk
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Andrew Durnford
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Diederik Bulters
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Junichiro Satomi
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Amanda Kwasnicki
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | | | - Ali Alaraj
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Edgar A Samaniego
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Minako Hayakawa
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Ethan Winkler
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Adib Abla
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Pui Man Rosalind Lai
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Rose Du
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | | | - Akash P Kansagra
- Departments of18Neurological Surgery.,20Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Louis J Kim
- Departments of1Neurological Surgery.,2Radiology, and.,4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
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11
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Chiu R, Chaker A, McGuire LS, Kwasnicki A, Du X, Alaraj A, Charbel FT. Socioeconomic Inequities in the Surgical Management of Moyamoya Disease. World Neurosurg 2021; 155:e188-e195. [PMID: 34400326 DOI: 10.1016/j.wneu.2021.08.033] [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: 05/08/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given the vasculopathic nature of moyamoya disease (MMD) and high susceptibility to ischemic events, patients with MMD often require surgical revascularization via an indirect or direct bypass, and analysis of disparities in receipt of appropriate management is critical. METHODS The 2012-2016 Nationwide Inpatient Sample was queried for patients admitted with a diagnosis of MMD using International Classification of Diseases codes. Patient baseline demographics, hospital characteristics, and associated symptoms were collected. Patients were grouped by receipt of bypass procedure, and propensity score matching was performed to identify socioeconomic disparities between operative and nonoperative groups. RESULTS Inclusion criteria were met by 4474 patients (827 pediatric patients and 3647 adult patients). Mean (SD) age for pediatric patients was 10.4 (4.6) years and for adult patients was 40.5 (14.4) years. Among pediatric patients, Black and Hispanic/Latino patients were less likely to undergo revascularization surgery (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.21-0.78, P ≤ 0.01; OR 0.47, 95% CI 0.26-0.84, P = < 0.01, respectively); among adult patients, Black and Hispanic/Latino patients were similarly less likely to undergo bypass procedures (OR 0.60, 95% CI 0.49-0.72, P ≤ 0.01; OR 0.73, 95% CI 0.55-0.96, P = 0.01, respectively). Pediatric and adult patients in the lowest and next to lowest income quartiles were also less likely to receive operative treatment (pediatric patients: OR 0.61, 95% CI 0.40-0.94, P = 0.02; OR 0.64, 95% CI 0.42-0.98, P = 0.04, respectively; adult patients: OR 0.82, 95% CI 0.88-0.98, P = 0.03). CONCLUSIONS Further investigation into socioeconomic disparities in adult and pediatric patients with MMD is warranted given the potential for inequities in access to appropriate intervention.
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Affiliation(s)
- Ryan Chiu
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Anisse Chaker
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Xinjian Du
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
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12
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Chen CJ, Buell TJ, Ding D, Guniganti R, Kansagra AP, Lanzino G, Brinjikji W, Kim L, 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, Chen S, Satomi J, Tada Y, Abla A, Phelps RRL, Du R, Lai R, Zipfel GJ, Sheehan JP. Observation Versus Intervention for Low-Grade Intracranial Dural Arteriovenous Fistulas. Neurosurgery 2021; 88:1111-1120. [PMID: 33582776 DOI: 10.1093/neuros/nyab024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 10/15/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Low-grade intracranial dural arteriovenous fistulas (dAVF) have a benign natural history in the majority of cases. The benefit from treatment of these lesions is controversial. OBJECTIVE To compare the outcomes of observation versus intervention for low-grade dAVFs. METHODS We retrospectively reviewed dAVF patients from institutions participating in the CONsortium for Dural arteriovenous fistula Outcomes Research (CONDOR). Patients with low-grade (Borden type I) dAVFs were included and categorized into intervention or observation cohorts. The intervention and observation cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was modified Rankin Scale (mRS) at final follow-up. Secondary outcomes were excellent (mRS 0-1) and good (mRS 0-2) outcomes, symptomatic improvement, mortality, and obliteration at final follow-up. RESULTS The intervention and observation cohorts comprised 230 and 125 patients, respectively. We found no differences in primary or secondary outcomes between the 2 unmatched cohorts at last follow-up (mean duration 36 mo), except obliteration rate was higher in the intervention cohort (78.5% vs 24.1%, P < .001). The matched intervention and observation cohorts each comprised 78 patients. We also found no differences in primary or secondary outcomes between the matched cohorts except obliteration was also more likely in the matched intervention cohort (P < .001). Procedural complication rates in the unmatched and matched intervention cohorts were 15.4% and 19.2%, respectively. CONCLUSION Intervention for low-grade intracranial dAVFs achieves superior obliteration rates compared to conservative management, but it fails to improve neurological or functional outcomes. Our findings do not support the routine treatment of low-grade dAVFs.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Ridhima Guniganti
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Akash P Kansagra
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Louis Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Diederik Bulters
- Department of Neurosurgery, University of Southampton, Southampton, United Kingdom
| | - Andrew Durnford
- Department of Neurosurgery, University of Southampton, Southampton, United Kingdom
| | - W Christopher Fox
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Minako Hayakawa
- Department of Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa, Iowa City, Iowa, USA
| | | | | | - Ali Alaraj
- Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois, Chicago, Illinois, USA
| | - J Marc C van Dijk
- Department of Neurosurgery, University of Groningen, Groningen, the Netherlands
| | | | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miami, Florida, USA.,Department of Radiology, University of Miami, Miami, Florida, USA
| | - Stephanie Chen
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
| | - Junichiro Satomi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Adib Abla
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Ryan R L Phelps
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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13
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Li Y, Chen SH, Guniganti R, Kansagra AP, Piccirillo JF, Chen CJ, Buell T, Sheehan JP, Ding D, Lanzino G, Brinjikji W, Kim LJ, Levitt MR, Abecassis IJ, Bulters DO, Durnford A, Fox WC, Polifka AJ, Gross BA, Sur S, McCarthy DJ, Yavagal DR, Peterson EC, Hayakawa M, Derdeyn C, Samaniego EA, Amin-Hanjani S, Alaraj A, Kwasnicki A, Charbel FT, van Dijk JMC, Potgieser AR, Satomi J, Tada Y, Abla A, Phelps R, Du R, Lai PMR, Zipfel GJ, Starke RM. Onyx embolization for dural arteriovenous fistulas: a multi-institutional study. J Neurointerv Surg 2021; 14:neurintsurg-2020-017109. [PMID: 33632883 DOI: 10.1136/neurintsurg-2020-017109] [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: 11/11/2020] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance. OBJECTIVE To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs. METHODS From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models. RESULTS A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes. CONCLUSIONS In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.
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Affiliation(s)
- Yangchun Li
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Ridhima Guniganti
- Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Akash P Kansagra
- Department of Neurological Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jay F Piccirillo
- Department of Neurological Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas Buell
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Andrew Durnford
- Department of Neurosurgery, University of Southampton, Southampton, Hampshire, UK
| | - W Christopher Fox
- Department of Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samir Sur
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami, Miami, Florida, USA
| | - Eric C Peterson
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Minako Hayakawa
- Division of Neurointerventional Surgery, Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Colin Derdeyn
- Department of Radiology and Interventional Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - J Marc C van Dijk
- Department of Neurosurgery, Universitair Medisch Centrum Groningen, Groningen, Groningen, Netherlands
| | - Adriaan Re Potgieser
- Department of Neurosurgery, University of Groningen, Groningen, Groningen, Netherlands
| | - Junichiro Satomi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yoshiteru Tada
- Department of Neurosurgery, Tokushima University, Tokushima, Tokushima, Japan
| | - Adib Abla
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Ryan Phelps
- Department of Neurosurgery, UCSF, San Francisco, California, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University, St Louis, Missouri, USA.,Department of Neurological Surgery, Washington University, St Louis, Missouri, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA .,Department of Radiology, University of Miami School of Medicine, Miami, Florida, USA
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14
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Engelhard HH, Willis AJ, Hussain SI, Papavasiliou G, Banner DJ, Kwasnicki A, Lakka SS, Hwang S, Shokuhfar T, Morris SC, Liu B. Etoposide-Bound Magnetic Nanoparticles Designed for Remote Targeting of Cancer Cells Disseminated Within Cerebrospinal Fluid Pathways. Front Neurol 2020; 11:596632. [PMID: 33329349 PMCID: PMC7729165 DOI: 10.3389/fneur.2020.596632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022] Open
Abstract
Magnetic nanoparticles (MNPs) have potential for enhancing drug delivery in selected cancer patients, including those which have cells that have disseminated within cerebrospinal fluid (CSF) pathways. Here, we present data related to the creation and in vitro use of new two-part MNPs consisting of magnetic gold-iron alloy cores which have streptavidin binding sites, and are coated with biotinylated etoposide. Etoposide was chosen due to its previous use in the CSF and ease of biotinylation. Etoposide magnetic nanoparticles (“Etop-MNPs”) were characterized by several different methods, and moved at a distance by surface-walking of MNP clusters, which occurs in response to a rotating permanent magnet. Human cell lines including D283 (medulloblastoma), U138 (glioblastoma), and H2122 (lung adenocarcinoma) were treated with direct application of Etop-MNPs (and control particles), and after remote particle movement. Cell viability was determined by MTT assay and trypan blue exclusion. Results indicated that the biotinylated etoposide was successfully bound to the base MNPs, with the hybrid particle attaining a maximum velocity of 0.13 ± 0.018 cm/sec. Etop-MNPs killed cancer cells in a dose-dependent fashion, with 50 ± 6.8% cell killing of D283 cells (for example) with 24 h of treatment after remote targeting. U138 and H2122 cells were found to be even more susceptible to the killing effect of Etop-MNPs than D283 cells. These findings indicate that the novel Etop-MNPs have a cytotoxic effect, and can be moved relatively rapidly at physiologic distances, using a rotating magnet. While further testing is needed, intrathecal administration of Etop-MNPs holds promise for magnetically-enhanced eradication of cancer cells distributed within CSF pathways, particularly if given early in the course of the disease.
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Affiliation(s)
- Herbert H Engelhard
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States.,Department of Bioengineering University of Illinois at Chicago, Chicago, IL, United States
| | - Alexander J Willis
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States.,Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Syed I Hussain
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States.,Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - Georgia Papavasiliou
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, United States
| | - David J Banner
- Department of Bioengineering University of Illinois at Chicago, Chicago, IL, United States
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States
| | - Sajani S Lakka
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | | | - Tolou Shokuhfar
- Department of Bioengineering University of Illinois at Chicago, Chicago, IL, United States
| | - Sean C Morris
- Pulse Therapeutics, Inc., St. Louis, MO, United States
| | - Bing Liu
- IMRA America, Inc., Ann Arbor, MI, United States
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15
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Pierce CF, Kwasnicki A, Lakka SS, Engelhard HH. Cerebral Microdialysis as a Tool for Assessing the Delivery of Chemotherapy in Brain Tumor Patients. World Neurosurg 2020; 145:187-196. [PMID: 32890850 DOI: 10.1016/j.wneu.2020.08.161] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 06/26/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/27/2022]
Abstract
The development of curative treatment for glioblastoma has been extremely challenging. Chemotherapeutic agents that have seemed promising have failed in clinical trials. Drugs that can successfully target cancer cells within the brain must first traverse the brain interstitial fluid. Cerebral microdialysis (CMD) is an invasive technique in which interstitial fluid can be directly sampled. CMD has primarily been used clinically in the setting of head trauma and subarachnoid hemorrhage. Our goal was to review the techniques, principles, and new data pertaining to CMD to highlight its use in neuro-oncology. We conducted a literature search using the PubMed database and selected studies in which the investigators had used CMD in either animal brain tumor models or clinical trials. The references were reviewed for additional information. Studies of CMD have shown its importance as a neurosurgical technique. CMD allows for the collection of pharmacokinetic data on drug penetrance across the blood-brain barrier and metabolic data to characterize the response to chemotherapy. Although no complications have been reported, the current CMD technique (as with any procedure) has risks and limitations, which we have described in the present report. Animal CMD experiments have been used to exclude central nervous system drug candidates from progressing to clinical trials. At present, patients undergoing CMD have been monitored in the intensive care unit, owing to the requisite tethering to the apparatus. This can be expected to change soon because of advances in microminiaturization. CMD is an extremely valuable, yet underused, technique. Future CMD applications will have central importance in assessing drug delivery to tumor cells in vivo, allowing a pathway to successful therapy for malignant brain tumors.
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Affiliation(s)
- Charles F Pierce
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amanda Kwasnicki
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sajani S Lakka
- Department of Medicine, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Herbert H Engelhard
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA; Department of Bioengineering, The University of Illinois at Chicago, Chicago, Illinois, USA.
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16
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Kwasnicki A, McGuire LS, Lichtenbaum R. Neurologic Clinical Manifestations of Fahr Syndrome and Hypoparathyroidism. World Neurosurg 2020; 144:115-116. [PMID: 32745648 DOI: 10.1016/j.wneu.2020.07.160] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
A 41-year-old female with a history of chronic hypoparathyroidism with Fahr syndrome presented with complaints of weakness and muscle spasticity. Brain imaging demonstrated diffuse intracranial calcifications. In addition, cervical spine imaging revealed extensive calcification along the anterior and posterior cervical vertebral bodies causing multilevel stenosis and cord compression. The patient underwent a multilevel posterior cervical decompression and fusion. Postoperatively, the patient had noted improvement in her upper and lower extremity strength and spasticity. This illustrative case demonstrates rare clinical and radiographic neurologic sequelae of long-standing hypoparathyroidism.
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Affiliation(s)
- Amanda Kwasnicki
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA.
| | - Laura Stone McGuire
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Roger Lichtenbaum
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA; Department of Neurological Surgery, Saint Joseph Hospital, Chicago, Illinois, USA
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17
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Jhanwar-Uniyal M, Labagnara M, Friedman M, Kwasnicki A, Murali R. Glioblastoma: molecular pathways, stem cells and therapeutic targets. Cancers (Basel) 2015; 7:538-55. [PMID: 25815458 PMCID: PMC4491669 DOI: 10.3390/cancers7020538] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [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: 07/11/2014] [Revised: 02/12/2015] [Accepted: 03/09/2015] [Indexed: 12/31/2022] Open
Abstract
Glioblastoma (GBM), a WHO-defined Grade IV astrocytoma, is the most common and aggressive CNS malignancy. Despite current treatment modalities, the survival time remains dismal. The main cause of mortality in patients with this disease is reoccurrence of the malignancy, which is attributed to treatment-resistant cancer stem cells within and surrounding the primary tumor. Inclusion of novel therapies, such as immuno- and DNA-based therapy, may provide better means of treating GBM. Furthermore, manipulation of recently discovered non-coding microRNAs, some of which regulate tumor growth through the development and maintenance of GBM stem cells, could provide new prospective therapies. Studies conducted by The Cancer Genome Atlas (TCGA) also demonstrate the role of molecular pathways, specifically the activated PI3K/AKT/mTOR pathway, in GBM tumorigenesis. Inhibition of the aforementioned pathway may provide a more direct and targeted method to GBM treatment. The combination of these treatment modalities may provide an innovative therapeutic approach for the management of GBM.
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Affiliation(s)
| | - Michael Labagnara
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA.
| | - Marissa Friedman
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA.
| | - Amanda Kwasnicki
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA.
| | - Raj Murali
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA.
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18
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Kwasnicki A, Jeevan D, Braun A, Murali R, Jhanwar-Uniyal M. Involvement of mTOR signaling pathways in regulating growth and dissemination of metastatic brain tumors via EMT. Anticancer Res 2015; 35:689-696. [PMID: 25667447] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Metastatic dissemination to the brain may involve a process termed epithelial-mesenchymal transition (EMT), which results in a migratory, invasive and proliferative cell phenotype. Recent studies suggest that Mechanistic target of rapamycin (mTOR, that exists in two multi-protein complexes (mTORC1 and mTORC2), may regulate EMT, in addition to controlling cell growth, survival, metabolism and motility. However, the role of mTOR in brain metastases remains elusive. We hypothesize that mTOR plays a crucial role in the process of EMT in brain metastasis and therefore serves as a target of therapy. MATERIALS AND METHODS Immunohistochemical analyses were performed to determine the expression of components of mTOR pathways. Immunofluorescence and immunoblotting were executed to determine the markers of EMT after treatments with siRNA or inhibitors of mTOR pathways. Cell proliferation using MTT, S-phase entry by determining EdU-incorporation, chemotactic and scratch-wound migration assays were performed. RESULTS Metastatic tumor samples expressed components of mTOR pathways, namely, mTOR, Raptor and Rictor with a significant overlap. Metastatic potential was enhanced in an astrocytic environment and suppressed following mTOR inhibition. mTOR inhibition resulted in nuclear localization of the epithelial marker of EMT, E-cadherin, and enhancement in expression of the mesenchymal marker vimentin. CONCLUSION Results suggest that the mTOR pathway is activated in metastatic brain tumors, and inhibition of mTOR signaling could provide therapeutic value in the management of patients with brain metastases.
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Affiliation(s)
- Amanda Kwasnicki
- Department of Neurosurgery, New York Medical College, Valhalla, NY, U.S.A
| | - Dhruve Jeevan
- Department of Neurosurgery, New York Medical College, Valhalla, NY, U.S.A
| | - Alex Braun
- Department of Pathology, New York Medical College, Valhalla, NY, U.S.A
| | - Raj Murali
- Department of Neurosurgery, New York Medical College, Valhalla, NY, U.S.A
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19
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Kwasnicki A, Jeevan D, Goyal A, Braun A, Murali R, Jhanwar-Uniyal M. Abstract 4358: Involvement of mTOR pathway in metastatic brain tumors. Cancer Res 2013. [DOI: 10.1158/1538-7445.am2013-4358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Metastatic dissemination to the brain occurs in almost forty percent of all cancers, and is ten times more common than primary brain tumors. Mammalian target of Rapamycin (mTOR), an atypical PI3K related kinase, exists in two distinct multiprotein complexes (mTORC1 and mTORC2). mTORC1/2 regulate various cellular functions and are shown to be activated in primary brain tumors such as glioblastoma and medulloblastoma. In addition, metastatic tumor cells possess a unique reprogramming resulting in a stem cell like phenotype with invasive, migratory and proliferative potential similar to that seen in glioblastoma, where mTOR appears to play an essential role. However, the involvement of the mTOR pathway in metastatic brain tumors remains to be elucidated. This study aimed to test the hypothesis that the mTOR pathway plays a critical role in metastatic brain tumors. In order to achieve our goals, expression of mTOR and its components (Raptor and Rictor) were studied in metastatic brain tumors using immunohistochemical analysis. Further, the function of mTOR in relation to proliferation, migration, and cell spreading was studied in a metastatic breast cancer cell line (MBA-MD 231). The expression of epithelial marker E-Cadherin and meschenchymal marker Vimentin following the inhibition of mTOR using pharmacological inhibitors (Rapamycin and PP242) as well as short interfering RNA (mTOR, Raptor and Rictor) was examined by immunofluorescence analysis. Results demonstrated that a significant number of metastatic brain tumors expressed mTOR, Raptor, and Rictor; 50% expressing all three components. The metastatic potential showed that migration of cancer cells was inhibited significantly by mTORC1 inhibition (Rapamycin) and mTORC1/2 inhibition (PP242) by 29% and 64%, respectively. Utilizing the EdU incorporation technique, S-phase cell cycle entry analysis rendered a 52% decline in proliferation after Rapamycin treatment. Cell spreading/attachment analysis exhibited total attachment of control cells within 20 minutes of plating. This effect was prevented by pretreatment with Rapamycin or PP242. Immunoflourescence analysis showed that E-cadherin underwent forced nuclear localization following acute inhibition of mTOR, using Rapamycin or siRNA treatments. These results were substantiated by Western blotting, suggesting its role in cellular reprogramming, namely Epithelial-Mesenchymal Transition or its counterparts. However, Vimentin expression remained unaltered. In conclusion, these results provide evidence that mTOR is enhanced in metastatic brain tumors, suggesting its critical role in achieving a metastatic potential to the brain. Importantly, these findings underscore the therapeutic value of mTOR inhibition in the management of patients with metastatic brain tumors.
Citation Format: Amanda Kwasnicki, Dhruve Jeevan, Anita Goyal, Alex Braun, Raj Murali, Meena Jhanwar-Uniyal. Involvement of mTOR pathway in metastatic brain tumors. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4358. doi:10.1158/1538-7445.AM2013-4358
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Affiliation(s)
- Amanda Kwasnicki
- 1Department of Neurosurgery New York Medical College, Valhalla, NY
| | - Dhruve Jeevan
- 1Department of Neurosurgery New York Medical College, Valhalla, NY
| | - Anita Goyal
- 1Department of Neurosurgery New York Medical College, Valhalla, NY
| | - Alex Braun
- 2Department of Pathology New York Medical College, Valhalla, NY
| | - Raj Murali
- 1Department of Neurosurgery New York Medical College, Valhalla, NY
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20
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Kwasnicki A, Butterworth C. 360 degrees peri-implant, keratinised, soft-tissue grafting with stereolithographic-aided dressing plate. Int J Oral Maxillofac Surg 2008; 38:87-90. [PMID: 19117727 DOI: 10.1016/j.ijom.2008.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 10/28/2008] [Indexed: 11/29/2022]
Abstract
Surgical procedures to improve the quality of peri-implant soft tissue are a routine part of dental implant practice, especially in the edentulous patient with a significant lack of attached keratinised tissue. The use of a dressing plate at the recipient site can be beneficial in supporting free, keratinised, soft-tissue grafts during the early healing phase, especially if grafting is undertaken around all aspects of the implant and not just to the facial section. This paper outlines the use of a dressing plate, constructed on a stereolithographic model, for use at second-stage implant surgery to allow for 360 degrees peri-implant, keratinised, soft-tissue grafting.
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Affiliation(s)
- A Kwasnicki
- Department of Restorative Dentistry, Liverpool University Dental Hospital, Liverpool, UK
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21
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Affiliation(s)
- A Kwasnicki
- Staff Grade Restorative Dentist, Liverpool University Dental Hospital, Liverpool, UK
| | - L Longman
- Consultant/Hon Senior Lecturer, Liverpool University Dental Hospital, Liverpool, UK
| | - G Wilkinson
- Professor of Liaison Psychiatry/Consultant Psychiatrist, Liverpool University Dental Hospital, Liverpool, UK
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