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Golub D, Lynch DG, Mehta SH, Donaldson H, Shah KA, White TG, Quach ET, Papadimitriou K, Kuffer AF, Woo HH, Link TW, Patsalides A, Dehdashti AR. The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series. Neurosurg Rev 2024; 47:189. [PMID: 38658425 DOI: 10.1007/s10143-024-02407-y] [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: 12/12/2023] [Revised: 01/26/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited. METHODS Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis and supported by comprehensive angiographic and intraoperative images. RESULTS One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk for endovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation. CONCLUSIONS This illustrative case series highlights the technical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.
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Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA.
| | - Daniel G Lynch
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Shyle H Mehta
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Hayley Donaldson
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kevin A Shah
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Eric T Quach
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | | | | | - Henry H Woo
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Thomas W Link
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
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Santhumayor BA, White TG, Golub D, Rivera M, Turpin J, Golombeck D, Ryu B, Shah K, Ortiz R, Black K, Katz JM, Dehdashti AR, Langer DJ. Impact of Cerebral Revascularization on Pial Collateral Flow in Patients With Unilateral Moyamoya Disease Using Quantitative Magnetic Resonance Angiography. Neurosurgery 2024:00006123-990000000-01092. [PMID: 38501815 DOI: 10.1227/neu.0000000000002905] [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] [Received: 10/17/2023] [Accepted: 01/12/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Moyamoya disease (MMD) is a chronic steno-occlusive disease of the intracranial circulation that depends on neoangiogenesis of collateral vessels to maintain cerebral perfusion and is primarily managed with cerebral revascularization surgery. A quantitative assessment of preoperative and postoperative collateral flow using quantitative magnetic resonance angiography with noninvasive optimal vessel analysis (NOVA) was used to illustrate the impact of revascularization on cerebral flow distribution. METHODS A retrospective review of patients with unilateral MMD who underwent direct, indirect, or combined direct/indirect cerebral revascularization surgery was conducted between 2011 and 2020. Using NOVA, flow was measured at the anterior cerebral artery (ACA), ACA distal to the anterior communicating artery (A2), middle cerebral artery (MCA), posterior cerebral artery (PCA), and PCA distal to the posterior communicating artery (P2). Pial flow (A2 + P2) and collateral flow (ipsilateral [A2 + P2])-(contralateral [A2 + P2]) were measured and compared before and after revascularization surgery. Total hemispheric flow (MCA + A2 + P2) with the addition of the bypass graft flow postoperatively was likewise measured. RESULTS Thirty-four patients with unilateral MMD underwent cerebral revascularization. Median collateral flow significantly decreased from 68 to 39.5 mL/min (P = .007) after bypass. Hemispheres with maintained measurable bypass signal on postoperative NOVA demonstrated significant reduction in median collateral flow after bypass (P = .002). Median total hemispheric flow significantly increased from 227 mL/min to 247 mL/min (P = .007) after bypass. Only one patient suffered an ipsilateral ischemic stroke, and no patients suffered a hemorrhage during follow-up. CONCLUSION NOVA measurements demonstrate a reduction in pial collateral flow and an increase in total hemispheric flow after bypass for MMD, likely representing a decrease in leptomeningeal collateral stress on the distal ACA and PCA territories. Further studies with these measures in larger cohorts may elucidate a role for NOVA in predicting the risk of ischemic and hemorrhagic events in MMD.
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Affiliation(s)
- Brandon A Santhumayor
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Danielle Golub
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Moses Rivera
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - David Golombeck
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Brendan Ryu
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Rafael Ortiz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
- Current Affiliation: Department of Neurosurgery, White Plains Hospital, White Plains, New York, USA
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - David J Langer
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
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Papadimitriou K, Quach ET, Golub D, Patsalides A, Dehdashti AR. Far Lateral Approach With C1 Hemilaminotomy for Excision of a Ruptured Fusiform Lateral Spinal Artery Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01080. [PMID: 38442494 DOI: 10.1227/ons.0000000000001113] [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] [Received: 10/18/2023] [Accepted: 01/08/2024] [Indexed: 03/07/2024] Open
Abstract
The lateral spinal artery (LSA) represents the most rostral extent of the posterolateral arterial axis of the spinal cord and supplies both the posterior and lateral aspects of the spinal cord.1 The LSA originates from either the intradural segment of vertebral artery or the lateral segment of the posterior inferior cerebellar artery.1,2 It terminates at the level of C5 because it anastomoses with the posterior spinal artery. Although the LSA is in communication with the subarachnoid space, subarachnoid hemorrhage (SAH) due to an LSA aneurysm is rare.3-6 Moreover, accurate diagnosis of vascular pathologies involving the LSA is challenging because the LSA is typically too small to be visualized with conventional angiography.2 Here, we present the case of a 74-year-old woman who presented to our institution with headache, nausea, and confusion due to posterior fossa SAH without any visible vascular malformation on initial diagnostic cerebral angiography. A right frontal external ventricular drain was placed for communicating hydrocephalus. Immediate cerebral angiogram was within normal limits. Two-week follow-up angiogram demonstrated a fusiform right LSA aneurysm. The endovascular treatment was not an option because of the risk of occlusion of proximal perforators of the right posterior spinal artery, resulting in a long segment ischemia. The patient underwent a right far lateral transcondylar approach with C1 hemilaminotomy and excision of the LSA aneurysm. The postoperative course was uneventful. The patient was neurologically intact. Six-month follow-up angiogram showed no evidence of residual aneurysm. LSA pathologies should be kept in mind with posterior fossa SAH. Surgical excision is an effective treatment option in carefully selected patients. The patient consented to the procedure.
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White TG, Shah KA, Koul P, Link T, Dehdashti AR, Katz JM, Patsalides A, Woo HH. The resolute Onyx drug eluting stent for neurointervention: A technical series. Interv Neuroradiol 2024; 30:14-21. [PMID: 35379028 PMCID: PMC10956464 DOI: 10.1177/15910199221084398] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/04/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Current methods for angioplasty and stenting of the intracranial vasculature for neurointervention are limited. The Wingspan Stent System is Food and Drug Administration (FDA) approved with human device exemption for a limited patient group and despite numerous prospective registries and trials demonstrating reasonable safety, still carries warnings from the FDA for its use. Given these limitations, we present the technical nuances and outcomes of the off-label use of the Resolute Onyx drug-eluting stent (DES) for neurointerventional purposes. METHODS Retrospective chart review of all patients undergoing a neurointerventional procedure with the Resolute Onyx DES was done from January 2017-2021. The Resolute Onyx is a coronary balloon-mounted drug-eluting (zotarolimus) single wire laser cut stent. Technical details and procedural outcomes were collected. RESULTS In total 40 patients had attempted placement of the Resolute Onyx DES with procedural success in 95% of patients. The most common vessel stented was the basilar artery, 30% (12/40). The most common indication was intracranial atherosclerotic disease in 62.5% (25/40) patients, followed by acute stroke in 17.5% (7/40) of patients. The technical and procedural outcomes were excellent with only one technical complication (2.5%). CONCLUSIONS This series describes the initial technical safety and utility of utilizing a new generation balloon-mounted drug-eluting stent for neurointerventional purposes. This stent offers the potential for improved navigability, delivery, and outcomes compared to current neurointerventional options and warrants further study.
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Affiliation(s)
- Timothy G. White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
| | - Kevin A. Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
| | - Prateeka Koul
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
| | - Amir R. Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
| | - Jeffrey M. Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
| | - Athos Patsalides
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
| | - Henry H. Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, United States
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Kuffer AF, Golub D, Dehdashti AR. Editorial: Clinical experience of open cerebral revascularization (bypass surgery) for the management of ischemic or hemorrhagic stroke. Front Neurol 2024; 14:1354100. [PMID: 38239319 PMCID: PMC10794517 DOI: 10.3389/fneur.2023.1354100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/22/2024] Open
Affiliation(s)
- Alexander F. Kuffer
- Northwell Health Neurosurgery, North Shore University Hospital, Manhasset, NY, United States
| | | | - Amir R. Dehdashti
- Northwell Health Neurosurgery, North Shore University Hospital, Manhasset, NY, United States
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Zandbergen IM, Huntoon KM, White TG, Bakker LEH, Verstegen MJT, Ghalib LM, van Furth WR, Pelsma ICM, Dehdashti AR, Biermasz NR, Prevedello DM. Efficacy and Safety of Endoscopic Transsphenoidal Resection for Prolactinoma: A Retrospective Multicenter Case-series. Arch Med Res 2023; 54:102919. [PMID: 38040527 DOI: 10.1016/j.arcmed.2023.102919] [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: 08/07/2023] [Revised: 11/03/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Endoscopic transsphenoidal surgery (ETSS) for prolactinoma is reserved for dopamine agonist (DA) resistance, intolerance, or apoplexy. High remission (overall 67%, microprolactinoma up to 90%), low recurrence (5-20%) rates highlighted that surgery might be first-line treatment. AIMS To report on outcomes of ETSS in a cohort of prolactinomas. METHODS Multicenter retrospective cohort of 137 prolactinoma patients (age 38.2 ± 13.7 years; 61.3% female, median follow-up 28.0 [15.0-55.5] months) operated between 2010-2019 with histopathological confirmation. RESULTS Median preoperative prolactin levels were 166 (98-837 µg/L; males 996 [159-2145 µg/L] vs. females 129 [84-223 µg/L], p <0.001). 56 (40.9%) microprolactinomas, 69 (50.4%) macroprolactinomas, and 7 (5.1%) giant prolactinomas were included, whereas no adenoma was detected in 5 (3.6%) patients. Males had larger tumors (macroprolactinomas: 38, 71.7%) vs. 31 (36.9%), p <0.001; giant prolactinomas: 7 (13.2%) vs. 0 (0.0%), (p <0.001). Prolactinomas were graded as KNOSP-3 in 15 (11.5%), and KNOSP-4 in 20 (15.3%) patients. Primary indication was DA intolerance (59, 43.1%); males 14 (26.4%) vs. females 45 (53.6%), p = 0.006. Long-term remission (i.e., DA-free prolactin level <1xULN) was achieved in 87 (63.5%) patients, being higher in intended complete resection (69/92 [75.0%]), and lower in males (25 [47.2%] vs. 62 females [73.8%], p = 0.002). Transient DI (n = 29, 21.2%) was the most frequent complication. CONCLUSIONS Despite high proportions of macroprolactinoma and KNOSP 3-4, long-term remission rates were 63.5% overall, and 83.3% in microprolactinoma patients. Males had less favorable remission rate compared to females. These findings highlight that ETSS may be a safe and efficacious treatment to manage prolactinoma.
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Affiliation(s)
- Ingrid Marijke Zandbergen
- Department of Neurosurgery, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands; Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands.
| | | | - Timothy G White
- Department of Neurosurgery, Hofstra University Northwell Health, Long Island, NY, USA
| | - Leontine Erica Henriëtte Bakker
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Luma Mudhafar Ghalib
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Wouter Ralph van Furth
- Department of Neurosurgery, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris Catharina Maria Pelsma
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra University Northwell Health, Long Island, NY, USA
| | - Nienke Ruurdje Biermasz
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH USA
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Golub D, McBriar JD, Donaldson H, Wong T, Unadkat P, White TG, Quach ET, Haddock S, Chitti B, Ziemba Y, Goenka A, Singer S, Schulder M, Dehdashti AR. Postoperative stereotactic radiosurgery for intracranial solitary fibrous tumors: systematic review and pooled quantitative analysis. J Neurooncol 2023; 165:229-239. [PMID: 37955760 DOI: 10.1007/s11060-023-04499-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/02/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Intracranial solitary fibrous tumors (SFTs), formerly hemangiopericytomas (HPCs), are rare, aggressive dural-based mesenchymal tumors. While adjuvant radiation therapy has been suggested to improve local tumor control (LTC), especially after subtotal resection, the role of postoperative stereotactic radiosurgery (SRS) and the optimal SRS dosing strategy remain poorly defined. METHODS PubMed, EMBASE, and Web of Science were systematically searched according to PRISMA guidelines for studies describing postoperative SRS for intracranial SFTs. The search strategy was defined in the authors' PROSPERO protocol (CRD42023454258). RESULTS 15 studies were included describing 293 patients harboring 476 intracranial residual or recurrent SFTs treated with postoperative SRS. At a mean follow-up of 21-77 months, LTC rate after SRS was 46.4-93% with a mean margin SRS dose of 13.5-21.7 Gy, mean maximum dose of 27-39.6 Gy, and mean isodose at the 42.5-77% line. In pooled analysis of individual tumor outcomes, 18.7% of SFTs demonstrated a complete SRS response, 31.7% had a partial response, 18.9% remained stable (overall LTC rate of 69.3%), and 30.7% progressed. When studies were stratified by margin dose, a mean margin dose > 15 Gy showed an improvement in LTC rate (74.7% versus 65.7%). CONCLUSIONS SRS is a safe and effective treatment for intracranial SFTs. In the setting of measurable disease, our pooled data suggests a potential dose response of improving LTC with increasing SRS margin dose. Our improved understanding of the aggressive biology of SFTs and the tolerated adjuvant SRS parameters supports potentially earlier use of SRS in the postoperative treatment paradigm for intracranial SFTs.
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Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA.
| | - Joshua D McBriar
- Zucker School of Medicine, Hofstra University/Northwell Health, Hempstead, NY, USA
| | - Hayley Donaldson
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Taylor Wong
- SUNY Downstate College of Medicine, Brooklyn, NY, USA
| | - Prashin Unadkat
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Eric T Quach
- Department of Neurosurgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Sara Haddock
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Bhargava Chitti
- Department of Radiation Oncology, Northwell Health, Manhasset, NY, USA
| | - Yonah Ziemba
- Department of Pathology, Northwell Health, Manhasset, NY, USA
| | - Anuj Goenka
- Department of Radiation Oncology, Northwell Health, Manhasset, NY, USA
| | - Samuel Singer
- Department of Neurology, Northwell Health, New Hyde Park, NY, USA
| | - Michael Schulder
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
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Yang K, Shah K, Begley SL, Prashant G, White T, Costantino P, Patsalides A, Lo SFL, Dehdashti AR. Extreme lateral infracondylar approach for internal jugular vein compression syndrome: A case series with preliminary clinical outcomes. Acta Neurochir (Wien) 2023; 165:3445-3454. [PMID: 37656307 DOI: 10.1007/s00701-023-05779-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/19/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Internal jugular vein (IJV) stenosis is associated with several neurological disorders including idiopathic intracranial hypertension (IIH) and pulsatile tinnitus. In cases of extreme bony compression causing stenosis in the infracondylar region, surgical decompression might be necessary. We aim to examine the safety and efficacy of surgical IJV decompression. METHODS We retrospectively reviewed patients who received surgical IJV decompression via the extreme lateral infracondylar (ELI) approach between July 2020 and February 2022. RESULTS Fourteen patients with IJV stenosis were identified, all with persistent headache and/or tinnitus. Six patients were diagnosed with IIH, three of whom failed previous treatment. Of the eight remaining patients, two failed previous treatment. All underwent surgical IJV decompression via styloidectomy, release of soft tissue, and removal of the C1 transverse process (TP). Follow-up imaging showed significant improvement of IJV stenosis in eleven patients and mild improvement in three. Eight patients had significant improvement in their presenting symptoms, and three had partial improvement. Two patients received IJV stenting after a lack of initial improvement. Two patients experienced cranial nerve paresis, and one developed a superficial wound infection. CONCLUSION The ELI approach for IJV decompression appears to be safe for patients who are not ideal endovascular candidates due to bony anatomy. Confirming long-term efficacy in relieving debilitating clinical symptoms requires longer follow-up and a larger patient cohort. Carefully selected patients with symptomatic bony IJV compression for whom there are no effective medical or endovascular options may benefit from surgical IJV decompression.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
- Community Neurosciences Institute, Community Health Partners, Fresno, CA, USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Giyarpuram Prashant
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
- Department of Neurosurgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Timothy White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Peter Costantino
- Department of Otolaryngology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Interventional Neuroradiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.
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Yang K, Begley SL, Lynch D, Turpin J, Aminnejad M, Farrokhyar F, Dehdashti AR. Long-term outcomes of surgical clipping of saccular middle cerebral artery aneurysms: a consecutive series of 92 patients. Neurosurg Rev 2023; 46:271. [PMID: 37843680 DOI: 10.1007/s10143-023-02167-1] [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: 07/13/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
Despite advances in endovascular treatment, microsurgical clipping of middle cerebral artery (MCA) aneurysms remains appropriate. We review the high occlusion rate and treatment durability seen with surgical clipping of MCA aneurysms. We retrospectively reviewed patients who underwent microsurgical clipping of saccular MCA aneurysms by a single surgeon. Outcomes included aneurysm occlusion rate and durability, modified Rankin scale (mRS), and postoperative neurological morbidities. Ninety-two patients with 92 saccular MCA aneurysms were included, 50% of which were ruptured aneurysms. The mean follow-up period was 59 months. Complete aneurysm occlusion was achieved in all except one patient (99%) with near-complete occlusion. MCA aneurysm clipping was durable, with only one patient (1%) requiring retreatment after 4 years due to regrowth. Of the cohort, 79.3% achieved mRS 0-2 at last follow-up, including all with unruptured aneurysms. Poor outcome at discharge was associated with age > 65 (p = .03), postoperative neurological morbidities (p = .006), and aneurysm rupture (p < .001). Older age remained the single correlate for poor long-term outcome (p = .04). For ruptured aneurysms, predictors of poor long-term outcome included hemiparesis on presentation (p = .017), clinical vasospasm requiring treatment (p = .026), and infarction related to vasospasm (p = .041). Older age (p = .046) and complex anatomy (p = .036) were predictors of new postoperative neurological morbidities in the unruptured group. MCA aneurysm clipping is safe, durable, and should be considered first-line treatment for patients with saccular MCA aneurysms, especially in centers with abundant surgical experience.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
- Community Neurosciences Institute, Community Health Partners, Fresno, CA, USA
| | - Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Daniel Lynch
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA
| | - Minoo Aminnejad
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Surgery, Department of Health, Evidence, Impact, McMaster University, Hamilton, ON, Canada
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Dr Manhasset, Hempstead, NY, 11030, USA.
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10
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Quach ET, Dehdashti AR. Posterior Inferior Cerebellar Artery Excision and End-to-End Reanastomosis for Treatment of a Giant, Partially Thrombosed Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e219-e220. [PMID: 37345921 DOI: 10.1227/ons.0000000000000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/17/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Eric T Quach
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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11
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Park J, Golub D, White TG, Ruelle M, Quach ET, Yang K, Shah HA, Fastenberg JH, Eisenberg MB, Dehdashti AR. Anterior-posterior diameter is a key driver of resectability and complications for pituitary adenomas with suprasellar extension in endoscopic transsphenoidal surgery. Pituitary 2023; 26:629-641. [PMID: 37713155 DOI: 10.1007/s11102-023-01354-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND As endoscopic transsphenoidal approaches are more routinely selected for progressively larger pituitary adenomas with parasellar extension, understanding potential anatomical factors that limit resection and contribute to complications is becoming increasingly important for tailoring a surgical approach. This study aimed to reevaluate existing predictive tools for resectability in pituitary adenomas specifically with suprasellar extension, and furthermore identify any additional measurable features that may be more useful in preoperative planning. METHODS A single-center retrospective chart review of adult patients who underwent endoscopic transsphenoidal surgery for pituitary adenomas with suprasellar extension from 2015 to 2020 was performed. Preoperative MRIs were systematically assessed to assign a Knosp classification, a Zurich Pituitary Score (ZPS), and for dimensional measurements of the suprasellar aspect of the lesions. Univariate comparisons and multivariate regression models were employed to assess the influence of these factors on extent of resection and postoperative complications. RESULTS Of the 96 patients with suprasellar pituitary adenomas who underwent endoscopic transsphenoidal surgery, 74 patients (77%) had a gross total resection (GTR). Neither Knosp grade nor ZPS score, even when dichotomized, demonstrated an association with GTR (Knosp 3A-4 versus Knosp 0-2, p = 0.069; ZPS III-IV versus ZPS I-II, p = 0.079). Multivariate regression analysis identified suprasellar anterior-posterior tumor diameter (SSAP) as the only significant predictor of extent of resection in this cohort (OR 0.951, 95% CI 0.905-1.000, p = 0.048*). A higher SSAP also had the strongest association with intraoperative CSF leaks (p = 0.0012*) and an increased overall rate of postoperative complications (p = 0.002*). Further analysis of the regression model for GTR suggested an optimal cut point value for SSAP of 23.7 mm, above which predictability for failing to achieve GTR carried a sensitivity of 89% and a specificity of 41%. CONCLUSIONS This study is unique in its examination of endoscopic transsphenoidal surgical outcomes for pituitary adenomas with suprasellar extension. Our findings suggest that previously established grading systems based on lateral extension into the cavernous sinus lose their predictive value in lesions with suprasellar extension and, more specifically, with increasing suprasellar anterior-posterior diameter.
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Affiliation(s)
- Jung Park
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Danielle Golub
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA.
| | - Timothy G White
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Marianne Ruelle
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Eric T Quach
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Kaiyun Yang
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Harshal A Shah
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Judd H Fastenberg
- Department of Otolaryngology-Head and Neck Surgery, Northwell Health, Manhasset, NY, USA
| | - Mark B Eisenberg
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
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12
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Begley SL, White TG, Khilji H, Katz J, Dehdashti AR. Disappearance of a small unruptured intracranial aneurysm: A case report and brief literature review. Neuroradiol J 2023; 36:621-624. [PMID: 36647339 PMCID: PMC10569197 DOI: 10.1177/19714009221150861] [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] [Indexed: 01/18/2023] Open
Abstract
Disappearing intracranial aneurysms are rare and have not been extensively reported in the literature. They are often small or partially thrombosed and carry a significant risk of recurrence. We discuss a unique case of a 65-year-old woman who presented in 2006 with a subarachnoid hemorrhage and was found to have a ruptured posterior communicating artery and an unruptured P1 aneurysm. Follow-up angiography and imaging showed no changes in the size of a left P1 aneurysm for 11 years (2006-2017). However, in 2021, 15 years after initial presentation, no aneurysm was seen on magnetic resonance angiography, and subsequent digital subtraction angiography in 2022 showed almost complete disappearance of the unruptured P1 aneurysm. Literature review reveals only six reported cases during which a small, unruptured anterior circulation aneurysm disappeared, or regressed on follow-up imaging and no reported cases in the posterior circulation.
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Affiliation(s)
- Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Hamza Khilji
- Department of Neurosurgery, Lenox Hill Hospital, Manhattan, NY, USA
| | - Jeffrey Katz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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13
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Turpin J, Lynch DG, White T, Shah KA, Yang K, Katz JM, Dehdashti AR. Hyperperfusion syndrome after superficial temporal artery-middle cerebral artery bypass for non-moyamoya steno-occlusive disease. J Stroke Cerebrovasc Dis 2023; 32:107222. [PMID: 37384979 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stroke is a major cause of morbidity and mortality worldwide, and intracranial stenoses increase the risk for stroke. Superficial temporal artery to middle cerebral artery bypass can be beneficial in selected patients with non-moyamoya steno-occlusive disease, however data is limited regarding the postoperative occurrence of hyperperfusion syndrome in this population. This case series describes the outcomes and complications, including hyperperfusion, in these patients who underwent bypass. METHODS This is a retrospective review of bypass procedures done for medically refractory intracranial stenosis at a single institution by a single surgeon between 2014 and 2021. RESULTS 30 patients underwent 33 bypass procedures for unequivocal non-moyamoya steno-occlusive disease. All patients had immediate bypass patency on post-operative day one. Major perioperative complications (9%) included one stroke and two cases of hyperperfusion syndrome. Minor perioperative complications (12%) included two seizures, one superficial wound infection and one deep vein thrombosis. Modified Rankin Score improved in 20 patients (74%), worsened in one patient (4%), and remained stable in seven patients (22%) at the last follow up. Twenty-three patients (85%) had scores ≤ 2. The recurrent stroke rate was 3% at 30 days and 7% at two years. The bypass patency rate at one year was 87.5%. CONCLUSION In this series, bypass for patients with medically refractory non-moyamoya steno-occlusive disease was well tolerated and effective, with overall favorable outcomes. The occurrence of hyperperfusion syndrome is rare but significant and should be considered in post-operative management of this population.
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Affiliation(s)
- Justin Turpin
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Daniel G Lynch
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Timothy White
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Kevin A Shah
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Kaiyun Yang
- Department of Neurosurgery, Community Health Partners, Fresno, CA, USA.
| | - Jeffrey M Katz
- North Shore University Hospital Department of Vascular Neurology, Manhasset, NY, USA.
| | - Amir R Dehdashti
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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14
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Spiessberger A, Gruter B, Prashant G, Haegler J, Eisenberg M, Cohen-Gadol AA, Dehdashti AR. A Contemporary Clinico-Anatomical Guide to Craniovertebral Junction Surgery. J Neurol Surg B Skull Base 2023; 84:413-420. [PMID: 37405236 PMCID: PMC10317559 DOI: 10.1055/s-0042-1755600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/20/2022] [Indexed: 10/14/2022] Open
Abstract
Background Surgical treatment of ventral and ventrolateral lesions of the craniocervical junction are among the most challenging neurosurgical pathologies to treat. Three surgical techniques, the far lateral approach (and its variations), the anterolateral approach, and the endoscopic far medial approach can be used to approach and resect lesions in this area. Objective The aim of the study is to examine the surgical anatomy of three skull base approaches to the craniocervical junction and review surgical cases to better understand the indications and possible complications for each of these approaches. Methods Cadaveric dissections with standard microsurgical and endoscopic instruments were performed for each of the three surgical approaches, and key steps and surgically relevant anatomy were documented. Six patients with appropriate pre-, post-, and intraoperative imaging and video documentation are presented and discussed accordingly. Results Based on our institutional experience, all three approaches can be utilized to safely and effectively approach a wide variety of neoplastic and vascular pathology. Unique anatomical characteristics, lesion morphology and size, and tumor biology should all be considered when determining the optimal approach. Conclusion Preoperative assessment of surgical corridors with 3D illustrations helps to define the best surgical corridor. 360 degree knowledge of the anatomy of craniovertebral junction allows safe surgical approach and treatment of ventral and ventrolateral located lesions using one of the three approaches.
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Affiliation(s)
| | - Basil Gruter
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Giyarpuram Prashant
- Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, United States
| | - Joshua Haegler
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Aargau, Switzerland
| | - Mark Eisenberg
- Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, United States
| | - Aaron A. Cohen-Gadol
- Department of Neurological Surgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana, United States
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15
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Begley SL, White TG, Shah KA, Turpin J, Toscano D, Dehdashti AR, Teron I, Link T, Patsalides A, Woo HH. A comparison of endovascular coil systems for the treatment of small intracranial aneurysms. Interv Neuroradiol 2023:15910199231182456. [PMID: 37312530 DOI: 10.1177/15910199231182456] [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] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Endovascular coiling of small, intracranial aneurysms remains controversial and difficult, despite advances in technology. METHODS We retrospectively reviewed data for 62 small aneurysms (<3.99 mm) in 59 patients. Occlusion rates, complications rates, and coil packing densities were compared between subgroups based upon coil type and rupture status. RESULTS Ruptured aneurysms predominated (67.7%). Aneurysms measured 2.99 ± 0.63 mm by 2.51 ± 0.61 mm with an aspect ratio of 1.21 ± 0.34 mm. Brands included Optima (Balt) (29%), MicroVention Hydrogel (24.2%), and Penumbra SMART (19.4%) coil systems. Average packing density was 34.3 ± 13.5 mm3. Occlusion rate was 100% in unruptured aneurysms; 84% utilized adjuvant devices. For ruptured aneurysms, complete occlusion or stable neck remnant was achieved in 88.6% while recanalization occurred in 11.4%. No rebleeding occurred. Average packing density (p = 0.919) and coil type (p = 0.056) did not impact occlusion. Aspect ratio was smaller in aneurysms with technical complications (p = 0.281), and aneurysm volume was significantly smaller in those with coil protrusion (p = 0.018). Complication rates did not differ between ruptured and unruptured aneurysms (22.6 vs. 15.8%, p = 0.308) or coil types (p = 0.830). CONCLUSION Despite advances in embolization devices, coiling of small intracranial aneurysms is still scrutinized. High occlusion rates are achievable, especially in unruptured aneurysms, with coil type and packing density suggesting association with complete occlusion. Technical complications may be influenced by aneurysm geometry. Advances in endovascular technologies have revolutionized small aneurysm treatment, with this series demonstrating excellent aneurysm occlusion especially in unruptured aneurysms.
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Affiliation(s)
- Sabrina L Begley
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Kevin A Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Daniel Toscano
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Ina Teron
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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16
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White TG, Krush M, Prashant G, Shah K, Katz JM, Link T, Woo HH, Dehdashti AR. Comparative outcomes of the treatment of unruptured paraophthalmic aneurysms in the era of flow diversion. Br J Neurosurg 2023:1-7. [PMID: 37161776 DOI: 10.1080/02688697.2023.2210220] [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] [Indexed: 05/11/2023]
Abstract
BACKGROUND Paraophthalmic aneurysms present a challenge to surgeons and their ideal management remains up for debate. We studied recent outcomes of these lesions in a single center. METHODS A retrospective chart review of all patients undergoing treatment for paraophthalmic aneurysms from 2017-2019 was performed. Factors including patient demographics, aneurysm characteristics, treatment modality, radiographic treatment outcome, clinical outcome, and length of stay were collected, and bivariate analysis was performed. RESULTS In total 84.5% (82/97) of aneurysms were treated endovascularly and 15.5% (15/97) surgically. In the surgery cohort, there were three transient perioperative complications (20%) and one minor postoperative complication (6.7%). Complete aneurysm occlusion or near complete (<2mm residual) was achieved in 100% (15/15). All but one patient had mRS ≤1 at the last follow-up. In the endovascular group, 78.1% (64/82) underwent flow diversion alone. Endovascular treatment was associated with a 4.9% (4/82) rate of periprocedural complications: 3 transient events, and 1 death, and a 3.7% (3/82) rate of delayed complications: 2 transient vision changes, and one death. Rate of total occlusion was 87.8% (72/82). 76 patients (92.7%) had mRS ≤1 at the last follow-up. Length of stay was significantly shorter in the endovascular group (3.4 days vs. 7.0 days) [p < 0.001]. CONCLUSIONS This series demonstrates similar safety to previously reported series as well as the efficacy of both surgical clipping and endovascular embolization of paraophthalmic aneurysms. Rate of complications and treatment efficacy were similar in both groups although this represents a single institution series not generalizable to all centers.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Morgan Krush
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Giyarpuram Prashant
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, NY, USA
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17
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Yang K, Shah K, Patsalides A, Knobel D, Dehdashti AR. Resection of Aggressive Recurrent Cavernous Sinus Meningioma-Stage 1, IMAX-RAG-MCA Bypass: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e110. [PMID: 36637314 DOI: 10.1227/ons.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/02/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Athos Patsalides
- Department of Interventional Neuroradiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Denis Knobel
- Department of Plastic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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18
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Yang K, Shah K, Patsalides A, Dehdashti AR. Resection of Aggressive Recurrent Cavernous Sinus Meningioma-Stage 2, Cavernous Sinus Resection: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e111-e112. [PMID: 36637315 DOI: 10.1227/ons.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/09/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Athos Patsalides
- Department of Interventional Neuroradiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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19
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Ballout AA, Libman RB, Choi Y, Schneider JR, Black K, Sideras P, Ayoub MS, Arora R, Langer DJ, Dehdashti AR, Katz JM. Abstract TMP71: Hypoperfusion And Thromboembolism Are Codominant Stroke Mechanisms In Adult Moyamoya Disease. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp71] [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: 02/05/2023]
Abstract
Background:
Treatment of moyamoya disease (MMD) has predominantly focused on flow augmentation since the mechanism of ischemic stroke has largely been attributed to hemodynamic failure. Recent studies have challenged this notion suggesting that thromboembolism may play a dominant role. The aim of our study was to investigate the mechanisms of ischemic stroke in MMD by assessing the relationship between infarction patterns and Quantitative Magnetic Resonance Angiography (QMRA) flow state.
Methods and Results:
This is a retrospective study of adult patients with suspected MMD that presented with MRI confirmed acute ischemic stroke predating or following QMRA by a maximum of six months, between 2009 and 2021. Of the 177 consecutive patients with MMD that underwent QMRA, 35 patients met inclusion, consisting of 41 hemispheres. Flow-status was dichotomized into low-flow and normal-flow based on published criteria. Mixed pattern was the most frequent finding (70.7%), followed by embolic (17.1%), perforator (7.3%), and internal borderzone (IBZ) (4.9%). Infarction patterns were then dichotomized into IBZ+ (internal borderzone alone or mixed) and IBZ- (no internal borderzone constituent) based on the constituents of the patterns. Low-flow states were insignificantly more frequent with IBZ+ compared to IBZ- (48.4% vs. 20.0%, p = 0.14). Ipsilateral PCA fractional flow was significantly higher with IBZ+ compared to IBZ- (345.0% vs. 214.7%, p = 0.04).
Conclusions:
Mixed infarction pattern was the most common pattern of infarction in patients with MMD, implying that at least 2 interrelated stroke mechanisms of hypoperfusion and thromboembolism likely coincide. An association between ICA flow status and the pattern of infarction was not found. Prospective studies evaluating the utility of antithrombotic agents in MMD are needed.
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Affiliation(s)
- Ahmad A Ballout
- Neurology, Donald and Barbara Zucker Sch of Medicine at Hofstra Northwell, Manhasset, NY
| | - Richard B Libman
- Donald and Barbara Zucker Sch of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Yuna Choi
- Neurology, Baylor College of Medicine, Houston, TX
| | - Julia R Schneider
- Donald and Barbara Zucker Sch of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Karen Black
- Radiology, Donald and Barbara Zucker Sch of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Panagiotis Sideras
- Radiology, Columbia Univ Irving Med Cntr at New York-Presbyterian Hosp, New York, NY
| | - Marc S Ayoub
- Neurosurgery, Donald and Barbara Zucker Sch of Medicine at Hofstra Northwell, Manhasset, NY
| | - Rohan Arora
- Neurology, Donald and Barbara Zucker Sch of Medicine at Hofstra Northwell, Manhasset, NY
| | - David J Langer
- Neurology, Donald and Barbara Zucker Sch of Medicine at Hofstra Northwell, New York, NY
| | - Amir R Dehdashti
- Neurosurgery, Donald and Barbara Zucker Sch of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Jeffrey M Katz
- Donald and Barbara Zucker Sch of Medicine at Hofstra/Northwell, Manhasset, NY
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20
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Sattur MG, Amans M, Fargen KM, Huisman TAGM, Brinjikji W, Hui F, Shingala A, Vosler PS, Pereira VM, Hepworth E, Dehdashti AR, Patsalides A, Lo SFL, Spiotta AM. Angiographic Evaluation of Cranial Venous Outflow Patterns in Patients With and Without Idiopathic Intracranial Hypertension. Oper Neurosurg (Hagerstown) 2023; 24:e29-e35. [PMID: 36227195 DOI: 10.1227/ons.0000000000000413] [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] [Received: 03/03/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Several collateral venous pathways exist to assist in cranial venous drainage in addition to the internal jugular veins. The important extrajugular networks (EJN) are often readily identified on diagnostic cerebral angiography. However, the angiographic pattern of venous drainage through collateral EJN has not been previously compared among patients with and without idiopathic intracranial hypertension (IIH). OBJECTIVE To quantify EJN on cerebral angiography among patients both with and without IIH and to determine whether there is a different EJN venous drainage pattern in patients with IIH. METHODS Retrospective imaging review of 100 cerebral angiograms (50 IIH and 50 non-IIH patients) and medical records from a single academic medical center was performed by 2 independent experienced neuroendovascular surgeons. Points were assigned to EJN flow from 0 to 6 using an increasing scale (with each patient's dominant internal jugular vein standardized to 5 points to serve as the internal reference). Angiography of each patient included 11 separately graded extrajugular networks for internal carotid and vertebral artery injections. RESULTS Patients in the IIH group had statistically significant greater flow in several of the extrajugular networks. Therefore, they preferentially drained through EJN compared with the non-IIH group. Right transverse-sigmoid system was most often dominant in both groups, yet there was a significantly greater prevalence of codominant sinus pattern on posterior circulation angiograms. CONCLUSION Patients with IIH have greater utilization of EJN compared with patients without IIH. Whether this is merely an epiphenomenon or possesses actual cause-effect relationships needs to be determined with further studies.
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Affiliation(s)
- Mithun G Sattur
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Matthew Amans
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Kyle Michael Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Thierry A G M Huisman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, Texas, USA
| | | | - Ferdinand Hui
- Neuroscience Institute, Division of Neurointerventional Surgery, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Aakash Shingala
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Peter S Vosler
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vitor Mendes Pereira
- Division of Neurosurgery, Departments of Surgery and Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ed Hepworth
- Department of Otolaryngology, ImmunoE Research Centers, Centennial, Colorado, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Athos Patsalides
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Alejandro M Spiotta
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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21
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Salem MM, Srinivasan VM, Tonetti DA, Ravindran K, Taussky P, Yang K, Karahalios K, Raygor KP, Naylor RM, Catapano JS, Tavakoli-Sabour S, Abdelsalam A, Chen SH, Grandhi R, Jankowitz BT, Baskaya MK, Mascitelli JR, Van Gompel JJ, Cherian J, Couldwell WT, Kim LJ, Cohen-Gadol AA, Starke RM, Kan P, Dehdashti AR, Abla AA, Lawton MT, Burkhardt JK. Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience. Neurosurgery 2023; 92:205-212. [PMID: 36519864 DOI: 10.1227/neu.0000000000002196] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/15/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports. OBJECTIVE To report a multicenter experience assessing microsurgery safety/efficacy. METHODS Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021). RESULTS Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%. CONCLUSION Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Krishnan Ravindran
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Kaiyun Yang
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kunal P Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Samon Tavakoli-Sabour
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Jacob Cherian
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | | | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Aaron A Cohen-Gadol
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
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22
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White TG, A Shah K, Fraser M, Turpin J, Teron I, W Link T, Dehdashti AR, Woo HH. FLAIR hyperintense vessels on MRI post brain arteriovenous malformation embolization: A novel finding associated with post-procedure intraparenchymal hemorrhage. Interv Neuroradiol 2022:15910199221146585. [PMID: 36572982 DOI: 10.1177/15910199221146585] [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] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Brain arteriovenous malformations (BAVMs) are frequently managed by endovascular embolization with a growing number of centers embolizing with intent to cure. Hemorrhage post-embolization is a severe and poorly understood complication. We present a novel imaging finding associated with post-embolization hemorrhage that has significantly impacted the management of patients at our institution. METHODS A retrospective review of all patients undergoing embolization of BAVM at a single center was performed. Post-embolization magnetic resonance imaging (MRI) was reviewed for the presence of T2 fluid-attenuated inversion recovery (FLAIR) hyperintense vessels (FHVs). Bivariate analysis was performed to determine associations between patient characteristics and risk of hemorrhage. RESULTS A total of 50 patients underwent 75 embolization procedures. Forty-six post-embolization MRIs were available for review. There were four hemorrhages and 100% of those presented with FHV. In contrast, only 11.9% of embolization procedures without post-procedural hemorrhage had FHVs on MRI. In total, 18.7% of embolizations led to some morbidity or mortality, with only 6.7% leading to permanent morbidity or mortality. In bivariate analysis, only the presence of FHVs was correlated with the risk of hemorrhage (p < 0.05). CONCLUSIONS This is the first series to describe the finding of hyperintense blood vessels on FLAIR imaging after embolization of BAVMs and correlate it with hemorrhage post embolization. This finding can help guide practitioners and potentially identify patients at risk of delayed hemorrhage post embolization.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Kevin A Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Madison Fraser
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Ina Teron
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Thomas W Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
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23
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Shah KA, White TG, Teron I, Turpin J, Dehdashti AR, Temes RE, Black K, Woo HH. Quantitative magnetic resonance angiography as an alternative imaging technique in the assessment of cerebral vasospasm after subarachnoid hemorrhage. Interv Neuroradiol 2022:15910199221138167. [PMID: 36357992 DOI: 10.1177/15910199221138167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION The major mechanism of morbidity of delayed cerebral ischemia after subarachnoid hemorrhage (SAH) is considered to be severe vasospasm. Quantitative MRA (QMRA) provides direct measurements of vessel-specific volumetric blood flow and may permit a clinically relevant assessment of the risk of ischemia secondary to cerebral vasospasm. PURPOSE To evaluate the utility of QMRA as an alternative imaging technique for the assessment of cerebral vasospasm after SAH. METHODS QMRA volumetric flow rates of the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) were compared with vessel diameters on catheter-based angiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of QMRA for detecting cerebral vasospasm was determined by receiver-operating characteristic curves. Spearman correlation coefficients were calculated for QMRA flow versus angiographic vessel diameter. RESULTS Sixty-six vessels (10 patients) were evaluated with QMRA and catheter-based angiography. The median percent QMRA flow of all vessels with angiographic vasospasm (55.0%, IQR 34.3-71.6%) was significantly lower than the median percent QMRA flow of vessels without vasospasm (91.4%, IQR 81.4-100.4%) (p < 0.001). Angiographic vasospasm reduced QMRA-assessed flow by 23 ± 5 (p = 0.018), 95 ± 12 (p = 0.042), and 16 ± 4 mL/min (p = 0.153) in the ACA, MCA, and PCA, respectively, compared to vessels without angiographic vasospasm. The sensitivity, specificity, PPV, and NPV of QMRA for the discrimination of cerebral vasospasm was 84%, 72%, 84%, and 72%, respectively, for angiographic vasospasm >25% and 91%, 60%, 87%, and 69%, respectively, for angiographic vasospasm >50%. The Spearman correlation indicated a significant association between QMRA flows and vessel diameters (rs = 0.71, p < 0.001). CONCLUSION Reduction in QMRA flow correlates with angiographic vessel narrowing and may be useful as a non-invasive imaging modality for the detection of cerebral vasospasm after SAH.
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Affiliation(s)
- Kevin A Shah
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Ina Teron
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Richard E Temes
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Karen Black
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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24
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Bin-Alamer O, Mallela AN, Palmisciano P, Gersey ZC, Elarjani T, Labib MA, Zenonos GA, Dehdashti AR, Sheehan JP, Couldwell WT, Lunsford LD, Abou-Al-Shaar H. Adjuvant stereotactic radiosurgery with or without postoperative fractionated radiation therapy in adults with skull base chordomas: a systematic review. Neurosurg Focus 2022; 53:E5. [DOI: 10.3171/2022.8.focus22239] [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] [Received: 04/21/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE
The objective of this retrospective study was to compare the survival of patients with biopsy-proven skull base chordoma who had undergone stereotactic radiosurgery (SRS) with versus without prior fractionated radiation therapy (RT).
METHODS
Relevant articles from database inception to September 2021 were retrieved from the PubMed, Scopus, Web of Science, and Cochrane databases for a systematic review of treatment protocols. Studies were included if they 1) involved adult patients (age ≥ 18 years) with histologically and radiologically confirmed chordomas located within the clival skull base region and treated with SRS; 2) reported data on clinical features, SRS protocols, and outcomes; and 3) were written in the English language. Studies were excluded if they 1) were literature reviews, case reports, technical notes, abstracts, or autopsy reports; 2) did not clearly differentiate the data of patients with chordomas from the data of patients with different tumors or the data of patients with chordomas in locations other than the skull base; or 3) lacked histological confirmation or treatment and outcome data. Extracted data included the following: study author and publication year, patient age and sex, symptoms, cranial nerve involvement, invaded structures, lesion size, treatment modality, surgical details, histopathological type, RT modality, SRS parameters, complications, postradiosurgery outcomes, complications, and survival outcomes.
RESULTS
After the selection process, 15 articles describing 130 patients met the study eligibility criteria, including 94 patients who had undergone postresection SRS (NoRT group) and 36 who had undergone postresection fractionated RT and subsequent SRS (RT group). The NoRT and RT groups were comparable in age (51.3 vs 47.4 years, respectively), sex (57.1% vs 58.3% male), tumor volume (9.5 vs 11.2 cm3), SRS treatment parameters (maximum dose: 35.4 vs 42.2 Gy, marginal dose: 19.6 vs 20.6 Gy, treatment isodose line: 60.2% vs 65.2%), and SRS adverse effects (10.9% vs 17.6%). For the entire cohort, the 3-, 5-, and 10-year progression-free survival (PFS) rates were 23%, 9%, and 3%, respectively, and the overall survival (OS) rates were 94%, 82%, and 76%, respectively. In the NoRT group, SRS was adjuvant treatment after resection in 38 patients (40.4%), salvage treatment for recurrent tumor treated with resection alone in 10 (10.6%), and not specified in 46 (48.9%). In the RT group, SRS was boost treatment in 9 patients (25.0%), salvage treatment after recurrence in 22 (61.1%), and not specified in 5 (13.9%). There was no difference between the two groups in terms of median PFS (24.0 months [Q1 34.0, Q3 15.0] vs 23.8 months [34.0, 18.0], respectively; p = 0.8) or median OS (293.0 months [not reached, 137.4] vs not reached [not reached, 48.0], respectively; p = 0.36). The adverse radiation effect rates were comparable between the groups (10.9% vs 17.6%, respectively; p = 0.4).
CONCLUSIONS
The role of SRS in the management of skull base chordomas is still evolving. This systematic literature review of biopsy-proven chordoma revealed that tumor control and survival rates for SRS alone after chordoma surgery were not inferior to those encountered after SRS plus fractionated RT.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arka N. Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Zachary C. Gersey
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Turki Elarjani
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Mohamed A. Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Georgios A. Zenonos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amir R. Dehdashti
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Jason P. Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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25
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White TG, Dehdashti AR. Macrovascular Decompression for Hemifacial Spasm: Three-Dimensional Operative Video. World Neurosurg 2022; 164:1. [PMID: 35483571 DOI: 10.1016/j.wneu.2022.04.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022]
Abstract
In 1%-2% of patients with symptomatic vascular compression of a cranial nerve, the compression may be due to a tortuous dolichoectatic vertebrobasilar artery. The most common technique used for microvascular decompression relies on the placement of a polytetrafluoroethylene (Teflon) pledget or other buffer between the root of the nerve and the offending vessel loop, thereby decompressing the cranial nerve. In cases of macrovascular compression by a large tortuous artery, these buffering techniques fail to produce lasting results with risk for cranial nerve compression-related deficit, specifically the facial nerve. In the Video 1, we demonstrate the use of a GORE-TEX (W.L. Gore & Associates Inc., Flagstaff, Arizona, USA) sling to transpose a dolichoectatic vertebral artery away from the facial nerve root entry. The patient consented to the procedure and to the publication of this video and their images. The technique demonstrated has been shown by other authors as well. Using GORE-TEX, we created a sling by cutting a slit into the GORE-TEX and looping it around the artery and then back through itself. We then used multiple aneurysm clips to attach the sling to a dural cuff made from the dura covering the petrous bone. While this technique completely resolved the compression from the vertebrobasilar artery, there was still a remaining vein contacting the nerve anterior to the artery. A Teflon pledget was placed between the vein and the root entry zone, as it was a pontine vein and we planned to preserve it. The patient recovered well without complication and was completely free from hemifacial spasm at >2 years long-term follow-up.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA.
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26
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Shah KA, Patsalides A, Dehdashti AR. Letter: Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study. Neurosurgery 2022; 90:e176-e177. [PMID: 35315799 DOI: 10.1227/neu.0000000000001933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/14/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Kevin A Shah
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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27
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Ballout AA, Libman RB, Schneider JR, Black K, Sideras P, Wang JJ, White TG, Dehdashti AR, Woo HH, Katz JM. Vertebrobasilar Stroke: Association Between Infarction Patterns and Quantitative Magnetic Resonance Angiography Flow State. J Am Heart Assoc 2022; 11:e023991. [PMID: 35170987 PMCID: PMC9075089 DOI: 10.1161/jaha.121.023991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Treatment and prognosis of vertebrobasilar atherosclerotic disease differs depending on stroke mechanism, such as artery‐to‐artery embolism, branch atheromatous disease, and hemodynamic ischemia. Our aim was to investigate the relationship between infarction pattern and flow status using quantitative magnetic resonance angiography (QMRA), to determine the validity of using infarction patterns to infer stroke mechanism. Methods and Results This is a retrospective study of patients with ischemic stroke with intra‐ or extracranial vertebrobasilar atherosclerotic stenosis, who underwent magnetic resonance imaging of the brain, neurovascular imaging, and QMRA, between 2009 and 2021. Patients with cerebral infarction predating or following QMRA by ≥1 year, or QMRA studies performed for basilar thrombosis, vertebral dissection, or only postangioplasty/stenting, were excluded. Poststenotic flow (basilar and posterior cerebral arteries) was dichotomized as low‐flow or normal‐flow based on published criteria. Of 1211 consecutive patients who underwent QMRA noninvasive optimal analysis, 69 met inclusion. Mixed patterns were most common (46.4%), followed by perforator (23.2%), borderzone (14.5%), and territorial (15.9%). Patients with low‐flow had a significantly higher rate of borderzone+ patterns (borderzone alone or in mixed pattern) compared with patients with normal‐flow (77.4% low‐flow versus 39.5% normal‐flow, P=0.002). Borderzone+ patterns were associated with 61.5% probability of low‐flow state, while no borderzone (perforator/territorial) patterns were associated with 76.7% probability of normal‐flow state. Conclusions Borderzone infarction pattern (alone or mixed) was associated with low poststenotic posterior circulation flow by QMRA. However, borderzone pattern only moderately predicted low‐flow state, and may be an unreliable flow marker. Therefore, infarct topography may complement, but should not replace hemodynamic studies to establish flow status.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Richard B Libman
- Department of Neurology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Julia R Schneider
- Department of Neurology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Karen Black
- Department of Radiology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Panagiotis Sideras
- Department of Radiology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Jason J Wang
- Department of Radiology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Timothy G White
- Department of Neurosurgery Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Amir R Dehdashti
- Department of Neurosurgery Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Henry H Woo
- Department of Neurosurgery Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Jeffrey M Katz
- Department of Neurology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY.,Department of Radiology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
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28
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Spiessberger A, Dogra S, Golub D, Grueter B, Nasim M, Schneider S, Moriggl B, Dehdashti AR, Schulder M. Contemporary surgical management of skull base chordomas - anatomical reflections on a single center experience retrospective case series. Clin Anat 2022; 35:366-374. [PMID: 35088437 DOI: 10.1002/ca.23840] [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] [Received: 11/16/2021] [Revised: 01/03/2022] [Accepted: 01/24/2022] [Indexed: 11/12/2022]
Abstract
Chordoma, a rare, locally aggressive tumor can affect the central skull base, usually centered at the midline. Complete surgical resection remains mainstay of therapy in case of primary as well as recurrent tumors. Owing to their secluded location, surgical resection of skull base chordomas remains a challenge, even though the recent advancement of endoscopic endonasal approaches has had a significant positive impact on the management of these patients. Endoscopic endonasal approaches have been shown to significantly reduce surgical morbidity when compared to traditional open approaches, however the classical endoscopic transclival midline approach fails to sufficiently expose parts of many skull base chordomas. More recent refinements of the technique, such as the interdural pituitary transposition and posterior clinoidectomy, the transpterygoid plate approach and the transcondylar far medial (TFM) approach enable the surgeon the increase the resection rate in these patients. This retrospective case series focuses on anatomical aspects in the surgical management of patients with skull base chordomas. We outline the surgical anatomy of contemporary endoscopic approaches to the skull base based intraoperative illustrations as well as pre- and postoperative 3D reconstructed CT and MR images if our patients. This article should help the clinical choose the most appropriate approach and be aware of relevant anatomy as well as potential shortcomings of a given approach.
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Affiliation(s)
- Alexander Spiessberger
- North Shore University Hospital - Hofstra School of Medicine, Department of Neurosurgery, 300 Community Drive, Manhasset, New York, USA
| | - Siddhant Dogra
- New York University School of Medicine, 550 1st Avenue, New York, New York, USA
| | - Danielle Golub
- North Shore University Hospital - Hofstra School of Medicine, Department of Neurosurgery, 300 Community Drive, Manhasset, New York, USA
| | - Basil Grueter
- University Hospital Zurich, Department of Neurosurgery, Frauenklinikstrasse 10, Zurich, SWITZERLAND
| | - Mansoor Nasim
- Zucker School of Medicine at Hofstra Northwell, Department of Pathology and Laboratory Medicine, 6 Ohio Drive - Suite 202, 11042 Lake Success, New York, USA
| | - Steven Schneider
- North Shore University Hospital - Hofstra School of Medicine, Department of Neurosurgery, 300 Community Drive, Manhasset, New York, USA
| | - Bernhard Moriggl
- Medical University Innsbruck, Division of Clinical and Functional Anatomy, Mullerstrasse 59, Innsbruck, AUSTRIA
| | - Amir R Dehdashti
- North Shore University Hospital - Hofstra School of Medicine, Department of Neurosurgery, 300 Community Drive, Manhasset, New York, USA
| | - Michael Schulder
- North Shore University Hospital - Hofstra School of Medicine, Department of Neurosurgery, 300 Community Drive, Manhasset, New York, USA
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29
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Prashant GN, Shah K, Woo HH, Dehdashti AR. Occipital Artery to Anterior Inferior Cerebellar Artery Bypass for Ruptured Dysplastic Proximal Anterior Inferior Cerebellar Artery Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:e133. [PMID: 35030102 DOI: 10.1227/ons.0000000000000080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Giyarpuram N Prashant
- Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, USA
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White TG, Dehdashti AR, Woo HH. Scepter mini assisted angiographic cure of a Vein of Galen Malformation with n-butyl cyanoacrylate. Interv Neuroradiol 2021; 27:663-666. [PMID: 33611967 PMCID: PMC8493341 DOI: 10.1177/1591019921993368] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/24/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Even in the modern endovascular era, the treatment of Vein of Galen Malformations (VOGM) is extremely challenging. While their natural history is very poor, endovascular embolization has emerged as the standard of care. These lesions often require multiple treatment sessions to decrease shunting, with each treatment including multiple pedicles. Here we present the first reported use of the Scepter Mini (Microvention, Aliso Viejo, CA) in the treatment of vein of Galen malformations. CLINICAL PRESENTATION A 7 month old female presented with an enlarging VOGM that was initially identified on prenatal ultrasound. Given the enlarging size of the lesion and failure to meet developmental milestones, the patient underwent planned endovascular embolization of the VOGM. The novel Scepter Mini balloon catheter was used for treatment of this lesion affording easy access to the target pedicle and immediate flow arrest which allowed for immediate cure of the lesion. CONCLUSION The novel Scepter Mini Balloon (Microvention, Aliso Viejo, CA) afforded excellent distal access with subsequent immediate flow arrest therefore facilitating endovascular cure. Initially, a staged approach was favored for the treatment of the lesion, but the flow arrest achieved by the Scepter mini facilitated immediate occlusion from a single pedicle.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, North Shore University Hospital, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, North Shore University Hospital, Manhasset, NY, USA
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Peto I, Abou-Al-Shaar H, White TG, Kwan K, Wagner K, Prashant GN, Chalif D, Katz JM, Dehdashti AR. Interdisciplinary treatment of posterior fossa dural arteriovenous fistulas. Acta Neurochir (Wien) 2021; 163:2515-2524. [PMID: 33683452 DOI: 10.1007/s00701-021-04795-2] [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: 11/16/2020] [Accepted: 02/25/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Posterior fossa dural arteriovenous fistulas (dAVFs) are rare vascular lesions with variable risk of hemorrhage, mostly depending on the pattern of the venous drainage. While endovascular embolization is the mainstay treatment for most dAVFs, some posterior fossa lesions require a multidisciplinary approach including surgery. The goal of our study was to examine the outcome of an interdisciplinary treatment for posterior fossa dAVFs. METHODS A retrospective review of patients treated for posterior fossa dAVFs was conducted. RESULTS A total of 28 patients with a mean age of 57.8 years were included. Patients presented with a Cognard grade I in 2 (7%), II a in 5 (18 %), II b in 7 (25%), II a + b in 5 (18%), III in 3 (11%), and IV in 6 (21%) cases. Hemorrhage was the initial presentation in 2 (22%) patients with Cognard grade IV, in 3 with Cognard grade III (33%), in 1 (11%) with Cognard II a + b, and 3 (33%) with Cognard II b. A complete angiographic cure was achieved in 24 (86%) patients-after a single-session embolization in 16 (57%) patients, multiple embolization sessions in 2 (7%), a multimodal treatment with embolization and surgical disconnection in 3 (11%), and with an upfront surgery in 3 (11%). Complete long-term obliteration was demonstrated in 18/22 (82%) at the mean follow-up of 17 months. Fistulas were converted into asymptomatic Cognard I lesion in 4 (14%) patients. CONCLUSION Posterior fossa dAVFs represent a challenging vascular pathology; however, despite their complexity, an interdisciplinary treatment can achieve high rates of angiographic and symptomatic cure with low morbidity and mortality rates. Long-term surveillance is warranted as late recurrences may occur.
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Affiliation(s)
- Ivo Peto
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA. .,Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA.
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA.,Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Timothy G White
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Kevin Kwan
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Katherine Wagner
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - David Chalif
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA.
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Ryu B, White TG, Shah KA, Turpin J, Link T, Dehdashti AR, Katz JM, Black K, Woo HH. Utility of quantitative magnetic resonance angiography and non-invasive optimal vessel analysis for identification of complications and long-term hemodynamic changes in post-pipeline embolization patients. Interv Neuroradiol 2021; 28:396-403. [PMID: 34346801 PMCID: PMC9326859 DOI: 10.1177/15910199211034668] [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] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Quantitative magnetic resonance angiography and non-invasive optimal vessel analysis serve as powerful tools to collect and analyze hemodynamic data from pipeline embolization patients. At our institution, patients receive post-embolization quantitative magnetic resonance angiography within 24 h of treatment and within 6 months for follow-up to evaluate pipeline patency. Here, we aim to elucidate the long-term hemodynamic changes following pipeline embolization device placement and report two cases in which in-stent stenosis was detected. METHODS Medical records of patients who underwent pipeline embolization device placement for an internal carotid artery aneurysm between 2017 and 2019 were reviewed. Patients who received post-procedure NOVA and follow-up NOVA were included in the study (n = 32). Location and size of aneurysm, number of pipeline embolization device deployed, and complications were collected along with the non-invasive optimal vessel analysis report (flow volume rate (ml/min), mean, systolic, and diastolic flow velocities (cm/s), and vessel diameter (mm)). Internal carotid artery vessel flow rate was measured proximal to the pipeline embolization device. Derivations of hemodynamic parameters (pulsatility index, Lindegaard ratio, and wall shear stress) were calculated. RESULTS The middle cerebral artery mean and diastolic flow velocities were significantly lower on the follow-up NOVA compared to the post-procedure NOVA. Moreover, follow-up NOVA demonstrated lower middle cerebral artery wall shear stress on the side with flow diversion compared to the post-procedure NOVA. In-stent stenosis, requiring intervention, was detected in two patients on follow-up NOVA. One patient had a successful balloon angioplasty of the stented internal carotid artery that resolved her stenosis. However, the second patient developed progressive stenosis and expired despite intervention. CONCLUSION Long-term hemodynamic adaptations post-pipeline embolization device demonstrate decreased wall shear stress and decreased mean and diastolic flow velocities in the distal middle cerebral artery, which suggest decreasing velocity of blood flow with endothelialization of the device. Furthermore, follow-up NOVA is a useful tool for detecting potential flow-related complications such as in-stent stenosis.
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Affiliation(s)
- Brendan Ryu
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Kevin A Shah
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas Link
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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Nouri M, Schneider JR, Shah K, White TG, Katz JM, Dehdashti AR. Cerebral Bypass for Aneurysms in the Era of Flow Diversion: Single-Surgeon Case Series. Oper Neurosurg (Hagerstown) 2021; 21:303-311. [PMID: 34245142 DOI: 10.1093/ons/opab215] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 09/15/2020] [Accepted: 04/29/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND With recent advances in endovascular treatments of brain aneurysms such as flow diverters, the role of cerebral revascularization needs to be re-evaluated. OBJECTIVE To evaluate the contemporary indications and outcomes of cerebral revascularization for brain aneurysms. METHODS A retrospective evaluation of a prospectively maintained database was performed to review clinical and imaging data of all the patients who underwent cerebral revascularization for brain aneurysms over the past 10 yr. RESULTS Among 174 cerebral revascularizations, 40 (in 36 patients) were done for the treatment of aneurysms. In total, 9 patients underwent combined endovascular treatment and surgical revascularization. Immediate aneurysm occlusion was achieved in 30 patients (83.3%). Immediate postoperative bypass patency was confirmed in 33 patients (92%). Postoperative neurological deficit was observed in 4 patients (11.1%). There were 2 mortalities in the postoperative period. Aneurysm total occlusion rate was 91% at 1 yr. Thirty patients had 1 yr clinical and radiological follow-up. Clinical evaluations showed modified Rankin Scale 2 or less in 25 patients at 1 yr. Bypass patency was confirmed in 27 (90%). Patients with fair/poor outcome were all in the subarachnoid hemorrhage group. Twenty-one patients had follow-up studies for 3 yr or beyond with no evidence of stroke or aneurysm recurrence. CONCLUSION Our results support that cerebral revascularization can be regarded as a viable and durable treatment option for these challenging aneurysms with acceptable morbidity. Cerebral bypass should be offered in selected cases where standard endovascular or surgical treatment is not efficacious or curative.
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Affiliation(s)
- Mohsen Nouri
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Julia R Schneider
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Kevin Shah
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Timothy G White
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Jeffrey M Katz
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
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Klironomos G, Chiluwal AK, Dehdashti AR. Technical Note: Extreme Lateral Supracerebellar Approach for Resection of Superior Cerebellar Peduncle Arteriovenous Malformations. Oper Neurosurg (Hagerstown) 2021; 20:E334-E339. [PMID: 33484142 DOI: 10.1093/ons/opaa472] [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: 08/14/2020] [Accepted: 11/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The surgical approaches to the region of the cerebello-mesencephalic sulcus and superior cerebellar peduncle (SCP) remain a neurosurgical challenge. OBJECTIVE To present the use of the extreme lateral supracerebellar infratentorial (SC-IT) approach to treat arteriovenous malformations (AVMs) of the SCP, which is a different entity compared to brainstem AVMs. METHODS We treated 4 patients with SCP AVMs in the last 5 yr at our institution. The mean age was 49.7 yr. The average nidus size was 2.12 cm. Of those, 3 patients presented with hemorrhage and 1 with headache and tinnitus. Extreme lateral SC-IT approach was used in all cases. RESULTS Complete resection was achieved in all cases as verified with postoperative angiogram. In 1 case, intraoperative rupture with intraventricular hemorrhage was encountered, and the patient required temporary external ventricular drainage. There was no permanent complication or neurological deficit. The modified Rankin Scale (at discharge or follow-up) was less than 2 in all cases. CONCLUSION The AVMs located primarily in the SCP are distinct compared to brainstem AVMs, and their management should be different. Extreme lateral SC-IT approach should be considered as a viable alternative surgical approach for resection of these AVMs, and excellent surgical results can be achieved.
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Affiliation(s)
- Georgios Klironomos
- Department of Neurosurgery, South Shore University Hospital, Northwell Health, Bay Shore, New York
| | - Amrit K Chiluwal
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
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Chiluwal AK, Nouri M, Knobel D, Dehdashti AR. Surgical Trapping of a Large Complex Middle Cerebral Artery Aneurysm With Double-Barrel Bypass: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E444-E445. [PMID: 33554252 DOI: 10.1093/ons/opab028] [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: 07/07/2020] [Accepted: 12/22/2020] [Indexed: 11/14/2022] Open
Abstract
Large middle cerebral artery (MCA) bifurcation aneurysms are known vascular lesions that are usually symptomatic but often difficult to treat (whether with open or endovascular techniques), especially when the M2 branches originate from the aneurysm dome.1-7 The challenge lies in securing the aneurysm while fully maintaining the flow in the vessels arising from the dome. Standard microsurgical clipping or endovascular techniques are not feasible in perfectly treating these aneurysms. Revascularization of the MCA branches with bypass and trapping of the aneurysm is often necessary. Here, we present a case of a large complex partially thrombosed right MCA bifurcation aneurysm with both the superior and the inferior divisions arising from the dome. The patient initially presented with a right MCA stroke and left hemiparesis. Using radial artery as an interposition graft, 2 bypasses-internal maxillary artery to the inferior division and superficial temporal artery to the superior division-were performed. The aneurysm was trapped and decompressed by placing clips at the M1 terminus and the M2 origins. Intraoperative angiography and postoperative NOVA (VasSol Inc.) magnetic resonance angiography (MRA) confirmed patency and excellent flow in the bypass grafts. The patient's postoperative course was uncomplicated, and at 2-mo follow-up, had significant improvement of her hemiparesis. The patient provided informed consent for the procedure.
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Affiliation(s)
- Amrit K Chiluwal
- Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, USA.,Department of Neurosurgery, Richmond Hills, New York, USA
| | - Mohsen Nouri
- Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, USA.,Department of Neurosurgery, Richmond Hills, New York, USA
| | - Denis Knobel
- Department of Plastic Surgery, North Shore University Hospital, Manhasset, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, USA
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White TG, Ryu B, Shah KA, Turpin J, Black K, Link T, Dehdashti AR, Katz JM, Woo HH. Quantitative magnetic resonance angiography to assess post embolization hemodynamics following pipeline embolization. Interv Neuroradiol 2021; 28:177-182. [PMID: 34151618 DOI: 10.1177/15910199211023650] [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] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Delayed intraparenchymal hemorrhage is a known complication of the Pipeline Embolization device (PED); however, its etiology is unclear and some have suggested it is a flow related phenomenon. Quantitative magnetic resonance angiography (QMRA) serves as a powerful tool to collect and analyze hemodynamic data. We report a detailed characterization of short-term hemodynamics after PED placement. METHODS Patients who underwent PED placement for a distal internal carotid artery (ICA) aneurysm between 2017 to 2019 with post embolization QMRA were reviewed. Aneurysm characteristics, flow volume rate (ml/min), mean, systolic, and diastolic flow velocities (cm/s), vessel diameter (mm), pulsatility index, Lindegaard ratio, and wall shear stress (WSS) were collected. RESULTS A total of 67 patients were included. Post-procedure patients were found to have a significantly lower ICA flow on the side with flow diversion when compared to the side without flow diversion (218 vs. 236.3; P < 0.05). Average ICA flow after flow diversion for aneurysms >2 cm was significantly lower when compared to the untreated side (187.7 vs. 240.4; P < 0.05). There was no difference in MCA or ACA flow or velocity. WSS was significantly lower in the treated ICA (8.2 vs. 9.0; P < 0.05). Lindegaard ratio was not different in the treated vs. contralateral untreated sides. CONCLUSION PED placement for distal ICA aneurysms results in lower flow, mean velocity, and WSS when compared to the contralateral untreated ICA. This is not demonstrated distal to the Pipeline device in the ACA or MCA territories. Ultimately these findings suggest hemodynamic changes are not a cause of PED complications.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Brendan Ryu
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Kevin A Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
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Schneider JR, Chiluwal AK, Nouri M, Prashant GN, Dehdashti AR. Retrosigmoid transhorizontal fissure approach to lateral pontine cavernous malformation: comparison to transpetrosal presigmoid retrolabyrinthine approach. J Neurosurg 2021; 136:205-214. [PMID: 34116504 DOI: 10.3171/2020.12.jns203608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The retrosigmoid (RS) approach is a classic route used to access deep-seated brainstem cavernous malformation (CM). The angle of access is limited, so alternatives such as the transpetrosal presigmoid retrolabyrinthine (TPPR) approach have been used to overcome this limitation. Here, the authors evaluated a modification to the RS approach, horizontal fissure dissection by using the RS transhorizontal (RSTH) approach. METHODS Relevant clinical parameters were evaluated in 9 patients who underwent resection of lateral pontine CM. Cadaveric dissection was performed to compare the TPPR approach and the RSTH approach. RESULTS Five patients underwent the TPPR approach, and 4 underwent the RSTH approach. Dissection of the horizontal fissure allowed for access to the infratrigeminal safe entry zone, with a direct trajectory to the middle cerebellar peduncle similar to that used in TPPR exposure. Operative time was longer in the TPPR group. All patients had a modified Rankin Scale score ≤ 2 at the last follow-up. Cadaveric dissection confirmed increased anteroposterior working angle and middle cerebellar peduncle exposure with the addition of horizontal fissure dissection. CONCLUSIONS The RSTH approach leads to a direct lateral path to lateral pontine CM, with similar efficacy and shorter operative time compared with more extensive skull base exposure. The RSTH approach could be considered a valid alternative for resection of selected pontine CM.
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White TG, Shah KA, Turpin J, Dehdashti AR, Link T, Katz JM, Woo HH. Single institution early clinical experience with the Scepter Mini balloon catheter. Neuroradiol J 2021; 34:562-567. [PMID: 34014796 DOI: 10.1177/19714009211013495] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The use of liquid embolic agents in the endovascular treatment of dural arteriovenous (dAVFs) fistulas and brain arteriovenous malformations (AVMs) has become common practice. The use of dual lumen balloon microcatheters has greatly improved the efficacy of liquid embolization. The purpose of this series is to discuss our early experience with the Scepter Mini dual lumen balloon microcatheter. METHODS A retrospective chart review was performed of all patients who underwent embolization with the Scepter Mini dual lumen balloon at a single institution. Technical details and procedural complications were recorded for each case. RESULTS In total, 10 Scepter Mini dual lumen balloon microcatheters were used in nine patients. All patients except two were treated for AVMs. Technical success was achieved in all but one case where one balloon had to be discarded due to precipitation of the tantalum powder. Average vessel diameter where the balloon was inflated was 1.1 mm (0.8-2.4 mm). It provided flow arrest in 100% of cases with no cases of reflux of embolic material. Balloon "jump back" was found to occur in 44.4% (4/9) of cases. Seven out of nine cases used Onyx, and two cases used n-butyl cyanoacrylate. CONCLUSIONS The Scepter Mini is a new dual lumen balloon ideal for distal access and can be used for embolization with liquid embolic agents with a high degree of technical success. Its great benefit is the immediate and safe flow arrest of distal vasculature upon balloon inflation. One important consideration for effective embolization is early identification of balloon jump back.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, USA
| | - Kevin A Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, USA
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, USA
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, USA
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O'Donnell D, Dehdashti AR. Hearing Preservation Surgery in the Sitting Position for Grade 3B Hannover Classification Vestibular Schwannoma: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E265. [PMID: 34017997 DOI: 10.1093/ons/opab151] [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: 08/28/2020] [Accepted: 03/14/2021] [Indexed: 11/15/2022] Open
Abstract
Surgical treatment of large vestibular schwannomas is challenging. Both facial and cochlear nerves should be preserved in patients who have no neurological deficit preoperatively. In this 3-dimensional video, we present a 35-yr-old patient who presented with documented increase in the size of a known vestibular schwannoma over the span of 3 yr. Surgery was favored among all treatment options due to his young age and the tumor size. Informed consent was obtained. Semisitting surgery allowed for bimanual microdissection of the tumor capsule from the surrounding arachnoid and cranial nerves with 2 micro dissectors. The precision of microdissection is enhanced in the sitting position. Facial nerve stimulation remained stable at 0.05 mA. The auditory evoked potential remained unchanged during the surgery. Complete resection of the tumor and preservation of facial and cochlear nerves was achieved. The patient had a stable hearing grade B and a normal facial nerve function at 3-mo follow-up.
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Affiliation(s)
- Devon O'Donnell
- Department of Neurosurgery, Northshore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northshore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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Shah KA, White TG, Teron I, Link T, Dehdashti AR, Katz JM, Woo HH. Volume-based sizing of the Woven EndoBridge (WEB) device: A preliminary assessment of a novel method for device size selection. Interv Neuroradiol 2021; 27:473-480. [PMID: 33478310 DOI: 10.1177/1591019920987685] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Accurate sizing of the Woven EndoBridge (WEB) device is of critical importance as it determines procedural safety and successful occlusion of wide neck bifurcation aneurysms. The aim of this study was to assess the ability of aneurysm volume to assist in accurate WEB size selection. METHODS All patients with an intracranial aneurysm treated with the WEB SL or WEB SLS device between March 2019 and October 2019 were identified for this retrospective study. Aneurysm volumes were calculated with auto-segmentation using a three-dimensional volume rendering program on an independent Syngo workstation (Siemens Healthineers AG). Pearson correlation coefficients were calculated for aneurysm auto-segmented volumes and WEB volumes, as well as for aneurysm height × width and WEB height × width. Follow-up angiographic outcomes were collected at 6-9 months post-procedure. RESULTS Twenty-nine aneurysms were evaluated by 3D rotational angiography. The correlation coefficient with WEB size was larger for auto-segmented aneurysm volumes (r = 0.979) compared to height × width measurements (r = 0.867). Using Fisher r-to-z transformations, we found the difference between the two correlations to be statistically significant (p = 0.0007). Follow-up angiography available in 13 subjects demonstrated an 85% complete aneurysm occlusion rate. CONCLUSION Aneurysm volumes are highly correlated with WEB volumes, with auto-segmentation volumes displaying statistically significant difference against conventional height by width measurements. These results suggest that volumetric measurements of aneurysm size provide a useful adjuvant measure to assist in appropriate size selection of the WEB device.
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Affiliation(s)
- Kevin A Shah
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Timothy G White
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Ina Teron
- Department of Neurosurgery, Southside Hospital, Northwell Health, Bay Shore, USA
| | - Thomas Link
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Jeffrey M Katz
- Department of Neurology, North Shore University Hospital, Northwell Health, Manhasset, USA
| | - Henry H Woo
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, USA
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White TG, Shah K, Turpin J, Park J, Katz J, Dehdashti AR, Woo HH. FLAIR Hyperintense Vessels After Embolization of Brain Arteriovenous Malformations Predicts Delayed Intraparenchymal Hemorrhage. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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White TG, Shah K, Turpin J, Dehdashti AR, Katz J, Woo HH. Flow Changes After Pipeline Flow Diversion; Do Altered Hemodynamics Underly Complications? Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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White TG, Shah K, Turpin J, Link T, Dehdashti AR, Katz JM, Woo HH. Technical aspects of combined intrasaccular and endoluminal flow diversion. Interv Neuroradiol 2020; 27:346-352. [PMID: 33249923 DOI: 10.1177/1591019920973844] [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] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The concurrent use of endoluminal flow diversion with coils is a viable option when treating complex or large aneurysms. Alternatives to coil embolization as an adjunctive treatment are currently limited. The Food and Drug Administration recently approved the Woven EndoBridge (WEB) device (Microvention, Aliso Viejo, California) as an intrasaccular flow diverter for wide-neck bifurcation aneurysms. We present the technical aspects of combined WEB device plus endoluminal flow diversion for the treatment of complex wide-necked intracranial aneurysms. METHODS A retrospective chart review of all patients treated via intrasaccular flow diversion at a single institution over the last 12 months was performed. RESULTS In total, seven patients underwent treatment of eight aneurysms via combined intrasaccular and endoluminal flow diversion. Of the seven patients, six were treated in a single setting. The most common aneurysm location was the posterior communicating artery. The majority of the aneurysms required steam shaping of the Via deployment catheter to place the WEB device orthogonally to the aneurysm dome. There were no complications. CONCLUSIONS We believe this is one of the first series reporting the combined use of the WEB device and endoluminal flow diversion for the treatment of intracranial aneurysms. This series demonstrates that the concurrent use of the WEB device with endoluminal flow diversion is safe for achieving immediate aneurysm treatment and may enhance the long-term durability in complex aneurysms.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
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White TG, Prashant GN, Unadkat P, Dehdashti AR. Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers. Acta Neurochir (Wien) 2020; 162:2743-2744. [PMID: 32681343 DOI: 10.1007/s00701-020-04492-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
- Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Prashin Unadkat
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA.
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Peto I, Nouri M, Agazzi S, Langer D, Dehdashti AR. Pterygo-Maxillary Fissure as a Landmark for Localization of Internal Maxillary Artery for Use in Extracranial-Intracranial Bypass. Oper Neurosurg (Hagerstown) 2020; 19:E480-E486. [PMID: 32585696 DOI: 10.1093/ons/opaa177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/15/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Internal maxillary artery (IMax) is a relatively new donor vessel used in the extracranial-intracranial bypass surgery. However, unfamiliarity and relatively elaborate techniques of its harvest precluded its widespread use. OBJECTIVE To present a simplified technique of IMax harvest based on constant anatomical landmarks without the need of extensive skull-base drilling while providing adequate space for proximal anastomosis. METHODS Cadaveric dissection on 4 cadaveric heads (8 sides) was performed. Zygomatic osteotomy was performed and temporal muscle was dissected off the zygomatic process of the frontal bone and the frontal process of the zygomatic bone and reflected inferiorly into the bony gap created by the zygomatic osteotomy. Posterior wall of the maxilla (PWoM) was palpated. Following PWoM inferiorly leads to pterygo-maxillary fissure (PMF), which is a constant landmark IMax passes through. RESULTS IMax was localized following this technique before its entrance into PMF in every specimen. Proximal dissection was carried on to the exposed adequate length of the vessel. Depending on the relationship with the lateral pterygoid muscle, this might need to be incised to allow for identification of the IMax. After its transection, proximal stump is mobilized superiorly into the surgical field. Clinical application of this technique was demonstrated on an aneurysm case. CONCLUSION Using the palpation of the PWoM as a landmark for localization of PMF facilitates harvesting of IMax without need for extensive skull-base drilling and shortens the time of the surgery.
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Affiliation(s)
- Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College Of Medicine, Tampa, Florida.,Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
| | - Mohsen Nouri
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College Of Medicine, Tampa, Florida
| | - David Langer
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York
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Peto I, Abou-Al-Shaar H, White TG, Abunimer AM, Kwan K, Zavadskiy G, Wagner K, Black K, Eisenberg M, Bruni M, Dehdashti AR. Sources of residuals after endoscopic transsphenoidal surgery for large and giant pituitary adenomas. Acta Neurochir (Wien) 2020; 162:2341-2351. [PMID: 32700080 DOI: 10.1007/s00701-020-04497-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Giant and large pituitary adenomas (PA) constitute a specific subset of PAs, with gross total resection (GTR) rates frequently not exceeding 50%. Both an anatomical inaccessibility and an inadequate tumor visualization are thought to play a role. This study analyzes risk factors for postoperative residuals after endoscopic transsphenoidal pituitary surgery for large and giant pituitary adenomas. METHODS A retrospective analysis of patients with giant and large PA operated between 2015 and 2018 was performed. RESULTS Forty patients (13 females, 27 males) were included in the analysis (30 large and 10 giant PAs). The mean MRI follow-up time was 5.9 ± 6.54 months. Overall, GTR was achieved in 29 patients (72.5%), subtotal resection in 9 (22.5%), and the inconclusive result was in 2 (5%). Unexpected residuals represented 7 (77.7%) of all 9 residual tumors. The most frequent intraoperative factor associated with unexpected residual tumors was improper identification of residual tumor due to obstruction of view in 2 (28.5%) cases and inability to distinguish normal tissue from tumor in the other two (28.5%). Sub-analysis based on tumor size revealed that with large PAs, GTR was achieved in 25 (83.3%), STR in 4 (13.3%), and inconclusive in 1 (3.3%) patient. In patients with giant PAs, GTR was achieved in 4 (40%), STR in 5 (50%), and inconclusive in 1 (10%). Analysis of preoperative factors showed a significant association of residual tumors with larger suprasellar AP distance (p = 0.041), retrosellar extension (p = 0.007), and higher Zurich Score (p = 0.029). CONCLUSION Large and giant PAs are challenging lesions with high subtotal resection rates. Suprasellar AP distance, retrosellar extension, and higher Zurich Score seem to be significant predictors of degree of resection in these tumors. Improving the intraoperative ability to distinguish tumor from a normal tissue might further decrease the number of unexpected residuals.
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Affiliation(s)
- Ivo Peto
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA.
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, 33606, USA.
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Timothy G White
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin Kwan
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | | | - Katherine Wagner
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Karen Black
- Department of Neuroradiology, North Shore University Hospital, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Mark Eisenberg
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Margherita Bruni
- Department of Otolaryngology, New York Head & Neck Institute, New York, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA.
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Schneider JR, Chiluwal AK, Arapi O, Kwan K, Dehdashti AR. Near Total Versus Gross Total Resection of Large Vestibular Schwannomas: Facial Nerve Outcome. Oper Neurosurg (Hagerstown) 2020; 19:414-421. [PMID: 32330283 DOI: 10.1093/ons/opaa056] [Citation(s) in RCA: 5] [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: 07/12/2019] [Accepted: 02/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Large vestibular schwannomas (VSs) with brainstem compression are generally reserved for surgical resection. Surgical aggressiveness must be balanced with morbidity from cranial nerve injury. The purpose of the present investigation is to evaluate the clinical presentation, management modality, and patient outcomes following near total resection (NTR) vs gross total resection (GTR) of large VSs. OBJECTIVE To assess facial nerve outcome differences between GTR and NTR patient cohorts. METHODS Between January 2010 and March 2018, a retrospective chart review was completed to capture patients continuously who had VSs with Hannover grades T4a and T4b. NTR was decided upon intraoperatively. Primary data points were collected, including preoperative symptoms, tumor size, extent of resection, and postoperative neurological outcome. RESULTS A total of 37 patients underwent surgery for treatment of large and giant (grade 4a and 4b) VSs. Facial nerve integrity was preserved in 36 patients (97%) at the completion of surgery. A total of 27 patients underwent complete resection, and 10 had near total (>95%) resection. Among patients with GTR, 78% (21/27) had House-Brackmann (HB) grade I-II facial nerve function at follow-up, whereas 100% (10/10) of the group with NTR had HB grade I-II facial nerve function. Risk of meningitis, cerebrospinal fluid leak, and sinus thromboses were not statistically different between the 2 groups. There was no stroke, brainstem injury, or death. The mean follow-up was 36 mo. CONCLUSION NTR seems to offer a benefit in terms of facial nerve functional outcome compared to GTR in surgical management of large VSs without significant risk of recurrence.
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Affiliation(s)
- Julia R Schneider
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
| | - Amrit K Chiluwal
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
| | - Orseola Arapi
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
| | - Kevin Kwan
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
| | - Amir R Dehdashti
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
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Peto I, Nouri M, Katz J, Woo H, Dehdashti AR. Contralateral Transfalcine Approach to Deep Parasagittal Arteriovenous Malformations-Technical Note. World Neurosurg 2020; 143:495-501. [PMID: 32791227 DOI: 10.1016/j.wneu.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resection of deep medial frontal and parietal arteriovenous malformations (AVMs) is often challenging due to a tangential angle of attack and deep, narrow working corridor. Adequate visualization of the AVM and its feeding arteries without brain retraction is of particular importance when operating in or near eloquent cortical areas, where brain manipulation could inadvertently result in neurologic deficits. The aim of this paper is to provide a step-by-step description of surgical approach and report our experience with the contralateral transfalcine approach for resection of deep-seated parasagittal AVMs. METHODS Contralateral transfalcine resection of deep frontal, parietal, and cingulate gyrus AVMs was performed with the unaffected hemisphere positioned in a gravity-dependent manner in 5 cases. Surgical procedures were video documented, and an illustrative case is presented. All 5 patients had a modified Rankin Scale score of 0 or 1 at the last follow-up. RESULTS Complete resection of the AVM was achieved in all 5 cases. No permanent major neurologic deficit was observed postoperatively. This approach allowed a superior visualization of arterial feeders, the parenchymal side of the AVM, and an early control of small parenchymal feeders while minimizing retraction of the brain. CONCLUSIONS The contralateral transfalcine approach is a useful technique in the cerebrovascular surgeon's armamentarium for management of deep-seated medial frontal, parietal, and cingulate gyrus AVMs in or around eloquent brain areas, allowing to minimize normal brain retraction and avoid associated neurologic deficits.
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Affiliation(s)
- Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA; Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Mohsen Nouri
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Jeffrey Katz
- Department of Neurology, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Henry Woo
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA.
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Nouri M, Dehdashti AR. Commentary: Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites. Oper Neurosurg (Hagerstown) 2020; 19:E130. [PMID: 32281627 DOI: 10.1093/ons/opaa078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mohsen Nouri
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York
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Chiluwal AK, Klironomos G, Dehdashti AR. Surgical Resection of a Complex Spetzler-Martin Grade IV Medial Sylvian Arteriovenous Malformation: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 19:E60. [PMID: 31742361 DOI: 10.1093/ons/opz312] [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: 08/04/2018] [Accepted: 08/05/2019] [Indexed: 11/14/2022] Open
Abstract
Sylvian arteriovenous malformations (AVMs) are challenging lesions for surgical management. They are classified according to the Sugita classification based on the location of the nidus in the sylvian fissure: pure, lateral, medial, and deep. Resection of these lesions are fraught with risks, as it requires extensive arachnoid dissection in the sylvian fissure in close proximity to surrounding eloquent tissue, and the presence of en passage arteries can resemble feeding arteries. In this video illustration, the authors describe a complex, Spetzler-Martin Grade IV right sylvian AVM and its surgical resection. By Sugita classification, this was a medial sylvian AVM, with an associated flow related middle cerebral artery (MCA) bifurcation aneurysm. Informed consent was obtained from the patient prior to the procedures. The AVM was embolized preoperatively, and surgical resection was carried out via a pterional approach. The detail of the AVM resection is described in the video clip. Postoperative digital subtraction angiography showed complete excision of the lesion, and the patient was discharged to home on postoperative day 6 without any neurological deficit. In 1-yr follow-up angiogram, beside complete obliteration of the AVM, the flow-related MCA bifurcation aneurysm as well as the M1 and M2 vessels have decreased in size and are much less prominent in comparison to the pretreatment angiography.
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Affiliation(s)
- Amrit K Chiluwal
- Department of Neurosurgery, Northwell Neuroscience Institute, North Shore University Hospital, Manhasset, New York
| | - Georgios Klironomos
- Department of Neurosurgery, Northwell Neuroscience Institute, North Shore University Hospital, Manhasset, New York
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Neuroscience Institute, North Shore University Hospital, Manhasset, New York
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