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Catapano JS, Koester SW, Hanalioglu S, Farhadi DS, Naik A, Hartke JN, Tunc O, Winkler EA, Chang SW, Lawton MT, Jadhav AP, Ducruet AF, Albuquerque FC. Middle meningeal artery embolization associated with reduced chronic subdural hematoma volume and midline shift in the acute postoperative period. J Neurointerv Surg 2024; 16:478-481. [PMID: 37321836 DOI: 10.1136/jnis-2022-020054] [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: 02/16/2023] [Accepted: 05/21/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization for endovascular treatment of chronic subdural hematoma (cSDH) is growing in popularity. cSDH volume and midline shift were analyzed in the immediate postoperative window after MMA embolization. METHODS A retrospective analysis of cSDHs managed via MMA embolization from January 1, 2018 to March 30, 2021 was performed at a large quaternary center. Pre- and postoperative cSDH volume and midline shift were quantified with CT. Postoperative CT was obtained 12 to 36 hours after embolization. Paired t-tests were used to determine significant reduction. Multivariate analysis was performed using logistic and linear regression for percent improvement from baseline volume. RESULTS In total, 80 patients underwent MMA embolization for 98 cSDHs during the study period. The mean (SD) initial cSDH volume was 66.54 (34.67) mL, and the mean midline shift was 3.79 (2.85) mm. There were significant reductions in mean cSDH volume (12.1 mL, 95% CI 9.32 to 14.27 mL, P<0.001) and midline shift (0.80 mm, 95% CI 0.24 to 1.36 mm, P<0.001). In the immediate postoperative period, 22% (14/65) of patients had a>30% reduction in cSDH volume. A multivariate analysis of 36 patients found that preoperative antiplatelet and anticoagulation use was significantly associated with an expansion in volume (OR 0.028, 95% CI 0.000 to 0.405, P=0.03). CONCLUSION MMA embolization is safe and effective for the management of cSDH and is associated with significant reductions in hematoma volume and midline shift in the immediate postoperative period.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sahin Hanalioglu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Osman Tunc
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Steven W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Hackett AM, Adereti CO, Walker AP, Nico E, Scherschinski L, Rhodenhiser EG, Eberle AT, Naik A, Giraldo JP, Hartke JN, Rahmani R, Winkler EA, Catapano JS, Lawton MT. Racial and Socioeconomic Status among a Patient Population Presenting with Aneurysmal Subarachnoid Hemorrhage versus Unruptured Intracranial Aneurysm: A Single-Center Study. Brain Sci 2024; 14:394. [PMID: 38672043 PMCID: PMC11047834 DOI: 10.3390/brainsci14040394] [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: 01/31/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Racial and socioeconomic health disparities are well documented in the literature. This study examined patient demographics, including socioeconomic status (SES), among individuals presenting with aneurysmal subarachnoid hemorrhage (aSAH) and unruptured intracranial aneurysm (UIA) to identify factors associated with aSAH presentation. A retrospective assessment was conducted of all patients with aSAH and UIA who presented to a large-volume cerebrovascular center and underwent microsurgical treatment from January 2014 through July 2019. Race and ethnicity, insurance type, and SES data were collected for each patient. Comparative analysis of the aSAH and UIA groups was conducted. Logistic regression models were also employed to predict the likelihood of aSAH presentation based on demographic and socioeconomic factors. A total of 640 patients were included (aSAH group, 251; UIA group, 389). Significant associations were observed between race and ethnicity, SES, insurance type, and aneurysm rupture. Non-White race or ethnicity, lower SES, and having public or no insurance were associated with increased odds of aSAH presentation. The aSAH group had poorer functional outcomes and higher mortality rates than the UIA group. Patients who are non-White, have low SES, and have public or no insurance were disproportionately affected by aSAH, which is historically associated with poorer functional outcomes.
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Affiliation(s)
- Ashia M. Hackett
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Christopher O. Adereti
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA 01805, USA;
| | - Ariel P. Walker
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Elsa Nico
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Emmajane G. Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Adam T. Eberle
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Juan P. Giraldo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Joelle N. Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013, USA (E.N.); (L.S.); (J.P.G.); (R.R.)
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Isikbay M, Caton MT, Mattay R, Han W, Cooke DL, Raper D, Winkler EA, Savastano L, Narsinh KH, Hetts SW, Amans MR. Arteriovenous shunts of the cervical spine: patient demographics, presentation, patterns of high-risk venous drainage, and updated classification. J Neurointerv Surg 2024:jnis-2023-021353. [PMID: 38604766 DOI: 10.1136/jnis-2023-021353] [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: 01/16/2024] [Accepted: 03/27/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Intracranial dural arteriovenous (AV) fistula classifications focus on presence/absence of retrograde flow in the cortical veins of the brain as this angiographic finding portends a worse prognosis. However, prior categorization systems of AV shunts in the spine do not incorporate these features. We propose an updated classification for spinal shunting lesions that terms any shunting lesion with retrograde flow in any cortical vein of the brain or spinal cord medullary vein as "high risk". To present this classification, we analyzed our center's most recent experience with cervical spine shunting lesions. METHODS The electronic medical record at our institution was reviewed to identify shunting lesions of the cervical spine and patient demographics/presentation. Comprehensive craniospinal digital subtraction angiograms were evaluated to classify shunt location, type (arteriovenous malformation (AVM) vs arteriovenous fistula (AVF)), and presence of high-risk venous drainage. RESULTS Some 52 lesions were identified and categorized as pial/dural/epidural/paravertebral AVFs and intramedullary/extraspinal AVMs. Lesions were classified as high risk or not depending on the presence of retrograde flow into at least one vein that directly drains the spinal cord or brain. All patients who presented with either hemorrhage or infarct had underlying high-risk lesions. Additionally, 50% (17/34) of symptomatic patients with high-risk lesions presented with neurological extremity symptoms (OR=10.0, p=0.037) most of which fit a myelopathic pattern. CONCLUSION We present an updated classification system for shunting lesions of the spine that focuses on high-risk retrograde flow to the brain or spine in addition to anatomical location in order to better inform patient management.
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Affiliation(s)
- Masis Isikbay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Raghav Mattay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Woody Han
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel Raper
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Luis Savastano
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew Robert Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Koester SW, Catapano JS, Hartke JN, Rudy RF, Cole TS, Naik A, Winkler EA, Graffeo CS, Srinivasan VM, Jadhav AP, Ducruet AF, Lawton MT, Albuquerque FC. Evaluation of ChatGPT in knowledge of newly evolving neurosurgery: middle meningeal artery embolization for subdural hematoma management. J Neurointerv Surg 2024:jnis-2024-021480. [PMID: 38604767 DOI: 10.1136/jnis-2024-021480] [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] [Accepted: 03/03/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Sagare AP, Bell RD, Zhao Z, Ma Q, Winkler EA, Ramanathan A, Zlokovic BV. Retraction Note: Pericyte loss influences Alzheimer-like neurodegeneration in mice. Nat Commun 2024; 15:2882. [PMID: 38570509 PMCID: PMC10991248 DOI: 10.1038/s41467-024-47285-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Affiliation(s)
- Abhay P Sagare
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, California, 90033, USA
| | - Robert D Bell
- Center of Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, 14642, USA
| | - Zhen Zhao
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, California, 90033, USA
| | - Qingyi Ma
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, California, 90033, USA
| | - Ethan A Winkler
- Center of Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, 14642, USA
| | - Anita Ramanathan
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, California, 90033, USA
| | - Berislav V Zlokovic
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, California, 90033, USA.
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Srinivasan VM, Jubran JH, Stonnington HO, Catapano JS, Scherschinski L, Hendricks BK, Winkler EA, Rudy RF, Nguyen BA, Dabrowski SJ, Jadhav AP, Ducruet AF, Albuquerque FC. Flow diversion for basilar quadrifurcation aneurysms. J Neurointerv Surg 2024; 16:372-378. [PMID: 37253595 DOI: 10.1136/jnis-2022-019238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 05/01/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Flow-diverting devices (FDDs), such as the Pipeline Embolization Device, have been gaining traction for treating challenging posterior circulation aneurysms. Few previous studies have focused on using FDDs to treat aneurysms of the basilar quadrifurcation. METHODS We retrospectively reviewed the use of FDDs to treat patients with basilar quadrifurcation aneurysms. Patients were assessed for aneurysm type, previous aneurysm treatment, technical success, periprocedural complications, and long-term aneurysm occlusion. RESULTS 34 patients were assessed; aneurysms of the basilar apex (n=23) or superior cerebellar artery (SCA) (n=7), or both (n=1), and posterior cerebral artery (PCA) (n=3). The mean (SD) largest aneurysm dimension was 8.7 (6.1) mm (range 1.9-30.8 mm). 14 aneurysms were previously surgically clipped or endovascularly coiled. All aneurysms had a saccular morphology. Complete or near-complete occlusion was achieved in 30 of 34 patients (88%) at final angiographic follow-up, a mean (SD) of 6.6 (5.4) months (range 0-19 months) postoperatively. No patient experienced postoperative symptomatic occlusions of the SCA or PCA; 4 patients developed asymptomatic posterior communicating artery occlusions; 28 patients (82%) experienced no complications; whereas 3 (9%) experienced major complications and 3 (9%) experienced minor complications; and 1 patient died as a result of subarachnoid hemorrhage. CONCLUSION Flow diversion may be a safe and effective option to treat basilar quadrifurcation aneurysms. Previously treated basilar quadrifurcation aneurysms with recurrence or residual lesion may benefit from additional treatment with an FDD. Further prospective studies should be directed toward validating these findings.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jubran H Jubran
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Henry O Stonnington
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Benjamin K Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Brandon A Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Stephen J Dabrowski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Catapano JS, Winkler EA, Rudy RF, Graffeo CS, Koester SW, Srinivasan VM, Cole TS, Baranoski JF, Scherschinski L, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Sex differences in patients with and without high-risk factors associated with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2024; 166:125. [PMID: 38457080 DOI: 10.1007/s00701-024-06021-1] [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: 11/21/2023] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Controversy remains regarding the appropriate screening for intracranial aneurysms or for the treatment of aneurysmal subarachnoid hemorrhage (aSAH) for patients without known high-risk factors for rupture. This study aimed to assess how sex affects both aSAH presentation and outcomes for aSAH treatment. METHOD A retrospective cohort study was conducted of all patients treated at a single institution for an aSAH during a 12-year period (August 1, 2007-July 31, 2019). An analysis of women with and without high-risk factors was performed, including a propensity adjustment for a poor neurologic outcome (modified Rankin Scale [mRS] score > 2) at follow-up. RESULTS Data from 1014 patients were analyzed (69% [n = 703] women). Women were significantly older than men (mean ± SD, 56.6 ± 14.1 years vs 53.4 ± 14.2 years, p < 0.001). A significantly lower percentage of women than men had a history of tobacco use (36.6% [n = 257] vs 46% [n = 143], p = 0.005). A significantly higher percentage of women than men had no high-risk factors for aSAH (10% [n = 70] vs 5% [n = 16], p = 0.01). The percentage of women with an mRS score > 2 at the last follow-up was significantly lower among those without high-risk factors (34%, 24/70) versus those with high-risk factors (53%, 334/633) (p = 0.004). Subsequent propensity-adjusted analysis (adjusted for age, Hunt and Hess grade, and Fisher grade) found no statistically significant difference in the odds of a poor outcome for women with or without high-risk factors for aSAH (OR = 0.7, 95% CI = 0.4-1.2, p = 0.18). CONCLUSIONS A higher percentage of women versus men with aSAH had no known high-risk factors for rupture, supporting more aggressive screening and management of women with unruptured aneurysms.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA.
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Winkler EA, Lawton MT. Transcallosal-Transchoroidal Fissure Approach for Midbrain and Thalamic Cavernous Malformations: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:347-348. [PMID: 37962341 DOI: 10.1227/ons.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 09/15/2023] [Indexed: 11/15/2023] Open
Abstract
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE Cavernous malformations of the third ventricle arise from the medial thalamus and/or periaqueductal midbrain. Microsurgical resection is indicated when the lifetime risk of hemorrhage outweighs the surgical risks. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT superior sagittal sinus, callosomarginal and pericallosal arteries, corpus callosum, foramen of Monro, choroidal fissure, fornix, thalamostriate veins, internal cerebral veins (ICVs), velum interpositum, and thalamus. ESSENTIAL STEPS OF THE PROCEDURE The patient consents to the procedure. With the patient supine, the head is turned 90° and laterally flexed 45°. A bifrontal craniotomy positioned two-thirds anterior and one-third posterior to the coronal suture is performed. The interhemispheric fissure is opened, and a 2-cm corpus callosotomy is performed. Choroid plexus cauterization exposes the choroidal fissure. Sharp division of the taenia fornicea opens the velum interpositum, where the thalamostriate vein can be followed around the venous angle to the ICV. The anterior septal vein may be divided to communicate between the foramen of Monro and choroidal fissure. Dissection between the ICVs opens the velum interpositum into the third ventricle. PITFALLS/AVOIDANCE OF COMPLICATIONS Frontal or deep vein occlusion causes venous infarction, and dissection on the nondominant hemisphere is preferred. Other complications include arterial infarction, fornix injury from choroidal fissure dissection or forniceal retraction, and thalamic or midbrain injury during lesion resection. VARIANTS AND INDICATIONS FOR THEIR USE The contralateral choroidal fissure is used for low-lying medial thalamic and midbrain lesions. The ipsilateral choroidal fissure is used for high-lying or large lesions extending laterally. Transchoroidal approaches are not needed for superior (transcallosal only) or anterior (contralateral transcallosal-contralateral transforaminal) thalamic lesions. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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Koester SW, Rhodenhiser EG, Dabrowski SJ, Scherschinski L, Hartke JN, Naik A, Karahalios K, Nico E, Hackett AM, Ciobanu-Caraus O, Lopez Lopez LB, Winkler EA, Catapano JS, Lawton MT. Optimal PHASES Scoring for Risk Stratification of Surgically Treated Unruptured Aneurysms. World Neurosurg 2024; 183:e447-e453. [PMID: 38154687 DOI: 10.1016/j.wneu.2023.12.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE The PHASES (Population, Hypertension, Age, Size, Earlier subarachnoid hemorrhage, Site) score was developed to facilitate risk stratification for management of unruptured intracranial aneurysms (UIAs). This study aimed to identify the optimal PHASES score cutoff for predicting neurologic outcomes in patients with surgically treated aneurysms. METHODS All patients who underwent microneurosurgical treatment for UIA at a large quaternary center from January 1, 2014, to December 31, 2020, were retrospectively reviewed. Inclusion criteria included a modified Rankin Scale (mRS) score of ≤2 at admission. The primary outcome was 1-year mRS score, with a "poor" neurologic outcome defined as an mRS score >2. RESULTS In total, 375 patients were included in the analysis. The mean (SD) PHASES score for the entire study population was 4.47 (2.67). Of 375 patients, 116 (31%) had a PHASES score ≥6, which was found to maximize prediction of poor neurologic outcome. Patients with PHASES scores ≥6 had significantly higher rates of poor neurologic outcome than patients with PHASES scores <6 at discharge (58 [50%] vs. 90 [35%], P = 0.005) and follow-up (20 [17%] vs. 18 [6.9%], P = 0.002). After adjusting for age, Charlson Comorbidity Index score, nonsaccular aneurysm, and aneurysm size, PHASES score ≥6 remained a significant predictor of poor neurologic outcome at follow-up (odds ratio, 2.75; 95% confidence interval, 1.42-5.36, P = 0.003). CONCLUSIONS In this retrospective analysis, a PHASES score ≥6 was associated with significantly greater proportions of poor outcome, suggesting that awareness of this threshold in PHASES scoring could be useful in risk stratification and UIA management.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Emmajane G Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stephen J Dabrowski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Elsa Nico
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashia M Hackett
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Olga Ciobanu-Caraus
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Laura Beatriz Lopez Lopez
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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10
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Hanalioglu S, Gurses ME, Mignucci-Jiménez G, González-Romo NI, Winkler EA, Preul MC, Lawton MT. Infragalenic triangle as a gateway to dorsal midbrain and posteromedial thalamic lesions: descriptive and quantitative analysis of microsurgical anatomy. J Neurosurg 2024; 140:866-879. [PMID: 37878005 DOI: 10.3171/2023.6.jns222871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/16/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Anatomical triangles provide neurosurgeons with the specificity required to access deep targets, supplementing more general instructions, such as craniotomy and approach. The infragalenic triangle (IGT), bordered by the basal vein of Rosenthal (BVR), precentral cerebellar vein (PCV), and the quadrangular lobule of the cerebellum, is one of a system of anatomical triangles recently introduced to guide dissection to brainstem cavernous malformations and has not been described in detail. This study aimed to quantitatively analyze the anatomical parameters of the IGT and present key nuances for its microsurgical use. METHODS A midline supracerebellar infratentorial (SCIT) approach through a torcular craniotomy was performed on 5 cadaveric heads, and the IGT was identified in each specimen bilaterally. Anatomical measurements were obtained with point coordinates collected using neuronavigation. Three cadaveric brains were used to illustrate relevant brainstem anatomy, and 3D virtual modeling was used to simulate various perspectives of the IGT through different approach angles. In addition, 2 illustrative surgical cases are presented. RESULTS The longest edge of the IGT was the lateral edge formed by the BVR (mean ± SD length 19.1 ± 2.3 mm), and the shortest edge was the medial edge formed by the PCV (13.9 ± 3.6 mm). The mean surface area of the IGT was 110 ± 34.2 mm2 in the standard exposure. Full expansion of all 3 edges (arachnoid dissection, mobilization, and retraction) resulted in a mean area of 226.0 ± 48.8 mm2 and a 2.5-times increase in surface area exposure of deep structures (e.g., brainstem and thalamus). Thus, almost the entire tectal plate and its relevant safe entry zones can be exposed through an expanded unilateral IGT except for the contralateral inferior colliculus, access to which is usually hindered by PCV tributaries. Exposure of bilateral IGTs may be required to resect larger midline lesions to increase surgical maneuverability or to access the contralateral pulvinar. CONCLUSIONS The IGT provides a safe access route to the dorsal midbrain and reliable intraoperative guidance in the deep and complex anatomy of the posterior tentorial incisura. Its potential for expansion makes it a versatile anatomical corridor not only for intrinsic brainstem lesions but also for tumors and vascular malformations of the pineal region, dorsal midbrain, and posteromedial thalamus.
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11
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Koester SW, Rumalla K, Catapano JS, Sorkhi SR, Mahadevan V, Devine GP, Naik A, Winkler EA, Rudy RF, Baranoski JF, Cole TS, Graffeo CS, Srinivasan VM, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Modafinil Therapy and Mental Status Following Aneurysmal Subarachnoid Hemorrhage: Comprehensive Stroke Center Analysis. World Neurosurg 2024:S1878-8750(24)00253-5. [PMID: 38367859 DOI: 10.1016/j.wneu.2024.02.056] [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: 01/29/2024] [Accepted: 02/10/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Disorders of consciousness impair early recovery after aneurysmal subarachnoid hemorrhage (aSAH). Modafinil, a wakefulness-promoting agent, is efficacious for treating fatigue in stroke survivors, but data pertaining to its use in the acute setting are scarce. This study sought to assess the effects of modafinil use on mental status after aSAH. METHODS Modafinil timing and dosage, neurological examination, intubation status, and physical and occupational therapy participation were documented. Repeated-measures paired tests were used for a before-after analysis of modafinil recipients. Propensity score matching (1:1 nearest neighbor) for modafinil and no-modafinil cohorts was used to compare outcomes. RESULTS Modafinil (100-200 mg/day) was administered to 21% (88/422) of aSAH patients for a median (IQR) duration of 10.5 (4-16) days and initiated 14 (7-17) days after aSAH. Improvement in mentation (alertness, orientation, or Glasgow Coma Scale score) was documented in 87.5% (77/88) of modafinil recipients within 72 hours and 86.4% (76/88) at discharge. Of 37 intubated patients, 10 (27%) were extubated within 72 hours after modafinil initiation. Physical and occupational therapy teams noted increased alertness or participation in 47 of 56 modafinil patients (83.9%). After propensity score matching for baseline covariates, the modafinil cohort had a greater mean (SD) change in Glasgow Coma Scale score than the no-modafinil cohort at discharge (2.2 [4.0] vs. -0.2 [6.32], P = 0.003). CONCLUSIONS A temporal relationship with improvement in mental status was noted for most patients administered modafinil after aSAH. These findings, a favorable adverse-effect profile, and implications for goals-of-care decisions favor a low threshold for modafinil initiation in aSAH patients in the acute-care setting.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Samuel R Sorkhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Varun Mahadevan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Gregory P Devine
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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12
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Becerril-Gaitan A, Ding D, Ironside N, Buell TJ, Kansagra AP, Lanzino G, Brinjikji W, Kim L, Levitt MR, Abecassis IJ, Bulters D, Durnford A, Fox WC, Blackburn S, Chen PR, Polifka AJ, Laurent D, Gross B, Hayakawa M, Derdeyn C, Amin-Hanjani S, Alaraj A, van Dijk JMC, Potgieser ARE, Starke RM, Peterson EC, Satomi J, Tada Y, Abla AA, Winkler EA, Du R, Lai PMR, Zipfel GJ, Chen CJ, Sheehan JP. The VEBAS score: a practical scoring system for intracranial dural arteriovenous fistula obliteration. J Neurointerv Surg 2024; 16:272-279. [PMID: 37130751 DOI: 10.1136/jnis-2023-020282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Tools predicting intracranial dural arteriovenous fistulas (dAVFs) treatment outcomes remain scarce. This study aimed to use a multicenter database comprising more than 1000 dAVFs to develop a practical scoring system that predicts treatment outcomes. METHODS Patients with angiographically confirmed dAVFs who underwent treatment within the Consortium for Dural Arteriovenous Fistula Outcomes Research-participating institutions were retrospectively reviewed. A subset comprising 80% of patients was randomly selected as training dataset, and the remaining 20% was used for validation. Univariable predictors of complete dAVF obliteration were entered into a stepwise multivariable regression model. The components of the proposed score (VEBAS) were weighted based on their ORs. Model performance was assessed using receiver operating curves (ROC) and areas under the ROC. RESULTS A total of 880 dAVF patients were included. Venous stenosis (presence vs absence), elderly age (<75 vs ≥75 years), Borden classification (I vs II-III), arterial feeders (single vs multiple), and past cranial surgery (presence vs absence) were independent predictors of obliteration and used to derive the VEBAS score. A significant increase in the likelihood of complete obliteration (OR=1.37 (1.27-1.48)) with each additional point in the overall patient score (range 0-12) was demonstrated. Within the validation dataset, the predicted probability of complete dAVF obliteration increased from 0% with a 0-3 score to 72-89% for patients scoring ≥8. CONCLUSION The VEBAS score is a practical grading system that can guide patient counseling when considering dAVF intervention by predicting the likelihood of treatment success, with higher scores portending a greater likelihood of complete obliteration.
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Affiliation(s)
- Andrea Becerril-Gaitan
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Dale Ding
- Neurosurgery Department, University of Louisville, Louisville, Kentucky, USA
| | - Natasha Ironside
- Neurosurgery Department, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas J Buell
- Neurosurgery Department, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Akash P Kansagra
- Neurosurgery Department, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Louis Kim
- Neurosurgery Department, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Neurosurgery Department, University of Washington, Seattle, Washington, USA
| | | | - Diederik Bulters
- Neurosurgery Department, University of Southampton, Southampton, UK
| | - Andrew Durnford
- Neurosurgery Department, University of Southampton, Southampton, UK
| | - W Christopher Fox
- Neurosurgery Department, Mayo Clinic Jacksonville Campus, Jacksonville, Florida, USA
| | - Spiros Blackburn
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Peng Roc Chen
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Adam J Polifka
- Neurosurgery Department, University of Florida, Gainesville, Florida, USA
| | - Dimitri Laurent
- Neurosurgery Department, University of Florida, Gainesville, Florida, USA
| | - Bradley Gross
- Neurosurgery Department, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Minako Hayakawa
- Radiology and Interventional Radiology Department, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Colin Derdeyn
- Radiology and Interventional Radiology Department, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sepideh Amin-Hanjani
- Neurosurgery Department, University Hospitals/Case Western Reserve University, Cleveland, Ohio, USA
| | - Ali Alaraj
- Neurosurgery Department, University of Illinois Chicago, Chicago, Illinois, USA
| | - J Marc C van Dijk
- Neurosurgery Department, University of Groningen, Groningen, The Netherlands
| | | | - Robert M Starke
- Neurosurgery Department, University of Miami Miller School of Medicine, Miami, Florida, USA
- Radiology Department, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric C Peterson
- Neurosurgery Department, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Junichiro Satomi
- Neurosurgery Department, University of Tokushima, Tokushima, Japan
| | - Yoshiteru Tada
- Neurosurgery Department, University of Tokushima, Tokushima, Japan
| | - Adib A Abla
- Neurosurgery Department, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Neurosurgery Department, University of California San Francisco, San Francisco, California, USA
| | - Rose Du
- Neurosurgery Department, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pui Man Rosalind Lai
- Neurosurgery Department, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory J Zipfel
- Neurosurgery Department, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ching-Jen Chen
- Neurosurgery Department, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason P Sheehan
- Neurosurgery Department, University of Virginia Health System, Charlottesville, Virginia, USA
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13
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Koester SW, Hoglund BK, Ciobanu-Caraus O, Hartke JN, Pacult MA, Winkler EA, Catapano JS, Lawton MT. Hematologic and inflammatory predictors of outcome in patients with brain arteriovenous malformations. World Neurosurg 2024:S1878-8750(24)00197-9. [PMID: 38340796 DOI: 10.1016/j.wneu.2024.02.001] [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: 10/05/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE This study investigated the prognostic value of admission blood counts for AVM outcomes and compared admission blood counts for patients with ruptured and unruptured AVMs. METHODS A retrospective analysis of patients who underwent surgical treatment for a ruptured cerebral AVM between February 1, 2014, and March 31, 2020, was conducted. The primary outcome was poor neurologic outcome, defined as a modified Rankin Scale score ≥2 in patients with unruptured AVMs or >2 in those with ruptured AVMs. RESULTS A total of 235 patients were included; 80 (34%) had ruptured AVMs. At admission, patients with ruptured AVMs had a significantly lower mean (SD) hemoglobin level (12.78 [2.07] g/dL vs 13.71 [1.60] g/dL, p<0.001), hematocrit (38.1% [5.9%] vs 40.7%[4.6%], p<0.001), lymphocyte count (16% [11%] vs 26% [10%], p<0.001), and absolute lymphocyte count (1.41 [0.72]×103/μL vs 1.79 [0.68]×103/μL, p<0.001), and they had a significantly higher mean (SD) white blood cell count (10.4 [3.8] vs 7.6 [2.3]×103/μL, p<0.001), absolute neutrophil count (7.8[3.8]×103/μL vs 5.0[2.5]×103/μL, p<0.001), and neutrophil count (74% [14%] vs 64% [13%], p<0.001). Among patients with unruptured AVMs, white blood cell count ≥6.4×103/μL and absolute neutrophil count ≥3.4×103/μL were associated with a favorable neurologic outcome, whereas hemoglobin level ≥13.4 g/dL was associated with an unfavorable outcome. Among patients with ruptured AVMs, hypertension was associated with a threefold increase in the odds of a poor neurologic outcome. CONCLUSIONS This study found that patients with ruptured and unruptured AVMs present with characteristic profiles of hematologic and inflammatory parameters evident in their admission blood work.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Brandon K Hoglund
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Olga Ciobanu-Caraus
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark A Pacult
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
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14
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Zhao Z, Sagare AP, Ma Q, Halliday MR, Kong P, Kisler K, Winkler EA, Ramanathan A, Kanekiyo T, Bu G, Owens NC, Rege SV, Si G, Ahuja A, Zhu D, Miller CA, Schneider JA, Maeda M, Maeda T, Sugawara T, Ichida JK, Zlokovic BV. Author Correction: Central role for PICALM in amyloid-β blood-brain barrier transcytosis and clearance. Nat Neurosci 2024; 27:208. [PMID: 37985802 DOI: 10.1038/s41593-023-01509-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
- Zhen Zhao
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Abhay P Sagare
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Qingyi Ma
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Matthew R Halliday
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Pan Kong
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kassandra Kisler
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ethan A Winkler
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Anita Ramanathan
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Guojun Bu
- Department of Neuroscience, Mayo Clinic, Jacksonville, Florida, USA
| | - Nelly Chuqui Owens
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sanket V Rege
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gabriel Si
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ashim Ahuja
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Donghui Zhu
- Department of Chemical, Biological and Bioengineering, North Carolina Agricultural and Technical State University, Greensboro, North Carolina, USA
| | - Carol A Miller
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Julie A Schneider
- Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Manami Maeda
- Division of Hematopoietic Stem Cell and Leukemia Research, Beckman Research Institute of the City of Hope, Duarte, California, USA
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takahiro Maeda
- Division of Hematopoietic Stem Cell and Leukemia Research, Beckman Research Institute of the City of Hope, Duarte, California, USA
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tohru Sugawara
- Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, and Department of Stem Cell Biology and Regenerative Medicine, University of Southern California, Los Angeles, California, USA
| | - Justin K Ichida
- Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, and Department of Stem Cell Biology and Regenerative Medicine, University of Southern California, Los Angeles, California, USA
| | - Berislav V Zlokovic
- Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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15
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Catapano JS, Koester SW, Rumalla K, Rangel IC, Stonnington HO, Singh R, Memon A, Kimata AR, Winkler EA, Baranoski JF, Cole TS, Graffeo CS, Srinivasan VM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. A Review of Preoperative Embolization Effectiveness in Patients With Arteriovenous Malformations. Neurosurgery 2024; 94:129-139. [PMID: 37522732 DOI: 10.1227/neu.0000000000002629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 06/01/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Preoperative embolization of arteriovenous malformations (AVMs) remains controversial. This study sought to analyze the cost-effectiveness of preoperative embolization of AVMs. METHODS Patients who underwent AVM resection at a single institute (January 1, 2015-December 31, 2020) were analyzed. Patients with preoperative embolization (embolization cohort) were compared with those without preoperative embolization (nonembolization cohort). Cost-effectiveness score (CE) was the primary outcome of interest and was determined by dividing the total 1-year cost by effectiveness, which was derived from a validated preoperative to last follow-up change in the modified Rankin Scale utility score. A lower CE signifies a more cost-effective treatment strategy. RESULTS Of 188 patients, 88 (47%) underwent preoperative embolization. The mean (SD) total cost was higher in the embolization group than in the nonembolization group ($117 594 [$102 295] vs $84 348 [$82 326]; P < .001). The mean (SD) CE was higher in the embolization cohort ($336 476 [$1 303 842]) than in the nonembolization cohort ($100 237 [$246 255]; P < .001). Among patients with Spetzler-Martin (SM) grade I and II AVMs, the mean (SD) CE was higher in the embolization (n = 40) than in the nonembolization (n = 72) cohort ($164 950 [$348 286] vs $69 021 [$114 938]; P = .004). Among patients with SM grade III AVMs, the mean (SD) CE was lower in the embolization (n = 33) than in the nonembolization (n = 25) cohort ($151 577 [$219 130] vs $189 195 [$446 335]; P = .006). The mean (SD) CE was not significantly different between cohorts among patients with higher-grade AVMs (embolization cohort [n = 3] vs nonembolization cohort [n = 15]: $503 639 [$776 492] vs $2 048 419 [$4 794 758]; P = .49). The mean CE for embolized SM grade III aneurysms was nonsignificant in the ruptured group; however, for the unruptured group, CE was significantly higher in the embolization cohort (n = 26; $160 871 [$240 535]) relative to the nonembolization cohort (n = 15; $108 152 [$166 446]) ( P = .006). CONCLUSION Preoperative embolization was cost-effective for patients with SM grade III AVMs but not for patients with lower-grade AVMs.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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16
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Baranoski JF, Koester SW, Catapano JS, Garcia JH, Pacult MA, Hoglund BK, Dabrowski SJ, Benner D, Winkler EA, Cole TS, Rutledge C, Srinivasan VM, Graffeo CS, Ducruet AF, Albuquerque FC, Lawton MT. Early Treatment of Ruptured Cerebral Arteriovenous Malformations: Analysis of Neurological Outcomes and Health Care Costs. Neurosurgery 2024; 94:212-216. [PMID: 37665224 DOI: 10.1227/neu.0000000000002641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND The timing of surgical resection is controversial when managing ruptured arteriovenous malformations (AVMs) and varies considerably among centers. OBJECTIVE To retrospectively analyze clinical outcomes and hospital costs associated with delayed treatment in a ruptured cerebral AVM patient cohort. METHODS Patients undergoing surgical treatment for a ruptured cerebral AVM (January 1, 2015-December 31, 2020) were retrospectively analyzed. Patients who underwent emergent treatment of a ruptured AVM because of acute herniation were excluded, as were those treated >180 days after rupture. Patients were stratified by the timing of surgical intervention relative to AVM rupture into early (postbleed days 1-20) and delayed (postbleed days 21-180) treatment cohorts. RESULTS Eighty-seven patients were identified. The early treatment cohort comprised 75 (86%) patients. The mean (SD) length of time between AVM rupture and surgical resection was 5 (5) days in the early cohort and 73 (60) days in the delayed cohort ( P < .001). The cohorts did not differ with respect to patient demographics, AVM size, Spetzler-Martin grade, frequency of preoperative embolization, or severity of clinical presentation ( P ≥ .15). Follow-up neurological status was equivalent between the cohorts ( P = .65). The associated mean health care costs were higher in the delayed treatment cohort ($241 597 [$99 363]) than in the early treatment cohort ($133 989 [$110 947]) ( P = .02). After adjustment for length of stay, each day of delayed treatment increased cost by a mean of $2465 (95% CI = $967-$3964, P = .002). CONCLUSION Early treatment of ruptured AVMs was associated with significantly lower health care costs than delayed treatment, but surgical and neurological outcomes were equivalent.
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Affiliation(s)
- Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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Srinivasan VM, Singh R, Karahalios K, Scherschinski L, Essibayi MA, Catapano JS, Winkler EA, Jadhav AP, Ducruet AF, Albuquerque FC. Endovascular Embolization of Basilar Artery Fenestration Aneurysms: A 21-Year Institutional Case Series. Oper Neurosurg (Hagerstown) 2023; 25:521-528. [PMID: 37707424 DOI: 10.1227/ons.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/21/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Basilar artery fenestration is a rare phenomenon sometimes associated with basilar artery fenestration aneurysms (BAFAs). This review investigates the natural history and management outcomes of BAFAs and describes the outcomes of BAFAs treated with embolization. METHODS A single-center database was queried for all cases of endovascular BAFA treatment. Data on complications, clinical and angiographic outcomes, and retreatment rates were collected. RESULTS Seventeen aneurysms across 17 patients were treated. The mean (SD) age was 56 (13) years, and 15 (88%) patients were women. Among 15 aneurysms with data available, 2 arose from the fenestration limbs and 13 from both limbs and the vertebral artery. Of 16 aneurysmal projections available, 7 projected anteriorly, 7 posteriorly, and 2 superiorly. Among 17 patients, balloon-assisted coiling was the most common treatment (n = 10), followed by primary coiling (n = 3), stent-assisted coiling (n = 2), coiling with flow diversion (n = 1), and balloon-assisted coiling and flow diversion (n = 1). Complications noted in 5 patients included hemorrhage, thromboembolism, paresthesias, vasospasm, and transient hemiparesis. Among 16 patients with postoperative results available, 12 showed favorable clinical outcomes, 3 were disabled, and 1 died. The rates of postoperative complete (Raymond-Roy Occlusion Classification 1) and incomplete (Raymond-Roy Occlusion Classification 2 and 3) occlusion among 15 patients with available data were 6 and 9, respectively. CONCLUSION Endovascular management of these rare aneurysms is feasible and safe, with high rates of favorable radiographic and clinical outcomes. This series reflects a general preference toward coiling and stent-assisted coiling, although flow diversion may be considered in select cases.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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18
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Catapano JS, Koester SW, Rhodenhiser EG, Scherschinski L, Karahalios K, Hoglund BK, Winkler EA, Hartke JN, Ciobanu-Caraus O, Naik A, Lopez Lopez LB, Rulney JD, Spetzler RF, Lawton MT. Mortality After Microsurgical Treatment of Unruptured Intracranial Aneurysms in the Modern Era. World Neurosurg 2023; 180:e415-e421. [PMID: 37769845 DOI: 10.1016/j.wneu.2023.09.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The incidence of mortality after treatment of unruptured intracranial aneurysms (UIAs) has been described historically. However, many advances in microsurgical treatment have since emerged, and most available data are outdated. We analyzed the incidence of mortality after microsurgical treatment of patients with UIAs treated in the past decade. METHODS The medical records of all patients with UIAs who underwent elective treatment at our large quaternary center from January 1, 2014, to December 31, 2020, were reviewed retrospectively. We analyzed mortality at discharge and 1-year follow-up as the primary outcome using univariate to multivariable progression with P < 0.20 inclusion. RESULTS During the 7-year study period, 488 patients (mean [SD] age = 58 [12] years) had UIAs treated microsurgically. Of these patients, 61 (12.5%) had a prior subarachnoid hemorrhage. One patient (0.2%) with a dolichoectatic vertebrobasilar aneurysm died while hospitalized, and 7 other patients (8 total; 1.6%) were determined to have died at 1-year follow-up (1 trauma, 2 myocardial infarction, 2 cerebrovascular accident, 1 pulmonary embolism, and 1 subdural hematoma complicated by abscess). On univariate analysis, significant risk factors for mortality at follow-up included diabetes mellitus, preoperative anticoagulant or antiplatelet use, aneurysm calcification, nonsaccular aneurysm, and higher American Society of Anesthesiologists grades (all P < 0.03). On multivariable logistic regression analysis, only nonsaccular aneurysms and higher American Society of Anesthesiologists grades were predictors of mortality. CONCLUSIONS A low mortality rate is associated with recent microsurgical treatment of UIAs. However, nonsaccular aneurysms and higher American Society of Anesthesiologists grades appear to be predictors of mortality.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Emmajane G Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Brandon K Hoglund
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Olga Ciobanu-Caraus
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Laura Beatriz Lopez Lopez
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jarrod D Rulney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Srinivasan VM, Karahalios K, Colasurdo M, Rhodenheiser E, Scherschinski L, Lazaro TT, Cortez G, Gross BA, Kühn AL, Puri A, Winkler EA, Catapano JS, Akamatsu Y, Thomas A, Hanel RA, Wakhloo A, Jadhav AP, Ducruet AF, Albuquerque FC, Kan P. Transvenous Embolization of Dural Arteriovenous Fistulas Through the Galenic (Deep Venous) System: Multicenter Case Series and Meta-Analysis. Oper Neurosurg (Hagerstown) 2023; 25:489-498. [PMID: 37747335 DOI: 10.1227/ons.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 06/13/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Arteriovenous fistulas involving the deep venous system have often been treated with microsurgery or transarterial embolization. Increasing familiarity with transvenous navigation and improved endovascular access systems may facilitate transvenous embolization (TVE) for these rare and challenging lesions. METHODS We performed a retrospective study of neurointerventional databases of 6 high-volume centers. We identified all cases of arteriovenous fistulas with deep transvenous embolizations for arteriovenous fistula. Details regarding demographics, fistula characteristics, treatment considerations, clinical outcomes, and fistula occlusion were obtained and analyzed. The meta-analysis used the same inclusion criteria. RESULTS Seventeen cases of TVE were identified. The most common reasons for TVE included prior treatment failure with microsurgery (n = 2) or transarterial embolization (n = 3) or inaccessible arterial pedicles (n = 4). For patients with full clinical outcome data (n = 14), 2 patients had worsened modified Rankin Scale, 8 patients had no change, and 4 were improved at a median clinical follow-up of 3.5 months. Angiographic obliteration was achieved in 15/17 cases (88.2%). In 1 case, catheterization around a sharp turn in the basal vein of Rosenthal could not be performed. In another case, despite successful TVE, there was residual lesion which was treated 1 year later by microsurgical clipping and excision. CONCLUSION Transvenous approaches for embolization of deep arteriovenous fistulas have become possible with modern endovascular catheter systems and liquid embolics. These lesions can be treated safely and effectively through endovascular approaches, which may spare patients the traversal of deep structures needed for microsurgical approaches to these regions. The outcomes of TVE are comparable with published outcomes of microsurgical interruption.
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Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Marco Colasurdo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston , TX , USA
| | - Emmajane Rhodenheiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Tyler T Lazaro
- Department of Neurosurgery, Baylor College of Medicine, Houston , TX , USA
| | - Gustavo Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville , FL , USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , PA , USA
| | - Anna Luisa Kühn
- Department of Radiology, University of Massachusetts Medical School, Worcester , MA , USA
| | - Ajit Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester , MA , USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , MA , USA
| | - Ajith Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , MA , USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville , FL , USA
| | - Ajay Wakhloo
- Department of Neurointerventional Radiology, Lahey Hospital and Medical Center, Tufts University School of Medicine, Burlington , MA , USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , AZ , USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston , TX , USA
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Catapano JS, Rumalla K, Srinivasan VM, Benner D, Winkler EA, Lawrence PM, Larson Keil K, Lawton MT. A taxonomy for deep cerebral cavernous malformations: subtypes of thalamic lesions. J Neurosurg 2023; 139:1681-1696. [PMID: 37209072 DOI: 10.3171/2023.3.jns23234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/07/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Anatomical taxonomy is a practical tool to successfully guide clinical decision-making for patients with brain arteriovenous malformations and brainstem cavernous malformations (CMs). Deep cerebral CMs are complex, difficult to access, and highly variable in size, shape, and position. The authors propose a novel taxonomic system for deep CMs in the thalamus based on clinical presentation (syndromes) and anatomical location (identified on MRI). METHODS The taxonomic system was developed and applied to an extensive 2-surgeon experience from 2001 through 2019. Deep CMs involving the thalamus were identified. These CMs were subtyped on the basis of the predominant surface presentation identified on preoperative MRI. Six subtypes among 75 thalamic CMs were defined: anterior (7/75, 9%), medial (22/75, 29%), lateral (10/75, 13%), choroidal (9/75, 12%), pulvinar (19/75, 25%), and geniculate (8/75, 11%). Neurological outcomes were assessed using modified Rankin Scale (mRS) scores. A postoperative score ≤ 2 was defined as a favorable outcome and > 2 as a poor outcome. Clinical and surgical characteristics and neurological outcomes were compared among subtypes. RESULTS Seventy-five patients underwent resection of thalamic CMs and had clinical and radiological data available. Their mean age was 40.9 (SD 15.2) years. Each thalamic CM subtype was associated with a recognizable constellation of neurological symptoms. The common symptoms were severe or worsening headaches (30/75, 40%), hemiparesis (27/75, 36%), hemianesthesia (21/75, 28%), blurred vision (14/75, 19%), and hydrocephalus (9/75, 12%). The thalamic CM subtype determined the selection of surgical approach. A single approach was associated with each subtype for most patients. The main exception to this paradigm was that in the surgeons' early experience, pulvinar CMs were resected through a superior parietal lobule-transatrial approach (4/19, 21%), which later evolved to the paramedian supracerebellar-infratentorial approach (12/19, 63%). Relative outcomes implied by mRS scores were unchanged or improved in most patients (61/66, 92%) postoperatively. CONCLUSIONS This study confirms the authors' hypothesis that this taxonomy for thalamic CMs can meaningfully guide the selection of surgical approach and resection strategy. The proposed taxonomy can increase diagnostic acumen at the patient bedside, help identify optimal surgical approaches, enhance the clarity of clinical communications and publications, and improve patient outcomes.
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Catapano JS, Rumalla K, Srinivasan VM, Winkler EA, Benner D, Lawrence PM, Larson Keil K, Lawton MT. A taxonomy for deep cerebral cavernous malformations: subtypes of basal ganglia lesions. J Neurosurg 2023:1-16. [PMID: 37922552 DOI: 10.3171/2023.7.jns231533] [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: 06/30/2023] [Accepted: 07/21/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Anatomical taxonomy is a practical tool that has successfully guided clinical decision-making for patients with brain arteriovenous malformations and brainstem cavernous malformations (CMs). Deep CMs are similarly complex lesions that are difficult to access and highly variable in size, shape, and position. The authors propose a novel taxonomy for deep CMs in the basal ganglia based on clinical presentation (syndromes) and anatomical location. METHODS The taxonomy system was developed and applied to an extensive 2-surgeon experience over 19 years (2001-2019). Lesions involving the basal ganglia were identified and subtyped on the basis of the predominant superficial presentation identified on preoperative MRI. Three subtypes of basal ganglia CMs were defined: caudate (31, 57%), putaminal (16, 30%), and pallidal (7, 13%). Neurological outcomes were assessed using the modified Rankin Scale (mRS). Postoperative mRS scores ≤ 2 were defined as a favorable outcome, and scores > 2 were defined as a poor outcome. Clinical and surgical characteristics and neurological outcomes were compared among subtypes. RESULTS Fifty-four basal ganglia lesions were identified in 54 patients. Each basal ganglia CM subtype was associated with a recognizable constellation of neurological symptoms. The most common symptoms at presentation were severe or worsening headaches (25, 43%), mild hemiparesis (13, 24%), seizures (7, 13%), and dysmetria or ataxia (6, 11%). Patients with caudate CMs were the most likely to present with headaches and constitutional symptoms. Patients with putaminal CMs were the most likely to present with hemibody sensory deficits and dysmetria or ataxia. Patients with pallidal CMs were the most likely to present with mild hemiparesis and visual field deficits. A single surgical approach was preferred (> 80% of cases) for each basal ganglia subtype: caudate (contralateral transcallosal-transventricular, 28/31, 90%), putaminal (transsylvian-anterior transinsular, 13/16, 81%), and pallidal (transsylvian supracarotid-infrafrontal, 7/7, 100%). Most patients with follow-up had stable or improved mRS scores postoperatively (94%, 44/47); mRS scores of > 2 at final follow-up did not differ among the 3 basal ganglia subtypes. CONCLUSIONS The study confirms the authors' hypothesis that this taxonomy for basal ganglia CMs meaningfully guides the selection of surgical approach and resection strategy. Furthermore, the proposed taxonomy can increase the diagnostic acumen at the patient bedside, help identify optimal surgical approaches, enhance the consistency of clinical communications and publications, and improve patient outcomes.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter M Lawrence
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kristen Larson Keil
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Baranoski JF, Catapano JS, Garcia JH, Cole TS, Winkler EA, Rudy RF, Rutledge C, Srinivasan VM, Graffeo CS, Lawton MT, Wanebo JE. Occipital Artery to Middle Cerebral Artery Direct Bypass: A Salvage Revascularization Technique for Ischemic Moyamoya Disease. World Neurosurg 2023; 179:e549-e556. [PMID: 37683920 DOI: 10.1016/j.wneu.2023.08.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVE The main treatment for moyamoya disease (MMD) is revascularization surgery. Most bypasses use the superficial temporal artery (STA) as the donor vessel. However, even if the STA-middle cerebral artery (MCA) bypass is functioning, the affected hemisphere can continue to be symptomatically malperfused. We sought to assess the efficacy of salvage direct revascularization surgery using the occipital artery (OA) as a donor vessel in patients with ischemic MMD who experience continued cerebral malperfusion despite previous successful STA-MCA bypass. METHODS We retrospectively analyzed the cerebrovascular databases of 2 surgeons and described patients in whom the OA was used as the donor vessel for direct revascularization. RESULTS Seven patients were included (5 women). Previous STA-MCA bypasses were direct (n = 2), indirect (n = 3), or combined/multiple (n = 2). The mean (SD) interval between STA-MCA and OA-MCA procedures was 29.2 (13.1) months. Despite an intact STA-MCA bypass in all 7 cases, all 7 patients had recurrent symptoms and demonstrated residual impaired cerebral perfusion. All 7 patients underwent successful OA-MCA direct revascularization. Follow-up perfusion imaging was obtained for 6 of 7 patients. All 6 of these patients demonstrated improved cerebral blood flow to the revascularized hemispheres. All 7 patients demonstrated clinical improvement. CONCLUSIONS Patients with ischemic MMD who have continued symptoms and cerebral malperfusion despite previous successful STA-MCA bypass present a challenging clinical scenario. Our series highlights the potential utility of the OA-MCA direct bypass as a salvage therapy for these patients.
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Affiliation(s)
- Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joseph H Garcia
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John E Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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23
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Scherschinski L, Han C, Kim YH, Winkler EA, Catapano JS, Schriber TD, Vajkoczy P, Lawton MT, Oh SP. Localized conditional induction of brain arteriovenous malformations in a mouse model of hereditary hemorrhagic telangiectasia. Angiogenesis 2023; 26:493-503. [PMID: 37219736 PMCID: PMC10542309 DOI: 10.1007/s10456-023-09881-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/30/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Longitudinal mouse models of brain arteriovenous malformations (AVMs) are crucial for developing novel therapeutics and pathobiological mechanism discovery underlying brain AVM progression and rupture. The sustainability of existing mouse models is limited by ubiquitous Cre activation, which is associated with lethal hemorrhages resulting from AVM formation in visceral organs. To overcome this condition, we developed a novel experimental mouse model of hereditary hemorrhagic telangiectasia (HHT) with CreER-mediated specific, localized induction of brain AVMs. METHODS Hydroxytamoxifen (4-OHT) was stereotactically delivered into the striatum, parietal cortex, or cerebellum of R26CreER; Alk12f/2f (Alk1-iKO) littermates. Mice were evaluated for vascular malformations with latex dye perfusion and 3D time-of-flight magnetic resonance angiography (MRA). Immunofluorescence and Prussian blue staining were performed for vascular lesion characterization. RESULTS Our model produced two types of brain vascular malformations, including nidal AVMs (88%, 38/43) and arteriovenous fistulas (12%, 5/43), with an overall frequency of 73% (43/59). By performing stereotaxic injection of 4-OHT targeting different brain regions, Alk1-iKO mice developed vascular malformations in the striatum (73%, 22/30), in the parietal cortex (76%, 13/17), and in the cerebellum (67%, 8/12). Identical application of the stereotaxic injection protocol in reporter mice confirmed localized Cre activity near the injection site. The 4-week mortality was 3% (2/61). Seven mice were studied longitudinally for a mean (SD; range) duration of 7.2 (3; 2.3-9.5) months and demonstrated nidal stability on sequential MRA. The brain AVMs displayed microhemorrhages and diffuse immune cell invasion. CONCLUSIONS We present the first HHT mouse model of brain AVMs that produces localized AVMs in the brain. The mouse lesions closely resemble the human lesions for complex nidal angioarchitecture, arteriovenous shunts, microhemorrhages, and inflammation. The model's longitudinal robustness is a powerful discovery resource to advance our pathomechanistic understanding of brain AVMs and identify novel therapeutic targets.
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Affiliation(s)
- Lea Scherschinski
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Chul Han
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Yong Hwan Kim
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Ethan A Winkler
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Joshua S Catapano
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Tyler D Schriber
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Michael T Lawton
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - S Paul Oh
- Department of Translational Neuroscience, Barrow Aneurysm and AVM Research Center, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA.
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Bell RD, Winkler EA, Sagare AP, Singh I, LaRue B, Deane R, Zlokovic BV. Pericytes Control Key Neurovascular Functions and Neuronal Phenotype in the Adult Brain and during Brain Aging. Neuron 2023; 111:3131-3132. [PMID: 37797582 PMCID: PMC10765950 DOI: 10.1016/j.neuron.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
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Sagare AP, Bell RD, Zhao Z, Ma Q, Winkler EA, Ramanathan A, Zlokovic BV. Author Correction: Pericyte loss influences Alzheimer-like neurodegeneration in mice. Nat Commun 2023; 14:6151. [PMID: 37788984 PMCID: PMC10547792 DOI: 10.1038/s41467-023-40730-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Affiliation(s)
- Abhay P Sagare
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, USA
| | - Robert D Bell
- Center of Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, NY, USA
| | - Zhen Zhao
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, USA
| | - Qingyi Ma
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, USA
| | - Ethan A Winkler
- Center of Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, NY, USA
| | - Anita Ramanathan
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, USA
| | - Berislav V Zlokovic
- Department of Physiology and Biophysics, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, USA.
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Catapano JS, Srinivasan VM, De La Peña NM, Singh R, Cole TS, Wilkinson DA, Baranoski JF, Rutledge C, Pacult MA, Winkler EA, Jadhav AP, Ducruet AF, Albuquerque FC. Direct puncture of the superior ophthalmic vein for carotid cavernous fistulas: a 21-year experience. J Neurointerv Surg 2023; 15:948-952. [PMID: 36261279 DOI: 10.1136/jnis-2022-019135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Direct puncture of the superior ophthalmic vein (SOV) is an alternative approach to traversing the inferior petrosal sinus for embolization of carotid cavernous fistulas (CCFs). OBJECTIVE To analyze direct SOV puncture for the treatment of CCFs and review the literature. METHODS All patients at a single center, treated for a CCF with direct SOV cannulation between January 1, 2000, and December 31, 2020, were retrospectively analyzed. An additional review of the literature for all case series for direct puncture of the SOV for treatment of CCF was performed. RESULTS During the 21-year study period, direct cannulation of the SOV for treatment of a CCF was attempted for 19 patients, with the procedure aborted for one patient because of an inability to navigate the wire into the distal aspect of the cavernous sinus. In 18 patients with direct SOV CCF treatment, 1 experienced a minor complication with an asymptomatic postoperative hemorrhage. Angiographic cure and improvement of symptoms were achieved in 17 patients with a mean (SD) follow-up of 6 (5.2) months. In the review of the literature, an additional 45 patients were reported to have direct cannulation of the SOV for CCF treatment, with angiographic cure in 43 (96%) and decreased objective visual acuity in 1 (2%). CONCLUSION Direct SOV cannulation to treat CCFs is safe and effective. Although it is typically used after other endovascular approaches have failed, SOV access for CCF treatment may be warranted as a first-line treatment for select patients.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nicole M De La Peña
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Rohin Singh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark A Pacult
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Scherschinski L, Winkler EA, Furey CG, Gooldy TC, Catapano JS, Lawton MT. Thoracic laminectomy and midline myelotomy for resection of a spinal ependymoma. Neurosurg Focus Video 2023; 9:V15. [PMID: 37854657 PMCID: PMC10580746 DOI: 10.3171/2023.6.focvid2386] [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] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/21/2023] [Indexed: 10/20/2023]
Abstract
Spinal cord ependymomas comprise 25% of all intramedullary tumors and are typically treated with resection. A man in his mid-60s presented with imbalance and sensory deficits in both lower extremities, and a spinal thoracic intramedullary ependymoma spanning the levels T2 and T3 was diagnosed. After a laminectomy was performed, the tumor was microsurgically resected, and the patient demonstrated no neurological deficits on postoperative examination. Subsequent MRI showed complete resection of the tumor. This video showcases a thoracic intramedullary ependymoma resected using careful microdissection into the median raphe as a safe entry zone to preserve neurological function.
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Affiliation(s)
- Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Charuta G Furey
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Timothy C Gooldy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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28
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Wang L, Pang K, Zhou L, Cebrián-Silla A, González-Granero S, Wang S, Bi Q, White ML, Ho B, Li J, Li T, Perez Y, Huang EJ, Winkler EA, Paredes MF, Kovner R, Sestan N, Pollen AA, Liu P, Li J, Piao X, García-Verdugo JM, Alvarez-Buylla A, Liu Z, Kriegstein AR. A cross-species proteomic map reveals neoteny of human synapse development. Nature 2023; 622:112-119. [PMID: 37704727 PMCID: PMC10576238 DOI: 10.1038/s41586-023-06542-2] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 08/15/2023] [Indexed: 09/15/2023]
Abstract
The molecular mechanisms and evolutionary changes accompanying synapse development are still poorly understood1,2. Here we generate a cross-species proteomic map of synapse development in the human, macaque and mouse neocortex. By tracking the changes of more than 1,000 postsynaptic density (PSD) proteins from midgestation to young adulthood, we find that PSD maturation in humans separates into three major phases that are dominated by distinct pathways. Cross-species comparisons reveal that human PSDs mature about two to three times slower than those of other species and contain higher levels of Rho guanine nucleotide exchange factors (RhoGEFs) in the perinatal period. Enhancement of RhoGEF signalling in human neurons delays morphological maturation of dendritic spines and functional maturation of synapses, potentially contributing to the neotenic traits of human brain development. In addition, PSD proteins can be divided into four modules that exert stage- and cell-type-specific functions, possibly explaining their differential associations with cognitive functions and diseases. Our proteomic map of synapse development provides a blueprint for studying the molecular basis and evolutionary changes of synapse maturation.
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Affiliation(s)
- Li Wang
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA.
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
| | - Kaifang Pang
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Li Zhou
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Arantxa Cebrián-Silla
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Susana González-Granero
- Laboratory of Comparative Neurobiology, Cavanilles Institute of Biodiversity and Evolutionary Biology, University of Valencia and CIBERNED, Valencia, Spain
| | - Shaohui Wang
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Qiuli Bi
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Matthew L White
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Brandon Ho
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Jiani Li
- Gilead Sciences, Foster City, CA, USA
| | - Tao Li
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
| | - Yonatan Perez
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Eric J Huang
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Mercedes F Paredes
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Rothem Kovner
- Department of Neuroscience, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Nenad Sestan
- Department of Neuroscience, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Alex A Pollen
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Pengyuan Liu
- Department of Chemistry, University of Massachusetts Lowell, Lowell, MA, USA
| | - Jingjing Li
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Xianhua Piao
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- Newborn Brain Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - José Manuel García-Verdugo
- Laboratory of Comparative Neurobiology, Cavanilles Institute of Biodiversity and Evolutionary Biology, University of Valencia and CIBERNED, Valencia, Spain
| | - Arturo Alvarez-Buylla
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Zhandong Liu
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Arnold R Kriegstein
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA.
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
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Garcia JH, Carrete L, Rutledge WC, Raygor KP, Winkler EA, Pereira MP, Nelson J, Kim H, Cooke DL, Hetts SW, Lawton MT, Abla AA. Factors Associated with Unfavorable Clinical Presentations in Patients with Ruptured BrainArteriovenous Malformations. World Neurosurg 2023; 178:e72-e78. [PMID: 37422187 DOI: 10.1016/j.wneu.2023.06.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Rupture of brain arteriovenous malformations (bAVMs) carries potentially devastating consequences. For patients presenting with ruptured bAVMs, several clinical grading systems have been shown to predict long-term patient morbidity and may be taken into consideration when making clinical decisions. Unfortunately, use of these scoring systems is typically limited to their prognostic value and offer little to patients in therapeutic benefit. Tools are needed not only to predict prognosis for patients experiencing ruptured bAVMs but to gain insight into what characteristics predispose patients to poor long-term outcomes before they rupture. Our objective was to find clinical, morphologic, and demographic variables that correlate with unfavorable clinical grades on presentation in patients with ruptured bAVMs. METHODS We retrospectively reviewed a cohort of patients with ruptured bAVMs. Linear regression models were used to test whether Glasgow Coma Scale (GCS) and Hunt-Hess scores on presentation(outcomes) were associated with patient and arteriovenous malformation (AVM) characteristics (predictors) individually. RESULTS GCS and Hunt-Hess were assessed following bAVM rupture for 121 brain cases. The median age at rupture was 28.5 years, and 62 (51%) were female. Smoking history was associated with worse GCS; current and past smokers had GCS scores 1.33 points lower on average than nonsmokers (95% confidence interval [CI] -2.59 to -0.07, P = 0.039) and had worse Hunt-Hess scores (0.42, 95% CI 0.07-0.77, P = 0.019). Associated aneurysms were associated with worse GCS (-1.60, 95% CI -3.16 to -0.05, P = 0.043) and trended towards worse Hunt-Hess scores (0.42 points, 95% CI -0.01 to 0.86, P = 0.057). CONCLUSIONS Patient smoking status and presence of an AVM associated aneurysm were shown to have modest correlations with unfavorable clinical grades (Hunt-Hess, GCS) on presentation, with unfavorable clinical grades being associated with long-term patient prognosis following bAVM rupture. Further investigation using AVM-specific grading scales and external data are needed to determine the utility of these and other variables in clinical practice for patients with bAVM.
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Affiliation(s)
- Joseph H Garcia
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Luis Carrete
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matheus Prado Pereira
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
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30
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Catapano JS, Winkler EA, Srinivasan VM, Dishion EL, Rutledge C, Baranoski JF, Cole TS, Rudy RF, Rumalla K, Zomaya MP, Jadhav AP, Ducruet AF, Albuquerque FC. Retained radial catheters associated with variant radial anatomy in neurointerventional procedures. J Neurointerv Surg 2023; 15:858-863. [PMID: 36190952 DOI: 10.1136/jnis-2022-019004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/15/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Transradial artery access (TRA) for neurointerventional procedures is gaining widespread acceptance. However, complications that were previously rare may arise as TRA procedures increase. Here we report a series of retained catheter cases with a literature review. METHODS All patients who underwent a neurointerventional procedure during a 23-month period at a single institution were retrospectively reviewed for a retained catheter in TRA cases. In cases of retained catheters, imaging was reviewed for anatomical variances in the radial artery, and clinical and demographic case details were analyzed. RESULTS A total of 1386 nondiagnostic neurointerventional procedures were performed during the study period, 631 (46%) initially via TRA. The 631 TRA cases were performed for aneurysm embolization (n=221, 35%), mechanical thrombectomy (n=116, 18%), carotid stent/angioplasty (n=40, 6%), arteriovenous malformation embolization (n=38, 6%), and other reasons (n=216, 34%). Thirty-nine (6%) TRA procedures crossed over to femoral access, most commonly because the artery of interest could not be catheterized (26/39, 67%). A retained catheter was identified in five cases (1%), and one (0.2%) patient had an entrapped catheter that was recovered. All six patients with a retained or entrapped catheter had aberrant radial anatomy. CONCLUSION Retained catheters for neurointerventional procedures performed via TRA are rare. However, this complication may be associated with variant radial anatomy. With the increased use of TRA for neurointerventional procedures, awareness of anatomical abnormalities that may lead to a retained catheter is necessary. We propose a simple protocol to avoid catheter entrapment, including in emergent situations such as TRA for stroke thrombectomy.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Evan L Dishion
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Martin P Zomaya
- The University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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31
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Graffeo CS, Srinivasan VM, Winkler EA, Lawton MT. Double-Interposition Bypass: Technical Case Report of a Novel Intraoperative Bypass Salvage Technique. Oper Neurosurg (Hagerstown) 2023; 25:e177-e182. [PMID: 37581431 DOI: 10.1227/ons.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/01/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Complex cerebrovascular bypass operations may confer an increased risk of intraoperative complications, such as graft thrombosis. Novel techniques are needed to optimize the management of these challenging cases. CLINICAL PRESENTATION A woman in her late 20s was incidentally diagnosed with a 1.5-cm basilar apex aneurysm, which grew to 3.5 cm over 2 years of active surveillance. Definitive treatment was then recommended with flow reversal and Hunterian ligation of the basilar trunk planned as a radial artery graft (RAG) bypass: M2 (S-Ec) RAG (E-Sc*) P2. Intraoperative graft thrombosis prompted multiple attempted salvage maneuvers; however, complete excision and repeat anastomosis were ultimately required. The procedure was completed using a novel double-interposition technique, with ligation of the index RAG approximately 1 cm proximal to the distal anastomosis (final bypass: M2 [S-Ec*] RAG [E-Ec*] RAG' [E-Sc] P2). These technical modifications yielded a less deep recipient site for the repeat bypass and an end-to-end anastomosis rather than an end-to-side anastomosis, collectively facilitating a more efficient and facile salvage. The patient recovered well from surgery, and flow reversal was successfully achieved within the aneurysm. CONCLUSION Despite the increased risk of intraoperative thrombosis with complex cerebrovascular bypass operations, facility with salvage techniques can lead to technically and clinically excellent outcomes. We report the successful use of a novel fourth-generation double-interposition bypass that shortens the working distance and uses a more favorable anastomosis technique. This bypass may facilitate safe and efficient microsurgery in patients who require complete revision of an intracranial-intracranial construct.
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Affiliation(s)
- Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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32
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Scherschinski L, Karahalios K, Srinivasan VM, Catapano JS, Jubran JH, Benner D, Rumalla K, Winkler EA, Graffeo CS, Lawton MT. Cost-Effectiveness of Forgoing Postoperative Catheter Angiography After Microsurgical Occlusion of Spinal Dorsal Intradural Arteriovenous Fistulas. World Neurosurg 2023; 176:e125-e134. [PMID: 37172715 DOI: 10.1016/j.wneu.2023.05.017] [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: 01/31/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Spinal dorsal intradural arteriovenous fistulas (DI-AVFs) represent 70% of all spinal vascular lesions. Diagnostic tools include pre- and postoperative digital subtraction angiography (DSA) and intraoperative indocyanine green videoangiography (ICG-VA). ICG-VA has a high predictive value in DI-AVF occlusion, but postoperative DSA remains a core component of postoperative protocols. The aim of this study was to evaluate the potential cost reduction of forgoing postoperative DSA after microsurgical occlusion of DI-AVFs. METHODS Cohort-based cost effectiveness study of all DI-AVFs within a prospective, single-center cerebrovascular registry from January 1, 2017, to December 31, 2021. RESULTS Complete data including intraoperative ICG-VA and costs were available for 11 patients. Mean (SD) age was 61.5 (14.8) years. All DI-AVFs were treated with microsurgical clip ligation of the draining vein. ICG-VA showed complete obliteration in all patients. Postoperative DSA was performed for 6 patients and confirmed complete obliteration. Mean (SD) cost contributions for DSA and ICG-VA were $11,418 ($4,861) and $12 ($2), respectively. Mean (SD) total costs were $63,543 ($15,742) and $53,369 ($27,609) for patients who did and did not undergo postoperative DSA, respectively. Comorbidity status was identified as the main driver of total cost (P = 0.01 after adjusting for postoperative DSA status). CONCLUSIONS ICG-VA is a powerful diagnostic tool in demonstrating microsurgical cure of DI-AVFs, with a negative predictive value of 100%. Eliminating postoperative DSA in patients with confirmed DI-AVF obliteration on ICG-VA may yield substantial cost savings, in addition to sparing patients the risk and inconvenience of a potentially unnecessary invasive procedure.
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Affiliation(s)
- Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jubran H Jubran
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Baranoski JF, Catapano JS, Rutledge C, Cole TS, Majmundar N, Winkler EA, Srinivasan VM, Jadhav AP, Ducruet AF, Albuquerque FC. Endovascular Treatment of Cerebrovascular Lesions Using Nickel- or Nitinol-Containing Devices in Patients with Nickel Allergies. AJNR Am J Neuroradiol 2023; 44:939-942. [PMID: 37474263 PMCID: PMC10411833 DOI: 10.3174/ajnr.a7936] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 06/11/2023] [Indexed: 07/22/2023]
Abstract
Nickel is used in many cerebral endovascular treatment devices. However, nickel hypersensitivity is the most common metal allergy, and the relative risk of treatment in these patients is unknown. This retrospective analysis identified patients with nickel or metal allergies who underwent cerebral endovascular treatment with nickel-containing devices. Seven patients with nickel and/or other metal allergies underwent treatment with 9 nickel-containing devices. None experienced periprocedural complications. No patient received treatment with corticosteroids or antihistamines. At a mean clinical follow-up for all patients of 22.8 months (range, 10.5-38.0 months), no patients had symptoms attributable to nickel allergic reactions. The mean radiographic follow-up for all patients at 18.4 months (range, 2.5-37.5 months) showed successful treatment of the targeted vascular pathologies, with no evidence of in-stent stenosis or other allergic or hypersensitivity sequelae. The treatment of cerebrovascular lesions with a nickel-containing device resulted in no adverse outcomes among these patients and was safe and effective.
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Affiliation(s)
- J F Baranoski
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - J S Catapano
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - C Rutledge
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - T S Cole
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - N Majmundar
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - E A Winkler
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - V M Srinivasan
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - A P Jadhav
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - A F Ducruet
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - F C Albuquerque
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Catapano JS, Koester SW, Bond KM, Srinivasan VM, Farhadi DS, Rumalla K, Cole TS, Baranoski JF, Winkler EA, Graffeo CS, Muñoz-Casabella A, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT, Jha RM. Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage Receiving Sulfonylureas: A Propensity-Adjusted Analysis. World Neurosurg 2023; 176:e400-e407. [PMID: 37236313 DOI: 10.1016/j.wneu.2023.05.073] [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: 02/21/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased blood-brain barrier permeability, disrupted tight junctions, and increased cerebral edema. Sulfonylureas are associated with reduced tight-junction disturbance and edema and improved functional outcome in aSAH animal models, but human data are scant. We analyzed neurological outcomes in aSAH patients prescribed sulfonylureas for diabetes mellitus. METHODS Patients treated for aSAH at a single institution (August 1, 2007-July 31, 2019) were retrospectively reviewed. Patients with diabetes were grouped by presence or absence of sulfonylurea therapy at hospital admission. The primary outcome was favorable neurologic status at last follow-up (modified Rankin Scale score ≤2). Variables with an unadjusted P-value of <0.20 were included in a propensity-adjusted multivariable logistic regression analysis to identify predictors of favorable outcomes. RESULTS Of 1013 aSAH patients analyzed, 129 (13%) had diabetes at admission, and 16 of these (12%) were receiving sulfonylureas. Fewer diabetic than nondiabetic patients had favorable outcomes (40% [52/129] vs. 51% [453/884], P = 0.03). Among diabetic patients, sulfonylurea use (OR 3.90, 95% CI 1.05-15.9, P = 0.046), Charlson Comorbidity Index <4 (OR 3.66, 95% CI 1.24-12.1, P = 0.02), and absence of delayed cerebral infarction (OR 4.09, 95% CI 1.20-15.5, P = 0.03) were associated with favorable outcomes in the multivariable analysis. CONCLUSIONS Diabetes was strongly associated with unfavorable neurologic outcomes. An unfavorable outcome in this cohort was mitigated by sulfonylureas, supporting some preclinical evidence of a possible neuroprotective role for these medications in aSAH. These results warrant further study on dose, timing, and duration of administration in humans.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kamila M Bond
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Amanda Muñoz-Casabella
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Naik A, Adeleye O, Koester SW, Winkler EA, Hartke JN, Karahalios K, Mihaljevic S, Rani A, Raikwar S, Rulney JD, Desai SM, Scherschinski L, Ducruet AF, Albuquerque FC, Lawton MT, Catapano JS, Jadhav AP, Jha RM. Cerebrospinal Fluid Biomarkers for Diagnosis and the Prognostication of Acute Ischemic Stroke: A Systematic Review. Int J Mol Sci 2023; 24:10902. [PMID: 37446092 DOI: 10.3390/ijms241310902] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Despite the high incidence and burden of stroke, biological biomarkers are not used routinely in clinical practice to diagnose, determine progression, or prognosticate outcomes of acute ischemic stroke (AIS). Because of its direct interface with neural tissue, cerebrospinal fluid (CSF) is a potentially valuable source for biomarker development. This systematic review was conducted using three databases. All trials investigating clinical and preclinical models for CSF biomarkers for AIS diagnosis, prognostication, and severity grading were included, yielding 22 human trials and five animal studies for analysis. In total, 21 biomarkers and other multiomic proteomic markers were identified. S100B, inflammatory markers (including tumor necrosis factor-alpha and interleukin 6), and free fatty acids were the most frequently studied biomarkers. The review showed that CSF is an effective medium for biomarker acquisition for AIS. Although CSF is not routinely clinically obtained, a potential benefit of CSF studies is identifying valuable biomarkers from the pathophysiologic microenvironment that ultimately inform optimization of targeted low-abundance assays from peripheral biofluid samples (e.g., plasma). Several important catabolic and anabolic markers can serve as effective measures of diagnosis, etiology identification, prognostication, and severity grading. Trials with large cohorts studying the efficacy of biomarkers in altering clinical management are still needed.
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Affiliation(s)
- Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Champaign, IL 61820, USA
| | - Olufunmilola Adeleye
- Mayo Clinic Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Sandra Mihaljevic
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Anupama Rani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Sudhanshu Raikwar
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Jarrod D Rulney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Shashvat M Desai
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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Catapano JS, Koester SW, Parikh PP, Rumalla K, Stonnington HO, Singh R, Winkler EA, Graffeo CS, Rudy RF, Srinivasan VM, Jha RM, Jadhav AP, Albuquerque FC, Lawton MT, Ducruet AF. Association between external ventricular drain removal or replacement and prophylactic anticoagulation in patients with aneurysmal subarachnoid hemorrhage: a propensity-adjusted analysis. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05651-1. [PMID: 37301800 DOI: 10.1007/s00701-023-05651-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Withholding prophylactic anticoagulation from patients with aneurysmal subarachnoid hemorrhage (aSAH) before external ventricular drain (EVD) removal or replacement remains controversial. This study analyzed whether prophylactic anticoagulation was associated with hemorrhagic complications related to EVD removal. METHOD All aSAH patients treated from January 1, 2014, to July 31, 2019, with an EVD placed were retrospectively analyzed. Patients were compared based on the number of prophylactic anticoagulant doses withheld for EVD removal (> 1 vs. ≤ 1). The primary outcome analyzed was deep venous thrombosis (DVT) or pulmonary embolism (PE) after EVD removal. A propensity-adjusted logistic-regression analysis was performed for confounding variables. RESULTS A total of 271 patients were analyzed. For EVD removal, > 1 dose was withheld from 116 (42.8%) patients. Six (2.2%) patients had a hemorrhage associated with EVD removal, and 17 (6.3%) patients had a DVT or PE. No significant difference in EVD-related hemorrhage after EVD removal was found between patients with > 1 versus ≤ 1 dose of anticoagulant withheld (4 of 116 [3.5%] vs. 2 of 155 [1.3%]; p = 0.41) or between those with no doses withheld compared to ≥ 1 dose withheld (1 of 100 [1.0%] vs. 5 of 171 [2.9%]; p = 0.32). After adjustment, withholding > 1 dose of anticoagulant versus ≤ 1 dose was associated with the occurrence of DVT or PE (OR 4.8; 95% CI, 1.5-15.7; p = 0.009). CONCLUSIONS In aSAH patients with EVDs, withholding > 1 dose of prophylactic anticoagulant for EVD removal was associated with an increased risk of DVT or PE and no reduction in catheter removal-associated hemorrhage.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Stefan W Koester
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Parth P Parikh
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Henry O Stonnington
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Rohin Singh
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Ethan A Winkler
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Robert F Rudy
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Ruchira M Jha
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA.
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Graffeo CS, Scherschinski L, Benner D, Devia DA, Thomas G, Koester SW, Catapano JS, Winkler EA, Srinivasan VM, Lawton MT. Approach Selection Strategies for Repeat Resection of Brain Cavernous Malformations: Cohort Study. Oper Neurosurg (Hagerstown) 2023; 24:590-601. [PMID: 36867084 DOI: 10.1227/ons.0000000000000668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/19/2022] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Neurosurgical management of cerebral cavernous malformations (CMs) often benefits from using skull base approaches. Although many CMs are cured by resection, residual or recurrent disease may require repeat resection. OBJECTIVE To review approach selection strategies for reoperation of CMs to aid decision-making for repeat procedures. METHODS In this retrospective cohort study, a prospectively maintained single-surgeon registry was queried for patients with CMs who underwent repeat resection from January 1, 1997, to April 30, 2021. RESULTS Of 854 consecutive patients, 68 (8%) underwent 2 operations; 40 had accessible data on both. In most reoperations (33/40 [83%]), the index approach was repeated. In most reoperations using the index approach (29/33 [88%]), that approach was deemed ideal (no equivalent or superior alternative), whereas in some (4/33 [12%]), the alternative approach was deemed unsafe because of conformation of the tract. Among patients with reoperations using an alternative approach (7/40 [18%]), 2 with index transsylvian approaches underwent bifrontal transcallosal approaches, 2 with index presigmoid approaches underwent extended retrosigmoid revisions, and 3 with index supracerebellar-infratentorial approaches underwent alternative supracerebellar-infratentorial trajectory revisions. Among patients with reoperations with an alternative approach considered or selected (11/40 [28%]), 8 of 11 patients had a different surgeon for the index resection than for the repeat resection. The extended retrosigmoid-based approaches were used most often for reoperations. CONCLUSION Repeat resection of recurrent or residual CMs is a challenging neurosurgical niche at the intersection of cerebrovascular and skull base disciplines. Suboptimal index approaches may limit surgical options for repeat resection.
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Affiliation(s)
- Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Bell RD, Winkler EA, Singh I, Sagare AP, Deane R, Wu Z, Holtzman DM, Betsholtz C, Armulik A, Sallstrom J, Berk BC, Zlokovic BV. Author Correction: Apolipoprotein E controls cerebrovascular integrity via cyclophilin A. Nature 2023; 617:E12. [PMID: 37142785 DOI: 10.1038/s41586-023-06118-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Robert D Bell
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Ethan A Winkler
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA
| | - Itender Singh
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA
| | - Abhay P Sagare
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA
| | - Rashid Deane
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA
| | - Zhenhua Wu
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA
| | - David M Holtzman
- Department of Neurology, Hope Center for Neurological Disorders, Knight Alzheimer's Disease Research Center, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Christer Betsholtz
- Division of Vascular Biology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Annika Armulik
- Division of Vascular Biology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
- Institute of Neuropathology, University Hospital Zürich, CH-8091, Zürich, Switzerland
| | - Jan Sallstrom
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA
| | - Bradford C Berk
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Berislav V Zlokovic
- Center for Neurodegenerative and Vascular Brain Disorders, University of Rochester Medical Center, Rochester, New York, USA.
- Center for Neurodegeneration and Regeneration, Zilkha Neurogenetic Institute and Department of Physiology and Biophysics, University of Southern California, Keck School of Medicine, Los Angeles, California, USA.
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Hackett AM, Koester SW, Rhodenhiser EG, Scherschinski L, Rulney JD, Naik A, Nico E, Eberle AT, Hartke JN, Fox BM, Winkler EA, Catapano JS, Lawton MT. A comprehensive assessment of self-reported symptoms among patients harboring an unruptured intracranial aneurysm. Front Surg 2023; 10:1148274. [PMID: 37151867 PMCID: PMC10160638 DOI: 10.3389/fsurg.2023.1148274] [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: 01/19/2023] [Accepted: 03/29/2023] [Indexed: 05/09/2023] Open
Abstract
Background Approximately 3.2%-6% of the general population harbor an unruptured intracranial aneurysm (UIA). Ruptured aneurysms represent a significant healthcare burden, and preventing rupture relies on early detection and treatment. Most patients with UIAs are asymptomatic, and many of the symptoms associated with UIAs are nonspecific, which makes diagnosis challenging. This study explored symptoms associated with UIAs, the rate of resolution of such symptoms after microsurgical treatment, and the likely pathophysiology. Methods A retrospective review of patients with UIAs who underwent microsurgical treatment from January 1, 2014, to December 31, 2020, at a single quaternary center were identified. Analyses included the prevalence of nonspecific symptoms upon clinical presentation and postoperative follow-up; comparisons of symptomatology by aneurysmal location; and comparisons of patient demographics, aneurysmal characteristics, and poor neurologic outcome at postoperative follow-up stratified by symptomatic versus asymptomatic presentation. Results The analysis included 454 patients; 350 (77%) were symptomatic. The most common presenting symptom among all 454 patients was headache (n = 211 [46%]), followed by vertigo (n = 94 [21%]), cognitive disturbance (n = 68[15%]), and visual disturbance (n = 64 [14%]). Among 328 patients assessed for postoperative symptoms, 258 (79%) experienced symptom resolution or improvement. Conclusion This cohort demonstrates that the clinical presentation of patients with UIAs can be associated with vague and nonspecific symptoms. Early detection is crucial to prevent aneurysmal subarachnoid hemorrhage. It is imperative that physicians not rule out aneurysms in the setting of nonspecific neurologic symptoms.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
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Walker E, Srienc AI, Guniganti RR, Brinjikji W, Chen CJ, Abecassis IJ, Levitt MR, Durnford A, Polifka AJ, Derdeyn CP, Samaniego EA, Kwasnicki AM, Alaraj A, Potgieser AR, Sur S, Tada Y, Winkler EA, Lai R, Du R, Abla AA, Satomi J, Starke RM, Van Dijk MC, Amin-Hanjani S, Hayakawa M, Gross BA, Fox WC, Butlers D, Kim LJ, Sheehan JP, Lanzino G, Osbun JW, Zipfel GJ. 483 Partial Treatment as a Risk Factor in Up-Conversion of Type 1 dAVFs. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_483] [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: 03/18/2023] Open
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Lu AY, Winkler EA, Garcia J, Raygor KP, Fullerton H, Fox C, Kim H, Auguste KI, Sun PP, Hetts S, Lawton MT, Abla AA, Gupta N. 350 A Comparison of Incidental and Symptomatic Unruptured Brain Arteriovenous Malformations in Children. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_350] [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: 03/18/2023] Open
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Naik A, Catapano J, Hartke JN, Koester SW, Winkler EA, Jadhav A, Ducruet AF, Albuquerque F. 484 Predictors of Outcome Clusters for Anterior Circulation Mechanical Thrombectomy: An Unsupervised Machine Learning Analysis of Prospective Data. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_484] [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: 03/18/2023] Open
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Lu AY, Winkler EA, Morshed R, Gupta N, Abla AA. 196 Increased Hemorrhage Risk With Brain AVM-Associated Aneurysms in Children. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_196] [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: 03/18/2023] Open
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Winkler EA, Kim C, Ross J, Garcia J, Gil E, Oh I, Chen L, Wu D, Catapano J, Raygor KP, Narsinh K, Kim H, Weinsheimer S, Cooke D, Walcott BP, Lawton MT, Gupta N, Zlokovic B, Chang EF, Abla AA, Lim DA, Nowakowski T. 385 A Cell Resolution Atlas of the Human Cerebrovasculature Reveals Angiogenic and Inflammatory Cell Programs in Arteriovenous Malformations. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_385] [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: 03/18/2023] Open
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Scherschinski L, Han C, Winkler EA, Vajkoczy P, Lawton MT, Oh SP. 475 Local Conditional Induction of Brain Arteriovenous Malformations in Alk1-Inducible Knock-Out Mice. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_475] [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: 03/18/2023] Open
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46
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Singh R, Hartke JN, Catapano JS, Scherschinski L, Rahmani R, Srinivasan VM, Winkler EA, Graffeo CS, Lawton MT. Surgical management of Eagle's syndrome causing neurovascular compression. Clin Neurol Neurosurg 2023; 226:107596. [PMID: 36764100 DOI: 10.1016/j.clineuro.2023.107596] [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: 09/13/2022] [Revised: 11/18/2022] [Accepted: 01/13/2023] [Indexed: 01/17/2023]
Affiliation(s)
- Rohin Singh
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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Lu AY, Winkler EA, Garcia JH, Raygor KP, Fullerton HJ, Fox CK, Kim H, Auguste KI, Sun PP, Hetts SW, Lawton MT, Abla AA, Gupta N. A comparison of incidental and symptomatic unruptured brain arteriovenous malformations in children. J Neurosurg Pediatr 2023; 31:463-468. [PMID: 36805316 DOI: 10.3171/2023.1.peds22541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 01/12/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE Patients with unruptured brain arteriovenous malformations (AVMs) may present with headaches, seizures, and/or neurological deficits. A smaller number of cases may be discovered incidentally. These lesions remain incompletely understood due to their sparse reporting. Herein, the authors describe the largest series to date comparing the presentation, angioarchitecture, and management of incidental versus symptomatic unruptured AVMs in children. METHODS The authors performed a retrospective analysis of patients who presented with brain AVMs from 1998 to 2022 at the University of California, San Francisco. Inclusion criteria were age ≤ 18 years at the time of presentation and an angiographically proven unruptured AVM that had been diagnosed postnatally. RESULTS Of 76 children with unruptured AVMs, 66 (86.8%) presented with headaches, seizures, and/or neurological deficit. Ten AVMs (13.1%) were incidentally discovered through unrelated disease workup (50%), cranial trauma (40%), or research study participation (10%). Compared with patients with symptomatic unruptured AVMs, patients with incidental unruptured AVMs had a smaller mean ± SD maximum nidus diameter (2.82 ± 1.1 vs 3.98 ± 1.52 cm, p = 0.025) and fewer had deep venous drainage (20% of patients vs 61%, p = 0.036). They also presented at an earlier age (10 ± 5.2 vs 13.5 ± 4 years, p = 0.043) and with longer duration to first treatment (541 ± 922 vs 196 ± 448 days, p = 0.005). During the observation period, 1 patient developed recurring headaches and demonstrated AVM nidus growth. Four AVMs greater than 3 cm in size or in a deep location were treated with radiosurgery. Six other AVMs were treated with resection, with 2 receiving preoperative embolization. Eight AVMs (80%) were obliterated on last follow-up. Postprocedural complications included 2 transient neurological deficits after resection and 1 case of delayed seizure development after radiosurgery. The mean follow-up period was 5.7 ± 5.7 years without any hemorrhage episodes. CONCLUSIONS A substantial proportion of pediatric patients with unruptured AVMs are discovered incidentally. With earlier presentation and more elementary angioarchitecture than symptomatic unruptured AVMs, these incidental lesions provide a snapshot into the natural history of AVM before symptom development or rupture.
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Affiliation(s)
| | - Ethan A Winkler
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | | | - Heather J Fullerton
- 3Department of Neurology, Pediatric Stroke and Cerebrovascular Disease Center, University of California, San Francisco, California; and
| | - Christine K Fox
- 3Department of Neurology, Pediatric Stroke and Cerebrovascular Disease Center, University of California, San Francisco, California; and
| | - Helen Kim
- 4Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | | | | | | | - Michael T Lawton
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Nalin Gupta
- Departments of1Neurological Surgery.,6Pediatrics, University of California, San Francisco, California
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48
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Rumalla K, Catapano JS, Mahadevan V, Sorkhi SR, Koester SW, Winkler EA, Graffeo CS, Srinivasan VM, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Socioeconomic Drivers of Outcomes After Aneurysmal Subarachnoid Hemorrhage Treatment at a Large Comprehensive Stroke Center. World Neurosurg 2023; 173:e109-e120. [PMID: 36775240 DOI: 10.1016/j.wneu.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Sparse data exist on socioeconomic disparities among patients treated for aneurysmal subarachnoid hemorrhage (aSAH). The authors analyzed factors possibly influencing patient outcomes, including having a primary care physician (PCP) at admission, family/caregiver support, a foreign language barrier, primary payer status, and race. METHODS Socioeconomic data were abstracted for patients treated endovascularly or microsurgically for aSAH at a single center (January 1, 2014-July 31, 2019). Binary logistic regression analyses were used to identify independent predictors of an unfavorable outcome (modified Rankin Scale [mRS] score >2) and for predictive modeling. RESULTS Among 422 patients, the median (interquartile range) follow-up was 2 (1-23) months. Lack of caregiver support was the only socioeconomic factor associated with an unfavorable outcome at discharge. Independent predictors of mRS score >2 at last follow-up included baseline markers of disease severity (P ≤ 0.03), nonwhite race (OR, 1.69; P = 0.047), lack of caregiver support (OR, 5.55; P = 0.007), and lack of a PCP (OR, 1.96; P = 0.007). Adjusting for follow-up mediated the effects of race and PCP, although caregiver support remained significant and PCP was associated with a lower mortality risk independent of follow-up (OR, 0.51; P = 0.047). Predischarge socioeconomic factors, alongside disease severity, predicted a follow-up mRS score >2 with excellent discrimination (area under the receiver operating curve, 0.81; 95% CI, 0.77-0.86). CONCLUSIONS At a large, urban, comprehensive stroke center, patients with PCPs, caregiver support, and white race had significantly better long-term outcomes after aSAH. These results reflect disparities in access to healthcare after aSAH for vulnerable populations with extensive lifetime needs.
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Affiliation(s)
- Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Varun Mahadevan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Samuel R Sorkhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Scherschinski L, Srinivasan VM, Karahalios K, Garcia JH, Koester SW, Jubran JH, Benner D, Winkler EA, Catapano JS, Labib MA, Graffeo CS, Lawton MT. You Take the Low Road: Differential Outcomes After Tangential and Transcortical Approaches to Medial Temporal Brain Arteriovenous Malformations. World Neurosurg 2023; 173:e81-e90. [PMID: 36758794 DOI: 10.1016/j.wneu.2023.02.005] [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: 10/21/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Microsurgical resection of medial temporal brain arteriovenous malformations (AVMs) is typically conducted through 2 approaches: the orbitozygomatic-tangential and subtemporal-transcortical. Relative indications and outcomes for these techniques have not been formally compared. METHODS The cerebrovascular database of a quaternary center was reviewed for patients with medial temporal AVMs treated between January 1, 1997, and July 31, 2021. Demographic characteristics, lesion characteristics, surgical approaches, and outcomes were retrospectively analyzed and compared. Postoperative outcome testing was performed using the Montreal Cognitive Assessment and Global Quality of Life Scale. RESULTS Fifty-nine patients were assessed. Mean (standard deviation) age was 31 (18) years; 30 (51%) patients were male. Of the AVMs, 29 (49%) were left-sided and 30 (51%) were right-sided. The tangential approach was selected in 20 (34%) cases, whereas the transcortical technique was preferred in 39 (66%). Improved modified Rankin Scale status was significantly associated with the tangential resection technique both in the early postoperative period (P = 0.02) and at last follow-up (P = 0.01). Differences between the tangential and transcortical approaches were not significant with respect to new postoperative deficits (5/20 [25%] vs. 12/39 [31%], P = 0.87) or the presence of residual AVM on follow-up angiography (1/20 [6%] vs. 5/39 [14%], P = 0.65). CONCLUSIONS The orbitozygomatic-tangential strategy was associated with favorable functional and quality-of-life outcomes after medial temporal AVM resection. These benefits are likely to be attributable to minimization of temporal retraction, avoidance of brain transgression, and avoidance of traction on the vein of Labbé, rendering the orbitozygomatic-tangential approach the preferred option for cases that are anatomically amenable to either strategy.
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Affiliation(s)
- Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joseph H Garcia
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jubran H Jubran
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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50
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Winkler EA, Garcia J, Tsang C, Nelson J, McCulloch C, Weinsheimer S, Fox CK, Fullerton H, Ko N, Su H, Nowakowski T, Cooke DL, Hetts S, Guney E, PEKMEZCI MELIKE, Tihan T, Lawton M, Abla A, Gupta N, Kim H. Abstract 52: Prevalence Of Somatic Activating Kras Mutations In Pediatric And Adult Sporadic Brain Arteriovenous Malformations. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.52] [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
Introduction:
Sporadic brain arteriovenous malformations (bAVMs) are a potentially treatable cause of stroke disproportionately affecting young people. Non-inherited somatic activating mutations in
KRAS
have been reported in ~50% of bAVM specimens primarily from adults. We hypothesized that
KRAS
mutations would be associated with an earlier age at diagnosis, larger bAVM size, or earlier time to hemorrhage.
Methods:
Sporadic bAVM tissue and clinical data were collected from patients seen at our institution. Genotyping was performed by digital droplet polymerase chain reaction to detect
KRAS
mutations (p.G12D, p.G12V or p.Q61H) in three batches and coded as presence/absence of any
KRAS
mutation (primary predictor). Age at diagnosis was dichotomized into adults (18 years) or children (<18 years). Regression analyses adjusting for genotyping batch were performed to test association of
KRAS
mutations between children and adults (logistic), with bAVM size (linear), or with time from diagnosis to hemorrhage (survival), censoring at treatment or last follow-up.
Results:
We analyzed data from 221 patients: median age at bAVM diagnosis was 20 years; 44% were diagnosed as children; 53% were female; and 56% were ruptured on presentation. Median bAVM diameter was 2.1 cm (IQR: 1.4 - 3.0).
KRAS
mutations were detected in 53% of samples. Childhood bAVMs were significantly more likely to harbor
KRAS
mutations than those diagnosed in adulthood (OR=2.20, 95% CI: 1.24 - 3.91, p=0.007).
KRAS
-mutant bAVMs tended to be larger than
KRAS
-wildtype bAVMs, but this did not reach significance (+0.29 cm, 95% CI: -0.03 - 0.62, p=0.08). No association was observed for time to hemorrhage (HR=1.31, 95% CI: 0.91 - 1.88, p=0.15).
Conclusions:
Somatic activating
KRAS
mutations are more prevalent in bAVMs diagnosed in childhood than adulthood. Further work is required to elucidate mechanisms of mutagenesis and bAVM progression, which may differ in children and adults.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Hua Su
- Univ of California, San Franc, San Francisco, CA
| | | | | | | | - Ekin Guney
- Univ of California San Francisco, San Francisco, CA
| | | | - Tarik Tihan
- Univ of California San Francisco, San Francisco, CA
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