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Salah WK, Findlay MC, Baker CM, Scoville JP, Bounajem MT, Ogilvy CS, Moore JM, Riina HA, Levy EI, Siddiqui AH, Spiotta AM, Cawley CM, Khalessi AA, Tanweer O, Hanel R, Gross BA, Kuybu O, Howard BM, Hoang AN, Baig AA, Khorasanizadeh M, Mendez Ruiz AA, Cortez G, Davies JM, Lang MJ, Thomas AJ, Tonetti DA, Khalife J, Sioutas GS, Carroll K, Abecassis ZA, Jankowitz BT, Ruiz Rodriguez J, Levitt MR, Kan PT, Burkhardt JK, Srinivasan V, Salem MM, Grandhi R. The Influence of Coagulopathy on Radiographic and Clinical Outcomes in Patients Undergoing Middle Meningeal Artery Embolization as Standalone Treatment for Non-acute Subdural Hematomas. J Neurotrauma 2024. [PMID: 38481125 DOI: 10.1089/neu.2023.0413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/μL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).
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Affiliation(s)
- Walid K Salah
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Cordell M Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan P Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael T Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Christopher S Ogilvy
- Department of Neurological Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Justin M Moore
- Department of Neurological Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Okkes Kuybu
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alex N Hoang
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Ammad A Baig
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | | | - Aldo A Mendez Ruiz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gustavo Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Jason M Davies
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Healthcare, Camden, New Jersey, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, Cooper University Healthcare, Camden, New Jersey, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Healthcare, Camden, New Jersey, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kate Carroll
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Zachary A Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Juan Ruiz Rodriguez
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Peter T Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Visish Srinivasan
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Salem MM, Sioutas GS, Khalife J, Kuybu O, Caroll K, Nguyen Hoang A, Baig AA, Salih M, Khorasanizadeh M, Baker C, Mendez AA, Cortez G, Abecassis ZA, Rodriguez JFR, Davies JM, Narayanan S, Cawley CM, Riina HA, Moore JM, Spiotta AM, Khalessi AA, Howard BM, Hanel R, Tanweer O, Tonetti DA, Siddiqui AH, Lang MJ, Levy EI, Kan P, Jovin T, Grandhi R, Srinivasan VM, Ogilvy CS, Gross BA, Jankowitz BT, Thomas AJ, Levitt MR, Burkhardt JK. General Versus Nongeneral Anesthesia for Middle Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score Matched Study. Neurosurgery 2024:00006123-990000000-01069. [PMID: 38412228 DOI: 10.1227/neu.0000000000002874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/01/2023] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The choice of anesthesia type (general anesthesia [GA] vs nongeneral anesthesia [non-GA]) in middle meningeal artery embolization (MMAE) procedures for chronic subdural hematomas (cSDH) differs between institutions and left to care team discretion given lack of standard guidelines. We compare the outcomes of GA vs non-GA in MMAE. METHODS Consecutive patients receiving MMAE for cSDH at 14 North American centers (2018-2023) were included. Clinical, cSDH characteristics, and technical/clinical outcomes were compared between the GA/non-GA groups. Using propensity score matching (PSM), patients were matched controlling for age, baseline modified Rankin Scale, concurrent/prior surgery, hematoma thickness/midline shift, and baseline antiplatelet/anticoagulation. The primary end points included surgical rescue and radiographic success rates (≥50% reduction in maximum hematoma thickness with minimum 2 weeks of imaging). Secondary end points included technical feasibility, procedural complications, and functional outcomes. RESULTS Seven hundred seventy-eight patients (median age 73 years, 73.2% male patients) underwent 956 MMAE procedures, 667 (70.4%) were non-GA and 280 were GA (29.6%). After running 1:3 PSM algorithm, this resulted in 153 and 296 in the GA and non-GA groups, respectively. There were no baseline/procedural differences between the groups except radial access more significantly used in the non-GA group (P = .001). There was no difference between the groups in procedural technical feasibility, complications rate, length of stay, surgical rescue rates, or favorable functional outcome at the last follow-up. Subsequent 1:1 sensitivity PSM retained the same results. Bilateral MMAE procedures were more performed under non-GA group (75.8% vs 67.2%; P = .01); no differences were noted in clinical/radiographic outcomes between bilateral vs unilateral MMAE, except for longer procedure duration in the bilateral group (median 73 minutes [IQR 48.3-100] vs 54 minutes [39-75]; P < .0001). Another PSM analysis comparing GA vs non-GA in patients undergoing stand-alone MMAE retained similar associations. CONCLUSION We found no significant differences in radiological improvement/clinical outcomes between GA and non-GA for MMAE.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Okkes Kuybu
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kate Caroll
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Mira Salih
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Mirhojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Cordell Baker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Aldo A Mendez
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gustavo Cortez
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Zachary A Abecassis
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Sandra Narayanan
- Departments of Neurology and Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ricardo Hanel
- Department of Cerebrovascular and Endovascular Surgery, Baptist Neurological Institute and Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Tudor Jovin
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Massachusetts, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
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Khorasanizadeh M, Paul U, Chang YM, Moore JM, Ogilvy CS, Thomas AJ. The effect of patient age on the degree of midline shift caused by chronic subdural hematomas: a volumetric analysis. J Neurosurg 2024; 140:537-543. [PMID: 37877977 DOI: 10.3171/2023.6.jns222890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/04/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Chronic subdural hematomas (CSDHs) are the among the most common conditions treated by neurosurgeons. Midline shift (MLS) is used as a radiological marker of CSDH severity and the potential need for urgent surgical evacuation. However, a patient's age may affect the degree of MLS for a given hematoma volume. This study aimed to investigate the correlation between the patient's age and the MLS caused by CSDH. METHODS The database of patients treated for CSDH was reviewed in a single institution. Patients with unilateral CSDH were included. To measure CSDH volume, the preprocedural head CT scans underwent 3D volumetric reconstruction using the TeraRecon software. The effect of age on MLS after adjusting for CSDH volume was investigated using linear regression analysis. RESULTS Sixty-nine hematomas in 69 patients were included. The age of patients ranged from 25 to 94 years (mean 71.6 years). Hematoma volume and MLS ranged from 27.8 to 215 mL (mean 99.3 mL) and 0-17 mm (mean 6.5 mm), respectively. On multivariate regression analysis, MLS showed a significant independent negative correlation with age after adjusting for CSDH volume (OR -0.11, 95% CI -0.16 to -0.06; p < 0.001), meaning that for a fixed CSDH volume, with each 10-year increase in age the MLS will reduce by 1.1 mm. Moreover, MLS-to-volume ratio showed a significant negative linear correlation with age (r2 = 0.32; p < 0.001). Ten-milliliter increments in CSDH volume resulted in a 1.09-mm increase in MLS in patients younger than 60 years, which is 2.4-fold higher compared to the 0.46-mm increase in those older than 75 years (p < 0.001). CONCLUSIONS For a fixed CSDH volume, older age correlates with significantly lower MLS. This could be explained by higher parenchymal compliance in older individuals due to increased brain atrophy, and a larger subdural space. Clinical use of MLS to estimate severity of CSDH and gauge treatment decisions should take the patient's age into account.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Umika Paul
- 2UMass Chan Medical School, Worcester, Massachusetts
| | - Yu-Ming Chang
- 3Department of Neuroradiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Justin M Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 4Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
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4
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Scoville JP, Joyce E, A. Tonetti D, Bounajem MT, Thomas A, Ogilvy CS, Moore JM, Riina HA, Tanweer O, Levy EI, Spiotta AM, Gross BA, Jankowitz BT, Cawley CM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Levitt MR, Binning M, Taussky P, Kan P, Grandhi R. Radiographic and clinical outcomes with particle or liquid embolic agents for middle meningeal artery embolization of nonacute subdural hematomas. Interv Neuroradiol 2023; 29:683-690. [PMID: 35673710 PMCID: PMC10680958 DOI: 10.1177/15910199221104631] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 04/11/2022] [Accepted: 05/15/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization is an apparently efficacious minimally invasive treatment for nonacute subdural hematomas (NASHs), but how different embolisates affect outcomes remains unclear. Our objective was to compare radiographic and clinical outcomes after particle or liquid MMA embolization. METHODS Patients who had MMA embolization for NASH were retrospectively identified from a multi-institution database. The primary radiographic and clinical outcomes-50% NASH thickness reduction and need for surgical retreatment within 90 days, respectively-were compared for liquid and particle embolizations in patients treated 1) without surgical intervention (upfront), 2) after recurrence, or 3) with concomitant surgery (prophylactic). RESULTS The upfront, recurrent, and prophylactic subgroups included 133, 59, and 16 patients, respectively. The primary radiographic outcome was observed in 61.8%, 61%, and 72.7% of particle-embolized patients and 61.3%, 55.6%, and 20% of liquid-embolized patients, respectively (p = 0.457, 0.819, 0.755). Hazard ratios comparing time to reach radiographic outcome in the particle and liquid groups or upfront, recurrent, andprophylactic timing were 1.31 (95% CI 0.78-2.18; p = 0.310), 1.09 (95% CI 0.52-2.27; p = 0.822), and 1.5 (95% CI 0.14-16.54; p = 0.74), respectively. The primary clinical outcome occurred in 8.0%, 2.4%, and 0% of patients who underwent particle embolization in the upfront, recurrent, and prophylactic groups, respectively, compared with 0%, 5.6%, and 0% who underwent liquid embolization (p = 0.197, 0.521, 1.00). CONCLUSIONS MMA embolization with particle and liquid embolisates appears to be equally effective in treatment of NASHs as determined by the percentage who reach, and the time to reach, 50% NASH thickness reduction and the incidence of surgical reintervention within 90 days.
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Affiliation(s)
- Jonathan P. Scoville
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael T. Bounajem
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | - Ajith Thomas
- Cooper Neuroscience Institute, Camden, New Jersey, USA
| | - Christopher S. Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M. Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Howard A. Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Elad I. Levy
- Departments of Neurosurgery and Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bradley A. Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Alexander A. Khalessi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California, USA
| | - Aditya S. Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew J. Ringer
- Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio, USA
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Rafael A. Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York, New York, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York, New York, USA
| | - Michael R. Levitt
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Mandy Binning
- Department of Neurosurgery, Global Neurosciences Institute Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah, USA
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Salih M, Khorasanizadeh M, Salem MM, Baig AA, Kim H, Lucke-Wold B, Hoh BL, Jankowitz BT, Burkhardt JK, Siddiqui AH, Taussky P, Thomas AJ, Moore JM, Ogilvy CS. Effect of Chronic Anticoagulation on Outcomes of Endovascular Treatment for Unruptured Intracranial Aneurysms-A Propensity-Matched Multicenter Study. Neurosurgery 2023; 93:1007-1018. [PMID: 37255291 DOI: 10.1227/neu.0000000000002523] [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: 01/14/2023] [Accepted: 03/21/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular treatment of unruptured intracranial aneurysms (UIAs) in patients receiving anticoagulant medications has not been well studied. Whether long-term anticoagulation (AC) use affects aneurysmal obliteration rates and treatment-related complications is unclear. METHODS Patients with endovascular treatment for UIA from 4 academic centers were identified and divided into AC and non-AC groups. Periprocedural complications, radiographic and clinical outcomes, and retreatment rates were compared between the 2 groups before and after propensity score matching. RESULTS The initial cohort consisted of 70 patients in the AC group and 355 in the non-AC group. After one-to-one nearest neighbor propensity matching, 38 pairs of patients were compared for periprocedural complications. The total number of complications were higher in the AC group yet not significant (18.4% vs 5.3%, P = .15). After adding imaging follow-up duration to matched variables, 36 pairs were obtained. There was no significant difference in Raymond-Roy occlusion rate between the 2 groups ( P = .74). However, retreatment rate trended higher in the AC group compared with the non-AC group (22.2% vs 5.6%, P = .09). When clinical follow-up duration was added among matched variables, 26 pairs of cases were obtained for long-term clinical outcomes. There was no significant difference in modified Rankin Scale score between the 2 groups ( P = .61). One-to-many nearest neighbor propensities matched analysis with bigger sample sizes yielded similar results. CONCLUSION The use of anticoagulants does not affect occlusion rates or long-term outcomes in endovascular treatment of UIAs. Retreatment rates were higher in the AC group; however, this was not statistically significant.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | - Ammad A Baig
- University at Buffalo Neurosurgery, Buffalo , New York , USA
| | - Hoon Kim
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | | | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
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6
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Khorasanizadeh M, Maroufi SF, Mukherjee R, Sankaranarayanan M, Moore JM, Ogilvy CS. Middle Meningeal Artery Embolization in Adjunction to Surgical Evacuation for Treatment of Subdural Hematomas: A Nationwide Comparison of Outcomes With Isolated Surgical Evacuation. Neurosurgery 2023; 93:1082-1089. [PMID: 37265340 DOI: 10.1227/neu.0000000000002554] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 02/26/2023] [Accepted: 04/12/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Surgical evacuation is the standard treatment for chronic subdural hematomas (CSDHs) but is associated with a high risk of recurrence and readmission. Middle meningeal artery embolization (MMAE) is a novel treatment approach which could be performed upfront or in adjunction to surgical evacuation. MMAE studies are limited by small sample sizes. This study aimed to describe and compare outcomes of MMAE in adjunction to surgery with those of surgery alone on a national level. METHODS The national Vizient Clinical Database was queried by use of a specific validated set of International Classification of Diseases, Tenth Revision codes (October 2018-June 2022). Patients with the diagnosis of nontraumatic CSDH who received MMAE and surgical drainage in the same hospitalization were identified, and their outcomes were compared with isolated surgical drainage. RESULTS A total of 606 subjects from 156 institutes and 6340 subjects from 369 institutes were included in the MMAE plus surgery (M&S) and surgery groups, respectively. Average length of stay was significantly longer in the M&S group (9.87 vs 7.53 days; P < .01). There was no significant difference in the in-hospital mortality rate (2.8% vs 2.9%), but the complication rate was significantly higher in the M&S group (8.7% vs 5.5%; P < .01). Complications that were significantly more common in the M&S group included aspiration pneumonia, postoperative sepsis, and anesthesia-related. Mean direct costs were significantly higher in the M&S group (28 834 vs 16 292 US dollars; P < .01). The 30-day readmission rate was significantly lower in the M&S group compared with the surgery group (4.2% vs 8.0%; P < .01). CONCLUSION This analysis of large-scale national data indicates that MMAE performed in adjunction to surgery for treatment of CSDH is associated with higher direct costs, higher complication rates, and longer length of stay but lower readmission rates compared with surgical evacuation alone.
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Affiliation(s)
- Mirhojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - Rajarshi Mukherjee
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston , Massachusetts , USA
| | - Madhav Sankaranarayanan
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston , Massachusetts , USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
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7
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Salem MM, Khorasanizadeh M, Nwajei F, Gomez-Paz S, Akamatsu Y, Jordan N, Maroufi SF, Thomas AJ, Ogilvy CS, Moore JM. Predictors of aneurysmal occlusion following intracranial aneurysms treatment with pipeline embolization device. Acta Neurochir (Wien) 2023; 165:2801-2809. [PMID: 37615726 DOI: 10.1007/s00701-023-05740-1] [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: 05/04/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Pipeline embolization device (PED) is thought to induce aneurysmal occlusion through diversion of flow away from the aneurysmal sac with subsequent thrombosis and endothelialization. The impact of different factors especially hypertension (HTN)-a known predisposing factor to hypercoagulability and altered endothelial function-on aneurysmal occlusion after flow diversion has not been studied. We sought to determine predictors of aneurysmal occlusion following PED treatment focusing on impact of blood pressure. METHODS Database of patients with cerebral aneurysms treated with PED from 2013 to 2019 at our institution was retrospectively reviewed. Patients were defined as hypertensive if (1) they had a documented history of HTN requiring anti-HTN medications or (2) average systolic blood pressure on three measurements was > 130 mmHg. The primary outcome was aneurysm occlusion status at the last imaging follow-up. Multivariable logistic regression model was constructed to assess the effect of HTN on occlusion, controlling for age, smoking, aneurysmal size, fusiform morphology, posterior circulation location, and incorporated branches. RESULTS A total of 331 aneurysms in 294 patients were identified for this analysis. The mean age was 59 years (79.9% female). Fifty-five percent of the cohort were classified as hypertensive. When controlling for other potential confounders, hypertensive patients trended toward higher odds of achieving complete occlusion compared to non-hypertensive patients (OR = 2.05; 95% CI = 0.99-4.25; p = 0.052). Meanwhile, age (OR = 0.91; 95% CI = 0.88-0.95; p < 0.001) and an incorporated branch into an aneurysm (OR = 0.22; 95% CI = 0.08-0.58; p < 0.002) were associated with decreased odds for complete aneurysmal occlusion. CONCLUSION Hypertensive patients show a trend toward higher odds of achieving complete occlusion when controlling for potential confounders. The HTN-induced hypercoagulable state, enhanced endothelial activation, and altered extracellular matrix regulation might be the contributing factors. Further research is warranted to explore clinical implications of these findings.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Noah Jordan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Camden, NJ, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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8
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Salem MM, Kuybu O, Nguyen Hoang A, Baig AA, Khorasanizadeh M, Baker C, Hunsaker JC, Mendez AA, Cortez G, Davies JM, Narayanan S, Cawley CM, Riina HA, Moore JM, Spiotta AM, Khalessi AA, Howard BM, Hanel R, Tanweer O, Levy EI, Grandhi R, Lang MJ, Siddiqui AH, Kan P, Ogilvy CS, Gross BA, Thomas AJ, Jankowitz BT, Burkhardt JK. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 Embolizations. Radiology 2023; 307:e222045. [PMID: 37070990 PMCID: PMC10323293 DOI: 10.1148/radiol.222045] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 08/15/2022] [Revised: 01/25/2023] [Accepted: 03/01/2023] [Indexed: 04/19/2023]
Abstract
Background Knowledge regarding predictors of clinical and radiographic failures of middle meningeal artery (MMA) embolization (MMAE) treatment for chronic subdural hematoma (CSDH) is limited. Purpose To identify predictors of MMAE treatment failure for CSDH. Materials and Methods In this retrospective study, consecutive patients who underwent MMAE for CSDH from February 2018 to April 2022 at 13 U.S. centers were included. Clinical failure was defined as hematoma reaccumulation and/or neurologic deterioration requiring rescue surgery. Radiographic failure was defined as a maximal hematoma thickness reduction less than 50% at last imaging (minimum 2 weeks of head CT follow-up). Multivariable logistic regression models were constructed to identify independent failure predictors, controlling for age, sex, concurrent surgical evacuation, midline shift, hematoma thickness, and pretreatment baseline antiplatelet and anticoagulation therapy. Results Overall, 530 patients (mean age, 71.9 years ± 12.8 [SD]; 386 men; 106 with bilateral lesions) underwent 636 MMAE procedures. At presentation, the median CSDH thickness was 15 mm and 31.3% (166 of 530) and 21.7% (115 of 530) of patients were receiving antiplatelet and anticoagulation medications, respectively. Clinical failure occurred in 36 of 530 patients (6.8%, over a median follow-up of 4.1 months) and radiographic failure occurred in 26.3% (137 of 522) of procedures. At multivariable analysis, independent predictors of clinical failure were pretreatment anticoagulation therapy (odds ratio [OR], 3.23; P = .007) and an MMA diameter less than 1.5 mm (OR, 2.52; P = .027), while liquid embolic agents were associated with nonfailure (OR, 0.32; P = .011). For radiographic failure, female sex (OR, 0.36; P = .001), concurrent surgical evacuation (OR, 0.43; P = .009), and a longer imaging follow-up time were associated with nonfailure. Conversely, MMA diameter less than 1.5 mm (OR, 1.7; P = .044), midline shift (OR, 1.1; P = .02), and superselective MMA catheterization (without targeting the main MMA trunk) (OR, 2; P = .029) were associated with radiographic failure. Sensitivity analyses retained these associations. Conclusion Multiple independent predictors of failure of MMAE treatment for chronic subdural hematomas were identified, with small diameter (<1.5 mm) being the only factor independently associated with both clinical and radiographic failures. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Chaudhary and Gemmete in this issue.
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Affiliation(s)
- Mohamed M. Salem
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Okkes Kuybu
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Alex Nguyen Hoang
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Ammad A. Baig
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Mirhojjat Khorasanizadeh
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Cordell Baker
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Joshua C. Hunsaker
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Aldo A. Mendez
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Gustavo Cortez
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Jason M. Davies
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Sandra Narayanan
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - C. Michael Cawley
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Howard A. Riina
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Justin M. Moore
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Alejandro M. Spiotta
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Alexander A. Khalessi
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Brian M. Howard
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Ricardo Hanel
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Omar Tanweer
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Elad I. Levy
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Ramesh Grandhi
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Michael J. Lang
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Adnan H. Siddiqui
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Peter Kan
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Christopher S. Ogilvy
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Bradley A. Gross
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Ajith J. Thomas
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Brian T. Jankowitz
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
| | - Jan-Karl Burkhardt
- From the Department of Neurosurgery, Hospital of the University of
Pennsylvania, Penn Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104
(M.M.S., B.T.J., J.K.B.); Department of Neurosurgery, University of Pittsburgh,
Pittsburgh, Pa (O.K., A.A.M., S.N., M.J.L., B.A.G.); Department of Neurosurgery,
Baylor College of Medicine, Houston, Tex (A.N.H., O.T., P.K.); Department of
Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at
Buffalo, Buffalo, NY (A.A.B., J.M.D., E.I.L., A.H.S.); Division of Neurosurgery,
Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, Mass
(M.K., J.M.M., C.S.O., A.J.T.); Department of Neurosurgery, University of Utah,
Salt Lake City, Utah (C.B., J.C.H., R.G.); Department of Cerebrovascular and
Endovascular Surgery, Baptist Neurologic Institute and Lyerly Neurosurgery,
Jacksonville, Fla (G.C., R.H.); Department of Neurosurgery, Emory University
School of Medicine, Atlanta, Ga (C.M.C., B.M.H.); Department of Neurosurgery,
NYU Langone Medical Center, New York, NY (H.A.R.); Department of Neurosurgery,
Medical University of South Carolina, Charleston, SC (A.M.S.); Department of
Neurosurgery, University of California–San Diego, La Jolla, Calif
(A.A.K.); Department of Neurosurgery, University of Texas Medical Branch,
Galveston, Tex (P.K.); and Department of Neurosurgery, Cooper University Health
Care, Cooper Medical School of Rowan University, Camden, NJ (A.J.T.)
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Salih M, Salem MM, Ravina K, Stippler M, Papavassiliou E, Alterman RL, Thomas A, Moore JM, Ogilvy CS. 765 Outcome of Chronic Subdural Hematoma Management in Patients on Long Term Antiplatelet Therapy—A Propensity Score Matched Analysis. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_765] [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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Khorasanizadeh M, Shutran M, Schirmer CM, Salem MM, Ringer AJ, Grandhi R, Mitha AP, Levitt MR, Jankowitz BT, Taussky P, Thomas AJ, Moore JM, Ogilvy CS. 396 North American Multicenter Experience of the Flow-Redirection Endoluminal Device (FRED) in the Treatment of Intracranial Aneurysms. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_396] [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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Salah WK, Baker C, Scoville JP, Hunsaker JC, Ogilvy CS, Moore JM, Riina HA, Levy EI, Spiotta AM, Jankowitz BT, Michael Cawley C, Khalessi AA, Tanweer O, Hanel R, Gross BA, Kuybu O, Hoang AN, Baig AA, Khorasanizadeh MH, Mendez AA, Cortez G, Davies JM, Narayanan S, Howard BM, Lang MJ, Siddiqui AH, Thomas A, Kan P, Burkhardt JK, Salem MM, Grandhi R. Middle meningeal artery embolization as a perioperative adjunct to surgical evacuation of nonacute subdural hematomas: An multicenter analysis of safety and efficacy. Interv Neuroradiol 2023:15910199231162665. [PMID: 36908233 DOI: 10.1177/15910199231162665] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND By 2030, nonacute subdural hematomas (NASHs) will likely be the most common cranial neurosurgery pathology. Treatment with surgical evacuation may be necessary, but the recurrence rate after surgery is as high as 30%. Minimally invasive middle meningeal artery embolization (MMAE) during the perioperative period has been posited as an adjunctive treatment to decrease the potential for recurrence after surgical evacuation. We evaluated the safety and efficacy of concurrent MMAE in a multi-institutional cohort. METHODS Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and MMAE in the perioperative period were retrospectively collected from 15 institutions. The primary outcome was the rate of recurrence requiring repeat surgical intervention. We collected clinical, treatment, and radiographic data at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data were also collected. RESULTS Preoperatively, the median hematoma width was 18 mm, and subdural membranes were present on imaging in 87.3% of patients. At 90-day follow-up, median NASH width was 6 mm, and 51.4% of patients had at least a 50% decrease of NASH size on imaging. Eight percent of treated NASHs had recurrence that required additional surgical intervention. Of patients with a modified Rankin Scale score at last follow-up, 87.2% had the same or improved mRS score. The total all-cause mortality was 6.0%. CONCLUSION This study provides evidence from a multi-institutional cohort that performing MMAE in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce recurrence in patients with NASHs.
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Affiliation(s)
- Walid K Salah
- Department of Neurosurgery, Clinical Neurosciences Center, 7060University of Utah, Salt Lake City, Utah, USA.,School of Medicine, 7060University of Utah, Salt Lake City, Utah, USA
| | - Cordell Baker
- Department of Neurosurgery, Clinical Neurosciences Center, 7060University of Utah, Salt Lake City, Utah, USA
| | - Jonathan P Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, 7060University of Utah, Salt Lake City, Utah, USA
| | - Joshua C Hunsaker
- School of Medicine, 7060University of Utah, Salt Lake City, Utah, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, 14221, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, La Jolla, California, USA
| | - Omar Tanweer
- Department of Neurosurgery, 3989Baylor College of Medicine, Houston, Texas, USA
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Okkes Kuybu
- Department of Neurology, 6614University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, 205297Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, 14221, USA
| | | | - Aldo A Mendez
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gustavo Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, 14221, USA
| | - Sandra Narayanan
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, 14221, USA
| | - Ajith Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, 7060University of Utah, Salt Lake City, Utah, USA
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Phillips KR, Enriquez-Marulanda A, Mackel C, Ogbonna J, Moore JM, Vega RA, Alterman RL. Predictors of extended length of stay related to craniotomy for tumor resection. World Neurosurg X 2023; 19:100176. [PMID: 37123627 PMCID: PMC10139985 DOI: 10.1016/j.wnsx.2023.100176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Background Hospital length of stay (LOS) related to craniotomy for tumor resection (CTR) is a marker of neurosurgical quality of care. Limiting LOS benefits both patients and hospitals. This study examined which factors contribute to extended LOS (eLOS) at our academic center. Methods Retrospective medical record review of 139 consecutive CTRs performed between July 2020 and July 2021. Univariate and multivariable analyses determined which factors were associated with an eLOS (≥8 days). Results Median LOS was 6 days (IQR 3-9 days). Fifty-one subjects (36.7%) experienced an eLOS. Upon univariate analysis, potentially modifiable factors associated with eLOS included days to occupational therapy (OT), physical therapy (PT), and case management clearance (p < .001); and discharge disposition (p < .001). Multivariable analysis revealed that pre-operative anti-coagulant use (OR 10.74, 95% CI 2.64-43.63, p = .001), Medicare (OR 4.80, 95% CI 1.07-21.52, p = .04), ED admission (OR 26.21, 95% CI 5.17-132.99, p < .001), transfer to another service post-surgery (OR 30.00, 95% CI 1.56-577.35, p = .02), and time to post-operative imaging (OR 2.91, 95% CI 1.27-6.65, p = .01) were associated with eLOS. Extended LOS was not significantly associated with ED visits (p = .45) or unplanned readmissions within 30 days of surgery (p = .35), and both (p = .04; p = .04) were less likely following a short LOS (<5 days). Conclusion While some factors driving LOS related to CTR are uncontrollable, expedient pre- and post-operative management may reduce LOS without compromising care.
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Salih M, Salem MM, Moore JM, Ogilvy CS. Optimal Cost-Effective Screening Strategy for Unruptured Intracranial Aneurysms in Female Smokers. Neurosurgery 2023; 92:150-158. [PMID: 36222540 DOI: 10.1227/neu.0000000000002166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/25/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The prevalence of intracranial aneurysms among female cigarette smokers was shown to be high in previous studies, yet the cost-effectiveness of screening them has never been explored. OBJECTIVE To explore the most cost-effective screening strategy for female smokers. METHODS A decision analytical study was performed with a Markov model to compare different screening strategies with no screening and to explore the most optimal screening strategy for female smokers. Input data for the model were extracted from literature. A single screening at different ages and multiple screening every 15 years, 10 years, 5 years, and 2 years were performed for female smokers in different age ranges. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of the model. Finally, value of information analysis was performed to investigate the value of collecting additional data. RESULTS Screening female smokers for unruptured intracranial aneurysm is cost-effective. All screening strategies yield extra quality-adjusted life years. Screening at younger age brings more health benefit at lower cost. Frequent screening strategies decrease rupture rate of aneurysms more with higher costs per quality-adjusted life year. Screening after age 70 years and frequent screening (every 2 years) after age 60 years is not optimal. Among all the parameters in the model, collecting additional data on utility of the unscreened population would be most valuable. CONCLUSION Screening female smokers for intracranial aneurysms once at younger age is most optimal. However, in clinical practice, the duration and intensity of exposure to cigarettes should be taken into consideration.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
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14
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Khorasanizadeh M, Shutran M, Schirmer CM, Salem MM, Ringer AJ, Grandhi R, Mitha AP, Levitt MR, Jankowitz BT, Taussky P, Thomas AJ, Moore JM, Ogilvy CS. North American multicenter experience with the Flow Redirection Endoluminal Device in the treatment of intracranial aneurysms. J Neurosurg 2022; 138:933-943. [PMID: 36087324 DOI: 10.3171/2022.7.jns221371] [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: 06/08/2022] [Accepted: 07/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow diverters have revolutionized the endovascular treatment of intracranial aneurysms. Here, the authors present the first large-scale North American multicenter experience using the Flow Redirection Endoluminal Device (FRED) in the treatment of cerebral aneurysms. METHODS Consecutive cerebral aneurysms treated with FRED at 7 North American centers between June 2020 and November 2021 were included. Data collected included patient demographic characteristics, aneurysm characteristics, periprocedural and long-term complications, modified Rankin Scale (mRS) scores, and radiological follow-up. RESULTS In total, 133 aneurysms in 116 patients were treated with 123 FRED deployment procedures and included in this study. One hundred twenty-six aneurysms (94.7%) were unruptured, 117 (88.0%) saccular, and 123 (92.5%) located in anterior circulation. The mean (range) aneurysm maximal width and neck width sizes were 7.2 (1.5-42.5) mm and 4.1 (1.0-15.1) mm, respectively. Successful FRED deployment was achieved in 122 procedures (99.2%). Adjunctive coiling was used in 4 procedures (3.3%). Radiological follow-up was available for 101 aneurysms at a median duration of 7.0 months. At last follow-up, complete occlusion was observed in 55.4% of patients, residual neck in 8.9%, and filling aneurysm in 35.6%; among cases with radiological follow-up duration > 10 months, these values were 21/43 (48.8%), 3/43 (7.0%), and 19/43 (44.2%), respectively. On multivariate regression analysis, age (OR 0.93, p = 0.001) and aneurysm neck size (OR 0.83, p = 0.048) were negatively correlated with odds of complete occlusion at latest follow-up. The retreatment rate was 6/124 (4.8%). The overall complication rate was 31/116 (26.7%). Parent vessel occlusion, covered branch occlusion, and in-stent stenosis were detected in 9/99 (9.1%), 6/63 (9.5%), and 15/99 (15.2%) cases, respectively. The FRED-related, symptomatic, thromboembolic, and hemorrhagic complication rates were 22.4%, 12.9%, 6.9%, and 0.9% respectively. The morbidity rate was 10/116 patients (8.6%). There was 1 death due to massive periprocedural internal carotid artery stroke, and 3.6% of the patients had an mRS score > 2 at the last follow-up (vs 0.9% at baseline). CONCLUSIONS As the first large-scale North American multicenter FRED experience, this study confirmed the ease of successful FRED deployment but suggested lower efficacy and a higher rate of complications than reported by previous European and South American studies on FRED and other flow-diverting devices. The authors recommend judicious use of this device until future studies can better elucidate the long-term outcomes of FRED treatment.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Max Shutran
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Mohamed M Salem
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J Ringer
- 4Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio
| | - Ramesh Grandhi
- 5Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Alim P Mitha
- 6Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Michael R Levitt
- 7Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Brian T Jankowitz
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Philipp Taussky
- 5Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Ajith J Thomas
- 8Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Justin M Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Enriquez-Marulanda A, Penumaka A, Ogilvy CS, Thomas AJ, Moore JM. In Reply: Safety and Efficacy of the Off-Label Use of Pipeline Embolization Device Based on the 2018 Food and Drug Administration-Approved Indications for Intracranial Aneurysms: A Single-Center Retrospective Cohort Study. Neurosurgery 2022; 91:e136. [PMID: 36053078 DOI: 10.1227/neu.0000000000002126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/19/2022] Open
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Khorasanizadeh M, Shutran M, Garcia A, Enriquez-Marulanda A, Moore JM, Ogilvy CS, Thomas AJ. Middle Meningeal Artery Embolization with Isolated Use of Coils for Treatment of Chronic Subdural Hematomas: A Case Series. World Neurosurg 2022; 165:e581-e587. [PMID: 35768059 DOI: 10.1016/j.wneu.2022.06.099] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) is a novel approach for treatment of chronic subdural hematoma (cSDH). Studies comparing different procedural techniques for MMAE are lacking. It is unclear whether isolated use of coils results in suboptimal outcomes compared to when particle embolization is also performed. The objectives of this study are to describe the outcomes of coil-only MMAE and compare them with those of combined use of coils and particles. METHODS A single-institution retrospective study of cSDH cases treated by MMAE was performed. Clinical outcomes, need for rescue surgery, and changes in hematoma's size were compared between the coil-only and coil + particle groups. RESULTS Ninety-four hematomas in 78 patients were included. Twelve cases were treated by a coil-only MMAE procedure, often due to presence of dangerous ophthalmic collaterals. No treatment-related complications were observed in the coil-only group. There was no significant difference between the coil-only and coil + particle groups in baseline hematoma axial thickness, volume, midline shift, and duration of follow-up. The rate of need for rescue surgery was similar between the 2 groups (8.3% vs. 8.5%; P = 0.98). Coiling alone resulted in a similar percentage of reduction in cSDH volume (68.3% vs. 71.8%; P = 0.8) and rate of achieving ≥50% reduction in volume (81.8% vs. 76.3%; P = 0.68) compared to coils + particles. CONCLUSIONS Isolated use of coils for endovascular treatment of cSDHs can be as effective as adjunct use of particle embolization. This method eliminates the risks of cranial nerve and visual complications associated with MMAE, can prevent procedural abortion due to presence of dangerous anastomoses, and reduces the technical complexity of the procedure.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Garcia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Camden, New Jersey, USA.
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Akamatsu Y, Gomez-Paz S, Tonetti DA, Vergara-Garcia D, Moholkar VM, Kuhn AL, Chida K, Singh J, Rodrigues KDM, Massari F, Moore JM, Ogilvy CS, Puri AS, Thomas AJ. Middle meningeal artery: An effective pathway for achieving complete obliteration following transarterial Ethylene Vinyl Copolymer (Onyx) embolization of dural arteriovenous fistulas. J Cerebrovasc Endovasc Neurosurg 2022; 24:210-220. [PMID: 35794751 PMCID: PMC9537646 DOI: 10.7461/jcen.2022.e2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 12/17/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Transarterial Onyx embolization is the mainstay of intracranial non-cavernous dural arteriovenous fistulas (dAVFs) treatment. Although the dural arterial supply varies depending on the location, the impact of arterial access on treatment outcomes has remained unclear. The aim of this study was to characterize factors as sociated with complete obliteration following transarterial Onyx embolization, with a special focus on arterial access routes and dAVF location. Methods A retrospective analysis of the patients who underwent transarterial Onyx embolization for intracranial dAVFs at two academic institutions was performed. Patients with angiographic follow-up were considered eligible to investigate the impact of the arterial access on achieving complete obliteration. Results Sixty-eight patients underwent transarterial Onyx embolization of intracranial dAVFs. Complete obliteration was achieved in 65% of all treated patients and in 75% of those with cortical venous reflux. Multivariable analysis identified middle meningeal artery (MMA) access to be a significant independent predictive factor for complete obliteration (OR, 2.32; 95% CI, 1.06-5.06; p=0.034). Subgroup analysis showed that supratentorial and lateral cerebellar convexity dAVFs (OR, 5.72, 95% CI, 1.89-17.33, p=0.002), and Borden type III classification at pre-treatment (OR, 3.13, 95% CI, 1.05- 9.35, p=0.041), were independent predictive factors for complete obliteration following embolization through the MMA. Conclusions MMA access is an independent predictive factor for complete obliteration following transarterial Onyx embolization for intracranial non-cavernous dAVFs. It is particularly effective for supratentorial and lateral cerebellar convexity dAVFs and those that are Borden type III.
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Affiliation(s)
- Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Neurosurgry, Iwate Medical University, Yahaba, Japan
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel A Tonetti
- Department of Neurosurgery University of California San Francisco, San Francisco, CA, USA
| | - David Vergara-Garcia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Viraj M Moholkar
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Anna Luisa Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Kohei Chida
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Neurosurgry, Iwate Medical University, Yahaba, Japan
| | - Jasmeet Singh
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Katyucia de Macedo Rodrigues
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Francesco Massari
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ajith J Thomas
- Department of Neurological Surgery, Cooper University Health Care, Camden, NJ, USA
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Enriquez-Marulanda A, Penumaka A, Ogilvy CS, Thomas AJ, Moore JM. Safety and Efficacy of the Off-Label Use of Pipeline Embolization Device Based on the 2018 Food and Drug Administration-Approved Indications for Intracranial Aneurysms: A Single-Center Retrospective Cohort Study. Neurosurgery 2022; 90:700-707. [PMID: 35319533 DOI: 10.1227/neu.0000000000001891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pipeline embolization device (PED; ev3/Covidien) has proven safe and effective for treating selected intracranial aneurysms. This device's versatility and popularity have driven increased interest in expanding the latest 2018 Food and Drug Administration-approved indications. OBJECTIVE To compare "off-label" and "on-label" PED treatment. METHODS Retrospective analysis of aneurysms treated with PED at a single center from 2013 to 2019. Comparisons were made based on the 2018 Food and Drug Administration-approved indications. RESULTS A total of 492 treated aneurysms were included (65.2% on-label and 34.8% off-label). Aneurysm complete and near-complete occlusion rate was nonsignificantly lower in the off-label group (80.9% vs 85.7%; P = .19). Off-label treatment had higher rate of poor functional outcomes (modified Rankin Scale [mRS] >2: 10.3% vs 3.5%; P = .002). Although pretreatment mRS was already higher in the off-label group (5.3% vs 0.3%; P < .001) and there were no differences in mRS worsening during follow-up (5.5% vs 2.9%; P = .15). We also found a trend to a higher rate of intracranial hemorrhagic complications in the off-label group (4.7% vs 1.6%; P = .05), but there were no differences in hemorrhages requiring surgical intervention (1.8% vs 1.3%; P = .65). There were no differences in retreatment, thromboembolic complications, and mortality rates. CONCLUSION Off-label PED treatment may be considered for select aneurysms, which are challenging to treat with other techniques. These cases have similar complete and near-complete occlusion rates compared with on-label cases. There are, however, higher risks of poor functional outcomes despite similar rates of thromboembolic and hemorrhagic complications. This is partly explained by the significantly higher pretreatment mRS score in the off-label group.
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Khorasanizadeh M, Chang YM, Enriquez-Marulanda A, Mizuhashi S, Moore JM, Ogilvy CS, Thoma AJ. 109 Morphological Changes in Chronic Subdural Hematomas Following Upfront Middle Meningeal Artery Embolization: Sequence, Timing, and Association with Outcomes. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Salih M, Salem MM, Moore JM, Thomas AJ, Ogilvy CS. 402 Cost-Effectiveness Analysis on Small (<5 mm) Unruptured Intracranial Aneurysm Follow-up Strategies. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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21
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Salih M, Salem MM, Moore JM, Ogilvy CS. 108 Cost-Effectiveness Analysis on Screening Females Who Smoke Cigarettes for Unruptured Intracranial Aneurysms. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Enriquez-Marulanda A, Gomez-Paz S, Salem MM, Mallick A, Arle JE, Stippler M, Papavassiliou E, Alterman RL, Ogilvy CS, Moore JM, Thomas AJ. 801 Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Salem MM, Dmytriw AA, Khorasanizadeh M, Lay SV, Renieri L, Sweid A, Moore JM, Jabbour P, Ogilvy CS, Limbucci N, Cognard C, Thomas AJ. 414 Flow Diversion for Middle Cerebral Artery Bifurcation Aneurysms: A Multicenter Cohort. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Enriquez-Marulanda A, Penumaka A, Ogilvy CS, Thomas AJ, Moore JM. 400 Safety and Efficacy of the Off-label Use of Pipeline Embolization Device Based on the 2018 FDA Approved Indications for Intracranial Aneurysms: A Single Center Retrospective Cohort Study. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Gomez-Paz S, Enriquez-Marulanda A, Ogilvy CS, Moore JM, Thomas AJ. In Reply: Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2022; 90:e108-e109. [PMID: 35107087 DOI: 10.1227/neu.0000000000001872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Enriquez-Marulanda A, Gomez-Paz S, Ogilvy CS, Moore JM, Thomas AJ. In Reply: Middle Meningeal Artery Embolization versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2022; 90:e97. [PMID: 35049525 DOI: 10.1227/neu.0000000000001845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 11/19/2022] Open
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Ascanio LC, Gupta R, Tachie-Baffour Y, Chida K, Dmytriw AA, Enriquez-Marulanda A, Chinnadurai A, Alturki AY, Ogilvy CS, Thomas AJ, Moore JM. Effect of cerebrospinal fluid drainage on clinical outcomes following aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2022; 97:1-6. [PMID: 34999308 DOI: 10.1016/j.jocn.2021.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/19/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We study the relationship between external ventricular drainage (EVD) of cerebrospinal fluid output and functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective chart review of patients presenting to a single center with aSAH was performed. The primary outcome was good functional outcomes assessed by a composite of the modified Rankin scale (mRS 0-2) at last follow-up. Secondary outcomes were clinical and radiographic vasospasm. For data analysis, multivariable generalized estimating equations adjusting for potential confounders were used. RESULTS A total of 119 patients were included; 91 (75.6%) presented with a modified Fisher grade 4 and 76 (63.9%) had hydrocephalus. The median EVD duration was 13 days. On average, most EVDs were set at 15 cmH2O (50, 42%). Follow-up was available in 109 patients; median time was 10.7 months; 69 (63.3%) had good outcomes. Multivariable analysis showed that EVDs set at 10 cmH2O had increased odds of good outcomes for every ml increase in the EVD output (OR = 1.02; 95% CI 1.01-1.03; p = 0.001). Post estimation analyses show that EVDs at 10 cmH2O with output close to 200 ml predicted a 50% probability of good outcomes. CONCLUSIONS Increased EVD outputs were associated with favorable outcomes at the last follow-up.
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Affiliation(s)
- Luis C Ascanio
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Raghav Gupta
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yaw Tachie-Baffour
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kohei Chida
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Anu Chinnadurai
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Abdulrahman Y Alturki
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Uhlmann EJ, Rabinovsky R, Varma H, El Fatimy R, Kasper EM, Moore JM, Vega RA, Thomas AJ, Alterman RL, Stippler M, Anderson MP, Uhlmann EN, Kipper FC, Krichevsky AM. Tumor-Derived Cell Culture Model for the Investigation of Meningioma Biology. J Neuropathol Exp Neurol 2021; 80:1117-1124. [PMID: 34850056 PMCID: PMC8716066 DOI: 10.1093/jnen/nlab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Meningioma is the most common primary central nervous system tumor. Although mostly nonmalignant, meningioma can cause serious complications by mass effect and vasogenic edema. While surgery and radiation improve outcomes, not all cases can be treated due to eloquent location. Presently no medical treatment is available to slow meningioma growth owing to incomplete understanding of the underlying pathology, which in turn is due to the lack of high-fidelity tissue culture and animal models. We propose a simple and rapid method for the establishment of meningioma tumor-derived primary cultures. These cells can be maintained in culture for a limited time in serum-free media as spheres and form adherent cultures in the presence of 4% fetal calf serum. Many of the tissue samples show expression of the lineage marker PDG2S, which is typically retained in matched cultured cells, suggesting the presence of cells of arachnoid origin. Furthermore, nonarachnoid cells including vascular endothelial cells are also present in the cultures in addition to arachnoid cells, potentially providing a more accurate tumor cell microenvironment, and thus making the model more relevant for meningioma research and high-throughput drug screening.
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Affiliation(s)
- Erik J Uhlmann
- From the Department of Neurology, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rosalia Rabinovsky
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hemant Varma
- Department of Pathology, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rachid El Fatimy
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ekkehard M Kasper
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rafael A Vega
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald L Alterman
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew P Anderson
- Department of Pathology, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erik N Uhlmann
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada.,Khoury College of Computer Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Franciela C Kipper
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anna M Krichevsky
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Ascanio LC, Enriquez-Marulanda A, Maragkos GA, Salem MM, Alturki AY, Ravindran K, Fehnel CR, Hanafy K, Ogilvy CS, Thomas AJ, Moore JM. Effect of Blood Pressure Variability During the Acute Period of Subarachnoid Hemorrhage on Functional Outcomes. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa019_s026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kan P, Maragkos GA, Srivatsan A, Srinivasan V, Johnson J, Burkhardt JK, Robinson TM, Salem MM, Chen S, Riina HA, Tanweer O, Levy EI, Spiotta AM, Kasab SA, Lena J, Gross BA, Cherian J, Cawley CM, Howard BM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Kelly CM, Jankowitz BT, Ogilvy CS, Moore JM, Levitt MR, Binning M, Grandhi R, Siddiq F, Thomas AJ. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa379_s082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Salem MM, Ravindran K, Enriquez-Marulanda A, Ascanio LC, Jordan N, Gomez-Paz S, Foreman PM, Ogilvy CS, Thomas AJ, Moore JM. Pipeline Embolization Device Versus Stent-Assisted Coiling for Intracranial Aneurysm Treatment: A Retrospective Propensity Score-Matched Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa041_s017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ogilvy CS, Gomez-Paz S, Kicielinski KP, Salem MM, Maragkos GA, Lee M, Vergara-Garcia D, Rojas R, Moore JM, Thomas AJ. Women With First-Hand Tobacco Smoke Exposure Have a Higher Likelihood of Having an Unruptured Intracranial Aneurysm Than Nonsmokers: A Nested Case-Control Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa227_s047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Salem MM, Khorasanizadeh M, Lay SV, Renieri L, Kuhn AL, Sweid A, Massari F, Moore JM, Tjoumakaris SI, Jabbour P, Puri AS, Ogilvy CS, Jankowitz BT, Burkhardt JK, Kan P, Limbucci N, Cognard C, Thomas AJ. Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort. J Neurointerv Surg 2021; 14:1084-1089. [PMID: 34732531 DOI: 10.1136/neurintsurg-2021-018224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Data regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches. METHODS Prospectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011-2018). The pertinent clinical and radiographic data were collected and analyzed. RESULTS 87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90-99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0-2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019). CONCLUSION FDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mirhojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sovann V Lay
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Francesco Massari
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Salem MM, Salih M, Nwajei F, Gomez-Paz S, Thomas AJ, Ogilvy CS, Moore JM. Cost-Effectiveness Analytic Comparison of Neuroimaging Follow-Up Strategies After Pipeline Embolization Device Treatment of Unruptured Intracranial Aneurysms. World Neurosurg 2021; 158:e206-e213. [PMID: 34757210 DOI: 10.1016/j.wneu.2021.10.154] [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: 09/17/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Flow diversion via a Pipeline embolization device (PED [Medtronic, Dublin, Ireland]) is one of the established modalities for the treatment of unruptured intracranial aneurysms that require a robust follow-up regimen. However, to date, no consensus has been reached regarding the optimal imaging modality and timing intervals for such a strategy. We studied the cost-effectiveness of different neuroimaging follow-up strategies after flow diversion with the PED. METHODS A decision-analytical study using Markov modeling was performed to compare 5 commonly used multistep follow-up strategies with different combinations of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): 1) DSA at 6 months and MRA at 12 and 24 months; 2) DSA at 6, 12, and 24 months; 3) MRA at 6, 12, and 24 months; 4) DSA at 6 and 12 months and MRA at 24 months; and 5) DSA at 12 months and MRA at 24 months. The input parameters were mainly collected from the latest meta-analysis, and 1-way, 2-way, and probabilistic sensitivity analyses were conducted to assess the robustness of our model. RESULTS Strategy 5, incorporating DSA at 12 months and MRA at 24 months, was the most cost-effective strategy for >99% of the 10,000 iterations in the probabilistic sensitivity analysis at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. The result remained robust in the 1- and 2-way sensitivity analyses. CONCLUSIONS Given the current data, delayed imaging follow-up at 1 year with DSA and 2 years with MRA after PED treatment of unruptured intracranial aneurysms is more cost-effective than early follow-up at 6 months.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Salem MM, Sweid A, Kuhn AL, Dmytriw AA, Gomez-Paz S, Maragkos GA, Waqas M, Parra-Farinas C, Salehani A, Adeeb N, Brouwer P, Pickett G, Ku J, X D Yang V, Weill A, Radovanovic I, Cognard C, Spears J, Cuellar-Saenz HH, Renieri L, Kan P, Limbucci N, Mendes Pereira V, Harrigan MR, Puri AS, Levy EI, Moore JM, Ogilvy CS, Marotta TR, Jabbour P, Thomas AJ. Repeat Flow Diversion for Cerebral Aneurysms Failing Prior Flow Diversion: Safety and Feasibility From Multicenter Experience. Stroke 2021; 53:1178-1189. [PMID: 34634924 DOI: 10.1161/strokeaha.120.033555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal persistence after flow diversion (FD) occurs in 5% to 25% of aneurysms, which may necessitate retreatment. There are limited data on safety/efficacy of repeat FD-a frequently utilized strategy in such cases. METHODS A series of consecutive patients undergoing FD retreatment from 15 centers were reviewed (2011-2019), with inclusion criteria of repeat FD for the same aneurysm at least 6 months after initial treatment, with minimum of 6 months post-retreatment imaging. The primary outcome was aneurysmal occlusion, and secondary outcome was safety. A multivariable logistic regression model was constructed to identify predictors of incomplete occlusion (90%-99% and <90% occlusion) versus complete occlusion (100%) after retreatment. RESULTS Ninety-five patients (median age, 57 years; 81% women) harboring 95 aneurysms underwent 198 treatment procedures. Majority of aneurysms were unruptured (87.4%), saccular (74.7%), and located in the internal carotid artery (79%; median size, 9 mm). Median elapsed time between the first and second treatment was 12.2 months. Last available follow-up was at median 12.8 months after retreatment, and median 30.6 months after the initial treatment, showing complete occlusion in 46.2% and near-complete occlusion (90%-99%) in 20.4% of aneurysms. There was no difference in ischemic complications following initial treatment and retreatment (4.2% versus 4.2%; P>0.99). On multivariable regression, fusiform morphology had higher nonocclusion odds after retreatment (odds ratio [OR], 7.2 [95% CI, 1.97-20.8]). Family history of aneurysms was associated with lower odds of nonocclusion (OR, 0.18 [95% CI, 0.04-0.78]). Likewise, positive smoking history was associated with lower odds of nonocclusion (OR, 0.29 [95% CI, 0.1-0.86]). History of hypertension trended toward incomplete occlusion (OR, 3.10 [95% CI, 0.98-6.3]), similar to incorporated branch into aneurysms (OR, 2.78 [95% CI, 0.98-6.8]). CONCLUSIONS Repeat FD for persistent aneurysms carries a reasonable success/safety profile. Satisfactory occlusion (100% and 90%-99% occlusion) was encountered in two-thirds of patients, with similar complications between the initial and subsequent retreatments. Fusiform morphology was the strongest predictor of retreatment failure.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Ahmad Sweid
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Adam A Dmytriw
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Georgios A Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Carmen Parra-Farinas
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Arsalaan Salehani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Nimer Adeeb
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Patrick Brouwer
- Department of Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden (P.B.)
| | - Gwynedd Pickett
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada (G.P.)
| | - Jerry Ku
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Victor X D Yang
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, QC, Canada (A.W.)
| | - Ivan Radovanovic
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.)
| | - Julian Spears
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Hugo H Cuellar-Saenz
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K.)
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Vitor Mendes Pereira
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Thomas R Marotta
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
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Salem MM, Salih M, Nwajei F, Williams N, Thomas AJ, Moore JM, Ogilvy CS. Longitudinal Cost Profiles of Pipeline Embolization Device Versus Stent-Assisted Coiling in Propensity-Matched Unruptured Small Anterior Circulation Aneurysms. Neurosurgery 2021; 89:867-872. [PMID: 34383055 DOI: 10.1093/neuros/nyab304] [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: 12/11/2020] [Accepted: 06/09/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The cost profiles of stent-assisted coiling (SAC) vs Pipeline embolization device (PED) in small unruptured anterior circulation aneurysms have not been studied. OBJECTIVE To compare the 2 modalities cost profiles in a propensity-matched cohort controlling for potential technical complexity confounders including size and location. METHODS Patients treated with either SAC or PED at our institution were identified. Following propensity-score algorithm, 46 patients, 23 in each group were matched. The procedural and follow-up costs in each group were analyzed and compared. RESULTS Median maximal aneurysm size in the SAC and PED cohort were 5.3 vs 5.1 mm, respectively. Costs of access guide materials were significantly higher in the SAC group (P < .01). The average implant cost was not significantly different between the SAC and PED cohorts (${\$}$13973.2 ± ${\$}$2886.2 vs ${\$}$14,760.7 ± ${\$}$3782.1, respectively; P = .43). Similarly, total procedural costs were not different (${\$}$18341.5 ± 4104 vs ${\$}$17484.3 ± 2914.1, respectively, P = .42). Although there were significantly more total follow-ups (P = .02) and longer follow-up duration (P = .01) in SAC cohort, no significant difference in follow-up costs between the 2 groups was identified (${\$}$20557 ± ${\$}$9247 vs ${\$}$18958 ± ${\$}$9171.9, P = .56). Overall cost was similar between the SAC (${\$}$38898.9 ± ${\$}$9645.5) and PED groups (${\$}$36442.4 ± ${\$}$9076) (P = .38). CONCLUSION In small unruptured anterior circulation aneurysms (excluding anterior communicating artery aneurysms) matched for technical complexity confounders, SAC and PED offer an overall equivalent economic cost profile. Postprocedural noninvasive imaging was more frequent in the SAC group. However, follow-up costs and total costs were not significantly different.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalie Williams
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Lad M, Gupta R, Para A, Gupta A, White MD, Agarwal N, Moore JM, Heary RF. An ACGME-based comparison of neurosurgical and orthopedic resident training in adult spine surgery via a case volume and hours-based analysis. J Neurosurg Spine 2021:1-11. [PMID: 34359032 DOI: 10.3171/2020.10.spine201066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In a 2014 analysis of orthopedic and neurological surgical case logs published by the Accreditation Council for Graduate Medical Education (ACGME), it was reported that graduating neurosurgery residents performed more than twice the number of spinal procedures in their training compared with graduating orthopedic residents. There has, however, been no follow-up assessment of this trend. Moreover, whether this gap in case volume equates to a similar gap in procedural hours has remained unstudied. Given the association between surgical volume and outcomes, evaluating the status of this disparity has value. Here, the authors assess trends in case volume and procedural hours in adult spine surgery for graduating orthopedic and neurological surgery residents from 2014 to 2019. METHODS A retrospective analysis of ACGME case logs from 2014 to 2019 for graduating orthopedic and neurological surgery residents was conducted for adult spine surgeries. Case volume was converted to operative hours by using periprocedural times from the 2019 Medicare/Medicaid Physician Fee Schedule. Graduating residents' spinal cases and hours, averaged over the study period, were compared between the two specialties by using 2-tailed Welch's unequal variances t-tests (α = 0.05). Longitudinal trends in each metric were assessed by linear regression followed by cross-specialty comparisons via tests for equality of slopes. RESULTS From 2014 to 2019, graduating neurosurgical residents logged 6.8 times as many spinal cases as their orthopedic counterparts, accruing 431.6 (95% CI 406.49-456.61) and 63.8 (95% CI 57.08-70.56) cases (p < 0.001), respectively. Accordingly, graduating neurosurgical residents logged 6.1 times as many spinal procedural hours as orthopedic surgery residents, accruing 1020.7 (95% CI 964.70-1076.64) and 166.6 (95% CI 147.76-185.35) hours (p < 0.001), respectively. Over these 5 years, both fields saw a linear increase in graduating residents' adult spinal case volumes and procedural hours, and these growth rates were higher for neurosurgery (+16.2 cases/year vs +4.4 cases/year, p < 0.001; +36.4 hours/year vs +12.4 hours/year, p < 0.001). CONCLUSIONS Graduating neurosurgical residents accumulated substantially greater adult spinal case volumes and procedural hours than their orthopedic counterparts from 2014 to 2019. This disparity has been widened by a higher rate of growth in adult spinal cases among neurosurgery residents. Accordingly, targeted efforts to increase spinal exposure for orthopedic surgery residents-such as using cross-specialty collaboration-should be explored.
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Affiliation(s)
- Meeki Lad
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Raghav Gupta
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey.,2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ashok Para
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Arjun Gupta
- 1Department of Neurosurgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Michael D White
- 3Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nitin Agarwal
- 3Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Justin M Moore
- 4Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Robert F Heary
- 5Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey
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Williams LC, Moore JM, Naples JG. Objective Pulsatile Tinnitus Caused by Vascular Anomaly of the Internal Maxillary Artery. Otol Neurotol 2021; 42:e970-e971. [PMID: 33625191 DOI: 10.1097/mao.0000000000003082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - James G Naples
- Department of Otolaryngology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Enriquez-Marulanda A, Gomez-Paz S, Salem MM, Mallick A, Motiei-Langroudi R, Arle JE, Stippler M, Papavassiliou E, Alterman RL, Ogilvy CS, Moore JM, Thomas AJ. Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2021; 89:486-495. [PMID: 34171921 DOI: 10.1093/neuros/nyab192] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 09/27/2020] [Accepted: 04/03/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization is an emerging minimally invasive endovascular technique for chronic subdural hematoma (cSDH). Currently, limited literature exists on its safety and efficacy compared with conventional treatment (open-surgical-evacuation-only). OBJECTIVE To compare MMA embolization to conventional treatment. METHODS Retrospective analysis of patients with cSDHs treated with MMA embolization in a single center from 2018 to 2019 was performed. Comparisons were made with a historical conventional treatment cohort from 2006 to 2016. Propensity score matching analysis was used to assemble a balanced group of subjects. RESULTS A total of 357 conventionally treated cSDH and 45 with MMA embolization were included. After balancing with propensity score matching, a total of 25 pairs of cSDH were analyzed. Comparing the embolization with the conventional treatment group yielded no significant differences in complications (4% vs 4%; P > .99), clinical improvement (82.6% vs 83.3%; P = .95), cSDH recurrence (4.3% vs 21.7%; P = .08), overall re-intervention rates (12% vs 24%; P = .26), modified Rankin scale >2 on last follow-up (17.4% vs 32%; P = .24), as well as mortality (0% vs 12%; P = .09). Radiographic improvement at last follow-up was significantly higher in the open surgery cohort (73.9% vs 95.6%; P = .04). However, there was a trend for lengthier last follow-up for the historical cohort (72 vs 104 d; P = .07). CONCLUSION There was a trend for lower recurrence and mortality rates in the embolization era cohort. There were significantly higher radiological improvement rates on last follow-up in the surgical only cohort era. There were no significant differences in complications and clinical improvement.
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Affiliation(s)
| | - Santiago Gomez-Paz
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Akashleena Mallick
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - J E Arle
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Efstathios Papavassiliou
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron L Alterman
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Gomez-Paz S, Akamatsu Y, Salem MM, Moore JM, Ogilvy CS, Thomas AJ. Direct Transverse Sinus Cannulation for Coil Embolization of a Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E288-E289. [PMID: 33517460 DOI: 10.1093/ons/opaa455] [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: 09/11/2020] [Accepted: 11/11/2020] [Indexed: 11/14/2022] Open
Abstract
A 65-yr-old male presented 2 mo after an episode of acute-onset headache associated with altered mental status. Imaging workup with cerebral angiography revealed a Cognard type IV right-sided transverse-sigmoid junction dural arteriovenous fistula (dAVF). The patient was treated with endovascular embolization of several pedicles from the middle meningeal (MMA) and occipital arteries. Residual filling and cortical venous reflux were noted on follow-up imaging. Therefore, definitive treatment of the persistent fistula was offered with a combined open and endovascular embolization approach.1 This would provide direct access into the sinus followed by embolization of the fistula. In the accompanying video, we present the case in detail and provide a discussion of the rational and treatment nuances associated with this approach. Patient consent was given prior to the procedure and consent and approval for this operative video were waived due to the retrospective nature of this manuscript and the anonymized video material.
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Affiliation(s)
- Santiago Gomez-Paz
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Yosuke Akamatsu
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Gomez-Paz S, Akamatsu Y, Salem MM, Moore JM, Thomas AJ, Ogilvy CS. Transvenous Coil Embolization of a Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E290-E291. [PMID: 33517405 DOI: 10.1093/ons/opaa454] [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: 09/11/2020] [Accepted: 11/11/2020] [Indexed: 11/14/2022] Open
Abstract
This case is a 66-yr-old woman with a 2-mo history of left-sided tinnitus. Workup with magnetic resonance angiography showed early opacification of the left sigmoid sinus and internal jugular vein as well as asymmetric and abundant opacification of the left external carotid artery branches, suspicious for a dural arteriovenous fistula (dAVF). Diagnosis was confirmed with cerebral angiography, consistent with a left-sided Cognard type I dAVF.1 Initial treatment attempt was made with transarterial 6% ethylene-vinyl alcohol copolymer (Onyx 18) embolization of feeders from the occipital and middle meningeal arteries. However, embolization was not curative and there was a recurrence of a highly bothersome tinnitus 3 wk following treatment. Angiography redemonstrated the transverse sinus dAVF with new recruitment arising from several feeders, including the left external carotid artery, middle meningeal artery, and superficial temporal artery, now Cognard type IIa. Definitive treatment through a transvenous coil embolization provided permanent obliteration of the fistula without recrudescence of symptoms on follow-up. In this video, the authors discuss the nuances of treating a dAVF via a transvenous embolization. Patient consent was given prior to the procedure, and consent and approval for this operative video were waived because of the retrospective nature of this manuscript and the anonymized video material.
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Affiliation(s)
- Santiago Gomez-Paz
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Yosuke Akamatsu
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Akamatsu Y, Gomez-Paz S, Vergara-Garcia D, Moholkar VM, Kuhn AL, Chida K, Singh J, Rodrigues KDM, Massari F, Moore JM, Puri AS, Ogilvy CS, Thomas AJ. Role of Surgical Intervention for Intracranial Dural Arteriovenous Fistulas With Cortical Venous Drainage in an Endovascular Era: A Case Series. Oper Neurosurg (Hagerstown) 2021; 20:364-372. [PMID: 33378448 DOI: 10.1093/ons/opaa423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/09/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intracranial dural arteriovenous fistulae (dAVFs) with cortical venous drainage (CVD) require treatment because of their aggressive clinical presentation and natural history. Although endovascular treatment is effective for the majority of these lesions in the current endovascular era, surgical management has been required if the lesions are not amenable to or fail endovascular treatments. OBJECTIVE To demonstrate the angioarchitecture that may necessitate surgical intervention. METHODS A retrospective review of the patients with intracranial dAVFs with CVD treated at 2 academic institutions between January 1, 2009, and July 31, 2019 was performed. Patients who required surgical intervention were selected in this study, and angiographic findings were analyzed. RESULTS A total of 81 dAVFs in 80 patients were treated during the study period. Endovascular treatments were attempted for 72 (88.9%) dAVFs, resulting in complete obliteration in 55 (76.4%). Surgical interventions were performed in 18 (22.2%) dAVFs, resulting in complete obliteration in all lesions. Overall, complete obliteration was achieved in 74 (93.7%) of 79 dAVFs with follow-up. In the surgically treated dAVFs, curative transarterial embolization was deterred by the angioarchitecture, which included dominant feeding vessels from the ophthalmic artery, meningohypophyseal trunk, posterior meningeal artery, pial artery, or ascending pharyngeal artery. Drainage through tortuous cortical vein, deep venous system, or isolated sinus made transvenous approach challenging. CONCLUSION Despite continued improvement in endovascular technology, surgical approaches to dAVFs are still of great value as initial and salvage treatment of dAVFs with angioarchitecture hampering endovascular treatment.
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Affiliation(s)
- Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Neurosurgery, Iwate Medical University, Yahaba, Japan
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - David Vergara-Garcia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Viraj M Moholkar
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Anna Luisa Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Kohei Chida
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Neurosurgery, Iwate Medical University, Yahaba, Japan
| | - Jasmeet Singh
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Katyucia de Macedo Rodrigues
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Francesco Massari
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Gomez-Paz S, Akamatsu Y, Salem MM, Moore JM, Ogilvy CS, Thomas AJ. Transarterial Embolization of a Transverse Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E41-E42. [PMID: 33316817 DOI: 10.1093/ons/opaa370] [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: 09/11/2020] [Accepted: 10/09/2020] [Indexed: 11/13/2022] Open
Abstract
A 40-yr-old male with no significant past medical history presented with sudden onset right-sided retro-orbital headache associated with vision loss after a session of strenuous exercise. Initial assessment with noncontrast head computed tomography at the local emergency department revealed a right sided occipital intracranial hemorrhage (ICH). On arrival the patient ad a left quadrantopsia with Glasgow Coma Scale of 15 and an ICH score of 0. A computed tomographic angiography showed a high density 6 × 9 mm vascular lesion associated with 2 tortuous vessels. Cerebral angiography revealed a right sided dural arteriovenous fistula, Cognard Type IV, with arterial feeders arising from dural branches of the right vertebral artery, the posterior division of the right middle meningeal artery and meningeal branches distal to the neuromeningeal trunk of the left ascending pharyngeal artery.1 Four days after the ICH event the patient was treated with endovascular Onyx embolization of the fistula, through a transradial approach. Immediate angiographic assessment showed complete obliteration of the dAVF. The patient was discharged home and recovered his visual field deficit over 3 mo. The following operative video includes a discussion of the endovascular technique and treatment nuances associated with the transarterial management of a dural arteriovenous fistula. Patient consent was given prior to the procedure and consent and approval for this operative video was waived due to the retrospective nature of this manuscript and the anonymized video material.
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Salem MM, Ascanio LC, Enriquez-Marulanda A, Gomez-Paz S, Mackel CE, Kamel S, Moore JM, Ogilvy CS, Thomas AJ. The use of staples for external ventricular drain catheter fixation: A single-institution experience. Clin Neurol Neurosurg 2021; 207:106761. [PMID: 34217006 DOI: 10.1016/j.clineuro.2021.106761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/11/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sutures are conventionally used for external ventricular drain (EVD) catheter fixation, but staples are an appealing alternative as they are quicker and easier to learn. We report our institutional experience with EVD fixation techniques and the patterns of catheter fixation. METHODS We conducted a retrospective review of all aneurysmal subarachnoid hemorrhage (aSAH) patients treated in a single US center between 2007 and 2017. RESULTS Out of 307 patients, 217 patients (62.2% female, mean age 59.5 years) met inclusion criteria harboring 268 EVDs. Two main configurations were used for EVD catheter fixation; spiral-shaped EVDs in 139 (51.9%) cases and arciform (C-shaped) EVDs in 129 (48.1%) of the cases. 220 (82.1%) were secured with staples and 48 (17.9%) with sutures. The most common complication was obstruction (n = 43, 16.2%), followed by infections (n = 18, 6.8%). Catheter dislodgements occurred in 16 (5.9%) catheters and 61 (22.8%) required repositioning/replacement. EVD dislodgement rates did not differ between the staples and sutures group, or between the spiral and C-shaped EVDs (p = 0.5 and 0.93, respectively). No cases of catheter perforation by the staples were encountered in our cohort. CONCLUSION Staples and sutures are equally valid and acceptable methods for EVD fixation with similar dislodgement rates. Scarce data exist in the literature regarding dislodgements, and further studies are needed to address its incidence and the best preventive strategies.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Luis C Ascanio
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Charles E Mackel
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Salih M, Moore JM, Ogilvy CS. Computed Tomography Angiography versus Digital Subtraction Angiography as a Primary Diagnostic Tool in Nontraumatic Subarachnoid Hemorrhage: Cost-Effectiveness Analysis Study. World Neurosurg 2021; 152:e398-e407. [PMID: 34062303 DOI: 10.1016/j.wneu.2021.05.103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Digital subtraction angiography (DSA) and computed tomographic angiography (CTA) are used to identify the cause of nontraumatic subarachnoid hemorrhage (SAH). There is no consensus on which to choose as the first diagnostic tool. We aimed to compare the cost-effectiveness of CTA versus DSA as a primary tool for identifying the cause of nontraumatic SAH. METHODS A decision analysis model was built to simulate patients undergoing DSA or CTA as a primary diagnostic tool for the cause of nontraumatic SAH. The input data for the study were extracted from literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model. RESULTS In the base case calculation, it cost $1261.82 less and yielded 0.0001 quality-adjusted life year (QALY) when DSA was used as a primary diagnostic imaging tool for nontraumatic SAH. Choosing DSA as a primary tool was cost-effective in more than 65% of iterations in probabilistic sensitivity analysis. Deterministic sensitivity analyses show when the probability of using endovascular treatment is >47.2%, choosing DSA is more cost-effective; otherwise, CTA is more optimal. CTA is more cost-effective when the cost for DSA >2.6 × CTA + $600. CONCLUSIONS Based on current literature and our model DSA as a primary diagnostic tool for the cause of nontraumatic SAH is more cost-effective. However, in clinical practice physicians can choose either DSA or CTA according to the scale of endovascular procedures used in their center, as well as the cost correlation between CTA and DSA, which varies among institutions.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA.
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts, USA
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Ascanio LC, Dmytriw AA, Chida K, Enriquez-Marulanda A, Mayeku J, Gupta R, Maragkos G, Alturki AY, Darbaz B, Thomas AJ, Ogilvy CS, Moore JM. Evaluation of the utility of early routine computed tomography angiography in subarachnoid hemorrhage patient outcomes. J Clin Neurosci 2021; 89:133-138. [PMID: 34119256 DOI: 10.1016/j.jocn.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The role of an early CTA approach in neurologically stable patients with nontraumatic SAH has not been assessed. This study explored the use of CTA in clinically stable SAH patients to pre-emptively identify cerebral vasospasm, to evaluate whether this approach is associated with improved clinical outcomes. METHODS We conducted a retrospective chart review of SAH patients presenting between July 2007 and December 2016 in a single academic center. Patients were divided into two groups: (1) Early CTA (stable patients who underwent a CTA between days 5-8 post-SAH), and (2) Standard Protocol. The co-primary outcomes were a composite of the mRS at discharge and last clinical follow-up (good = 0-2; poor = 3-6). A multivariable binary logistic regression was conducted to compare both groups against outcomes, controlling for potential confounders. RESULTS A total of 415 patients were included, 103 (24.8%) with early CTA, and 312 (75.2%) undergoing the standard protocol; the mean age was 57 years and 248 (59.8%) patients were female. Patients in the early CTA group had a higher modified Fisher grade (3-4) (87.4% vs 63.1%; p < 0.02). The multivariable analysis showed that early CTA was independently associated with lower poor outcomes at discharge (OR = 0.21, 95% CI 0.07-0.61, p = 0.004). Plus, vasospasm detection was associated with an increased risk of poor outcomes (OR = 4.77, 95% CI 1.41 - 16.10, p = 0.01). Early CTA was not associated with outcomes at clinical follow-up. CONCLUSION The early CTA surveillance approach was associated with better functional outcomes at discharge when compared to the current imaging standard practice.
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Affiliation(s)
- Luis C Ascanio
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kohei Chida
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Julie Mayeku
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Raghav Gupta
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Georgios Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Abdulrahman Y Alturki
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, The National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Berkan Darbaz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Gomez-Paz S, Akamatsu Y, Mallick A, Jordan NJ, Salem MM, Enriquez-Marulanda A, Thomas AJ, Ogilvy CS, Moore JM. Tortuosity Index Predicts Early Successful Reperfusion and Affects Functional Status After Thrombectomy for Stroke. World Neurosurg 2021; 152:e1-e10. [PMID: 33862300 DOI: 10.1016/j.wneu.2021.02.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/22/2021] [Accepted: 02/26/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The literature is scarce for studies evaluating the anatomy of cervical vessels in patients with stroke. We sought to investigate the effect of vessel tortuosity in procedural, angiographic, and functional outcomes in patients with acute ischemic stroke treated with mechanical thrombectomy (MT). METHODS Patients with an emergent large vessel occlusion of the anterior circulation treated with MT between 2015 and 2020 were included. The tortuosity of the internal carotid artery was recorded as the tortuosity index (TI) using the following formula: [(actual/straight length-1) × 100). A multivariable regression was performed to assess procedural, angiographic, and functional outcomes based on the TI. RESULTS A total of 212 patients were included. Median age was 72 years (interquartile range, 62-82 years); admission National Institutes of Health Stroke Scale score was 17 ± 6. Median TI was 7.9 (interquartile range, 3.7-19.7). A total of 127 patients (60%) had a TI <10. Early reperfusion (procedure time <60 minutes) was accomplished in 144 patients (67.9%). A multivariable analysis showed that patients with a TI <10 were more likely to achieve an early reperfusion (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.11-4.78; P = 0.025). A TI <10 was a predictor of successful reperfusion (OR, 2.0; CI, 1.05-3.93; P = 0.035) and an early reperfusion was the sole predictor of functional independence (most recent modified Rankin Scale score 0-2) (OR, 4.1; 95% CI, 1.62-10.53; adjusted P = 0.003). CONCLUSIONS Patients with a TI <10 are significantly more likely to achieve early successful reperfusion after MT for the treatment of acute ischemic stroke.
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Affiliation(s)
- Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Akashleena Mallick
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Noah J Jordan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Kan P, Maragkos GA, Srivatsan A, Srinivasan V, Johnson J, Burkhardt JK, Robinson TM, Salem MM, Chen S, Riina HA, Tanweer O, Levy EI, Spiotta AM, Kasab SA, Lena J, Gross BA, Cherian J, Cawley CM, Howard BM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Kelly CM, Jankowitz BT, Ogilvy CS, Moore JM, Levitt MR, Binning M, Grandhi R, Siddiq F, Thomas AJ. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations. Neurosurgery 2021; 88:268-277. [PMID: 33026434 DOI: 10.1093/neuros/nyaa379] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [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: 12/19/2019] [Accepted: 06/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE To determine the safety and efficacy of MMA embolization. METHODS Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Timothy M Robinson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephen Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York City, New York
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Medical Center, New York City, New York
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Sami Al Kasab
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Jonathan Lena
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Cherian
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew J Ringer
- Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida
| | - Rafael A Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Mandy Binning
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Montana
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Ahrendsen JT, Moore JM, Varma H. Neuroglial heterotopia of the middle ear: A case series and systematic literature review. Surg Neurol Int 2021; 12:60. [PMID: 33654563 PMCID: PMC7911201 DOI: 10.25259/sni_904_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 01/01/2023] Open
Abstract
Background The differential diagnosis for mass forming lesions of the middle ear is broad. While uncommon, neuroglial heterotopias can occur in the middle ear and can be a source of diagnostic confusion for clinician, radiologist, and pathologist alike. Methods We identified three cases of neuroglial heterotopia of the middle ear in our institutional archives from 2000 to 2020 and performed extensive histological and immunohistochemical characterization of the three lesions. We conducted a systematic literature review to identify 27 cases published in the English literature between the years 1980 and 2020. Only cases with histological verification of neuroglial heterotopia specifically involving the middle ear were included. We compiled the clinical, radiological, and histopathological findings for all 30 cases. Results Patients most frequently presented with chronic otitis media (40%), hearing loss (40%), or prior history of ear surgery or trauma (13%). The median age at surgery was 49 years with a male predominance (M:F 2:1); however, a bimodal age distribution was noted with an earlier onset (11 years or younger) in a subset of patients. Immunohistochemical characterization showed mature neuronal and reactive glial populations with low Ki67 proliferation index and chronic inflammatory infiltrates. There was no neuronal dysplasia or glial atypia, consistent with benign, nonneoplastic, mature glioneuronal tissue. Conclusion Immunohistochemical characterization of these lesions and clinical follow-up confirms their benign natural history. Potential etiologies include developmental misplacement, trauma, and chronic inflammation/ reactive changes resulting in sequestered encephalocele.
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Affiliation(s)
- Jared T Ahrendsen
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Massachusetts, United States
| | - Justin M Moore
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Massachusetts, United States
| | - Hemant Varma
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Massachusetts, United States
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Aaron KA, Vaughan J, Gupta R, Ali NES, Beth AH, Moore JM, Ma Y, Ahmad I, Jackler RK, Vaisbuch Y. The risk of ergonomic injury across surgical specialties. PLoS One 2021; 16:e0244868. [PMID: 33561117 PMCID: PMC7872272 DOI: 10.1371/journal.pone.0244868] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 12/17/2020] [Indexed: 12/11/2022] Open
Abstract
Lack of ergonomic training and poor ergonomic habits during the operation leads to musculoskeletal pain and affects the surgeon’s life outside of work. The objective of the study was to evaluate the severity of ergonomic hazards in the surgical profession across a wide range of surgical subspecialties. We conducted intraoperative observations using Rapid Entire Body Assessment (REBA) score system to identify ergonomic hazards. Additionally, each of the ten surgical subspecialty departments were sent an optional 14 question survey which evaluated ergonomic practice, environmental infrastructure, and prior ergonomic training or education. A total of 91 surgeons received intraoperative observation and were evaluated on the REBA scale with a minimum score of 0 (low ergonomic risk <3) and a maximum score of 10 (high ergonomic risk 8–10). And a total of 389 surgeons received the survey and 167 (43%) surgeons responded. Of the respondents, 69.7% reported suffering from musculoskeletal pain. Furthermore, 54.9% of the surgeons reported suffering from the highest level of pain when standing during surgery, while only 14.4% experienced pain when sitting. Importantly, 47.7% stated the pain impacted their work, while 59.5% reported pain affecting quality of life outside of work. Only 23.8% of surgeons had any prior ergonomic education. Both our subjective and objective data suggest that pain and disability induced by poor ergonomics are widespread among the surgical community and confirm that surgeons rarely receive ergonomic training. Intraoperative observational findings identified that the majority of observed surgeons displayed poor posture, particularly a poor cervical angle and use of ergonomic setups, both of which increase ergonomic risk hazards. This data supports the need for a comprehensive ergonomic interventional program for the surgical team and offers potential targets for future intervention.
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Affiliation(s)
- Ksenia A. Aaron
- Department of Otolaryngology–Head and Neck Surgery; Division of Otology/Neurotology Lateral Skull Base Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - John Vaughan
- Environmental Health & Safety Department, Stanford Health Care and Stanford University School of Medicine, Stanford, California, United States of America
| | - Raghav Gupta
- Rutgers New Jersey Medical School, Newark, New Jersey, United States of America
| | - Noor-E-Seher Ali
- Department of Otolaryngology–Head and Neck Surgery; Division of Otology/Neurotology Lateral Skull Base Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Alicia H. Beth
- Environmental Health & Safety Department, Stanford Health Care and Stanford University School of Medicine, Stanford, California, United States of America
| | - Justin M. Moore
- Department of Neurosurgery, Boston Medical Center, Boston University, Boston, Massachusetts, United States of America
| | - Yifei Ma
- Department of Otolaryngology–Head and Neck Surgery; Division of Otology/Neurotology Lateral Skull Base Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Iram Ahmad
- Department of Otolaryngology–Head and Neck Surgery; Division of Otology/Neurotology Lateral Skull Base Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Robert K. Jackler
- Department of Otolaryngology–Head and Neck Surgery; Division of Otology/Neurotology Lateral Skull Base Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Yona Vaisbuch
- Department of Otolaryngology–Head and Neck Surgery; Division of Otology/Neurotology Lateral Skull Base Surgery, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
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