1
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Walker E, Srienc A, Lew D, Guniganti R, Lanzino G, Brinjikji W, Hayakawa M, Samaniego EA, Derdeyn CP, Du R, Lai R, Sheehan JP, Starke RM, Abla A, Abdelsalam A, Gross B, Albuquerque F, Lawton MT, Kim LJ, Levitt M, Amin-Hanjani S, Alaraj A, Winkler E, Fox WC, Polifka A, Hall S, Bulters D, Durnford A, Satomi J, Tada Y, van Dijk JMC, Potgieser ARE, Chen CJ, Becerril-Gaitan A, Osbun JW, Zipfel GJ. Dural arteriovenous fistulas are not observed to convert to a higher grade after partial embolization. Neurosurg Focus 2024; 56:E8. [PMID: 38428013 DOI: 10.3171/2024.1.focus23745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/02/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Borden-Shucart type I dural arteriovenous fistulas (dAVFs) lack cortical venous drainage and occasionally necessitate intervention depending on patient symptoms. Conversion is the rare transformation of a low-grade dAVF to a higher grade. Factors associated with increased risk of dAVF conversion to a higher grade are poorly understood. The authors hypothesized that partial treatment of type I dAVFs is an independent risk factor for conversion. METHODS The multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research database was used to perform a retrospective analysis of all patients with type I dAVFs. RESULTS Three hundred fifty-eight (33.2%) of 1077 patients had type I dAVFs. Of those 358 patients, 206 received endovascular treatment and 131 were not treated. Two (2.2%) of 91 patients receiving partial endovascular treatment for a low-grade dAVF experienced conversion to a higher grade, 2 (1.5%) of 131 who were not treated experienced conversion, and none (0%) of 115 patients who received complete endovascular treatment experienced dAVF conversion. The majority of converted dAVFs localized to the transverse-sigmoid sinus and all received embolization as part of their treatment. CONCLUSIONS Partial treatment of type I dAVFs does not appear to be significantly associated with conversion to a higher grade.
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Affiliation(s)
- Erin Walker
- 1University of South Carolina School of Medicine, Greenville, South Carolina
- 2Department of Neurological Surgery, Washington University in St. Louis, Missouri
| | - Anja Srienc
- 2Department of Neurological Surgery, Washington University in St. Louis, Missouri
| | - Daphne Lew
- 3Center for Biostatistics and Data Science, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Ridhima Guniganti
- 2Department of Neurological Surgery, Washington University in St. Louis, Missouri
| | | | | | - Minako Hayakawa
- 5Department of Radiology and Interventional Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Edgar A Samaniego
- 6Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- 5Department of Radiology and Interventional Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Rose Du
- 7Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rosalind Lai
- 7Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jason P Sheehan
- 8Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Robert M Starke
- 9Neurosurgery Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Adib Abla
- 9Neurosurgery Department, University of Miami Miller School of Medicine, Miami, Florida
- 15Department of Neurosurgery, University of California, San Francisco, California
| | - Ahmed Abdelsalam
- 9Neurosurgery Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Bradley Gross
- 10Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Felipe Albuquerque
- 11Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- 11Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Louis J Kim
- 12Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Michael Levitt
- 12Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Sepideh Amin-Hanjani
- 13Neurosurgery Department, University Hospitals/Case Western Reserve University, Cleveland, Ohio
- 14Department of Neurosurgery, University of Illinois College of Medicine at Chicago, Illinois
| | - Ali Alaraj
- 14Department of Neurosurgery, University of Illinois College of Medicine at Chicago, Illinois
| | - Ethan Winkler
- 15Department of Neurosurgery, University of California, San Francisco, California
| | - W Christopher Fox
- 16Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Adam Polifka
- 17Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
| | - Samuel Hall
- 18Wessex Neurological Centre, Southampton General Hospital, Southampton, United Kingdom
| | - Diederik Bulters
- 18Wessex Neurological Centre, Southampton General Hospital, Southampton, United Kingdom
| | - Andrew Durnford
- 18Wessex Neurological Centre, Southampton General Hospital, Southampton, United Kingdom
| | | | - Yoshiteru Tada
- 19Department of Neurosurgery, University of Tokushima, Japan
| | - J Marc C van Dijk
- 20Department of Neurosurgery, University of Groningen, The Netherlands; and
| | | | - Ching-Jen Chen
- 21Department of Neurosurgery, University of Texas-Houston, Texas
| | | | - Joshua W Osbun
- 2Department of Neurological Surgery, Washington University in St. Louis, Missouri
| | - Gregory J Zipfel
- 2Department of Neurological Surgery, Washington University in St. Louis, Missouri
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2
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Elfil M, Morsi RZ, Ghozy S, Elmashad A, Siddiqui A, Al-Bayati AR, Alaraj A, Brook A, Kam AW, Chatterjee AR, Patsalides A, Waldau B, Prestigiacomo CJ, Matouk C, Schirmer CM, Altschul D, Parrella DT, Toth G, Jindal G, Shaikh HA, Dolia JN, Fifi JT, Fraser JF, DO JT, Amuluru K, Kim LJ, Harrigan M, Amans MR, Kole M, Mokin M, Abraham M, Jumaa M, Janjua N, Zaidat O, Youssef PP, Khandelwal P, Wang QT, Grandhi R, Hanel R, Kellogg RT, Ortega-Gutierrez S, Sheth S, Nguyen TN, Szeder V, Hu YC, Yoo AJ, Tanweer O, Jankowitz B, Heit JJ, Williamson R, Kass-Hout T, Crowley RW, El-Ghanem M, Al-Mufti F. Factors Affecting Selection of TraineE for Neurointervention (FASTEN). Interv Neuroradiol 2024:15910199241232726. [PMID: 38389309 DOI: 10.1177/15910199241232726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process. METHODS A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)]. CONCLUSION Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Elmashad
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Adnan Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY, USA
| | - Alhamza R Al-Bayati
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, Pittsburg, PA, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| | - Allan Brook
- Department of Neurosurgery, Montefiore Medical Center and Children's Hospital at Montefiore (CHAM), Bronx, NY, USA
| | - Anthony W Kam
- Department of Radiology, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA
| | - Arindam Rano Chatterjee
- Interventional Neuroradiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Athos Patsalides
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Ben Waldau
- Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Charles J Prestigiacomo
- Department of Neurological Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - David Altschul
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David T Parrella
- Interventional Neurology, Ascension Saint Thomas Hospital West, Nashville, TN, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Gaurav Jindal
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Hamza A Shaikh
- Department of Radiology, Cooper University Hospital, Camden, NJ, USA
| | | | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA
| | - Justin Thomas DO
- Department of Neurosurgery, McLaren Northern Hospital, Petoskey, MI, USA
| | - Krishna Amuluru
- Interventional Neuroradiology, Goodman Campbell Brain and Spine, Indianapolis, IN, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Mark Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew R Amans
- Departments of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Max Kole
- Department of Neurosurgery, Henry Ford Hospital, Detroit, MI, USA
| | - Max Mokin
- Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Osama Zaidat
- Department of Endovascular Neurosurgery, Mercy Health St Vincent Medical Center, Toledo, OH, USA
| | - Patrick P Youssef
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Qingliang Tony Wang
- Departments of Neurology/Neurosurgery, Maimonides Medical Center/SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, UT, USA
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Sunil Sheth
- Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Viktor Szeder
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Yin C Hu
- Department of Neurosurgery, UH Cleveland Medical Center, Cleveland, OH, USA
| | - Albert J Yoo
- Department of Radiology/Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | - Omar Tanweer
- Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Richard Williamson
- Department of Neurological Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Richard W Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Mohammad El-Ghanem
- Neuroendovascular Surgery, HCA Houston Northwest/University of Houston College of Medicine, Houston, TX, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
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3
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Meyer RM, Grandhi R, Lim DH, Salah WK, McAvoy M, Abecassis ZA, Bonow RH, Walker M, Ghodke BV, Menacho ST, Durfy S, Chesnut RM, Kim LJ, Bell RS, Levitt MR. A comparison of computed tomography angiography and digital subtraction angiography for the diagnosis of penetrating cerebrovascular injury: a prospective multicenter study. J Neurosurg 2024:1-4. [PMID: 38306650 DOI: 10.3171/2023.12.jns232070] [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] [Received: 09/12/2023] [Accepted: 12/04/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE In this research, the authors sought to characterize the incidence and extent of cerebrovascular lesions after penetrating brain injury in a civilian population and to compare the diagnostic value of head computed tomography angiography (CTA) and digital subtraction angiography (DSA) in their diagnosis. METHODS This was a prospective multicenter cohort study of patients with penetrating brain injury due to any mechanism presenting at two academic medical centers over a 3-year period (May 2020 to May 2023). All patients underwent both CTA and DSA. The sensitivity and specificity of CTA was calculated, with DSA considered the gold standard. The number of DSA studies needed to identify a lesion requiring treatment that had not been identified on CTA was also calculated. RESULTS A total of 73 patients were included in the study, 33 of whom had at least 1 penetrating cerebrovascular injury, for an incidence of 45.2%. The injuries included 13 pseudoaneurysms, 11 major arterial occlusions, 9 dural venous sinus occlusions, 8 dural arteriovenous fistulas, and 6 carotid cavernous fistulas. The sensitivity of CTA was 36.4%, and the specificity was 85.0%. Overall, 5.6 DSA studies were needed to identify a lesion requiring treatment that had not been identified with CTA. CONCLUSIONS Cerebrovascular injury is common after penetrating brain injury, and CTA alone is insufficient to diagnosis these injuries. Patients with penetrating brain injuries should routinely undergo DSA.
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Affiliation(s)
| | - Ramesh Grandhi
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Do H Lim
- Departments of1Neurological Surgery and
- 3Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Walid K Salah
- 4University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | | | - Melanie Walker
- Departments of1Neurological Surgery and
- 3Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Basavaraj V Ghodke
- Departments of1Neurological Surgery and
- 5Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Sarah T Menacho
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | - Randall M Chesnut
- Departments of1Neurological Surgery and
- 8School of Global Health, University of Washington, Seattle, Washington; and
| | - Louis J Kim
- Departments of1Neurological Surgery and
- 3Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Randy S Bell
- 6Uniformed Services University of Health Sciences, Bethesda, Maryland
- 7Department of Neurosurgery, Avera Mckennan Hospital and University Health Center, Sioux Falls, South Dakota
| | - Michael R Levitt
- Departments of1Neurological Surgery and
- 3Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
- 5Radiology, University of Washington School of Medicine, Seattle, Washington
- 9Department of Mechanical Engineering, University of Washington, Seattle, Washington
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4
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Sanchez S, Raghuram A, Wendt L, Hayakawa M, Chen CJ, Sheehan JP, Kim LJ, Abecassis IJ, Levitt MR, Meyer RM, Guniganti R, Kansagra AP, Lanzino G, Giordan E, Brinjikji W, Bulters DO, Durnford A, Fox WC, Smith J, Polifka AJ, Gross B, Amin-Hanjani S, Alaraj A, Kwasnicki A, Starke RM, Chen SH, van Dijk JMC, Potgieser ARE, Satomi J, Tada Y, Phelps R, Abla A, Winkler E, Du R, Lai PMR, Zipfel GJ, Derdeyn C, Samaniego EA. Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas. J Neurointerv Surg 2023; 15:903-908. [PMID: 35944975 DOI: 10.1136/jnis-2022-019160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs. METHODS The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990-2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed. RESULTS 60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs. CONCLUSION Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.
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Affiliation(s)
- Sebastian Sanchez
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ashrita Raghuram
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Linder Wendt
- Institute for Clinical and Translational Science, The University of Iowa, Iowa City, Iowa, USA
| | - Minako Hayakawa
- Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Louis J Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - R Michael Meyer
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Ridhima Guniganti
- Department of Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Enrico Giordan
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Diederik O Bulters
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - Andrew Durnford
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, Southampton, UK
| | - W Christopher Fox
- Department of Neurosurgery, Mayo Clinic Jacksonville Campus, Jacksonville, Florida, USA
| | - Jessica Smith
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Bradley Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Coral Gables, Florida, USA
| | - Stephanie H Chen
- Department of Neurosurgery, University of Miami, Coral Gables, Florida, USA
| | - J Marc C van Dijk
- Department of Neurosurgery, University of Groningen, Groningen, Groningen, Netherlands
| | - Adriaan R E Potgieser
- Department of Neurosurgery, University of Groningen, Groningen, Groningen, Netherlands
| | - Junichiro Satomi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yoshiteru Tada
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Ryan Phelps
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Colin Derdeyn
- Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Departments of Neurology, Radiology and Neurosurgery, The University of Iowa, Iowa City, Iowa, USA
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5
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Shenoy VS, Miller C, Sen RD, McAvoy M, Montoure A, Kim LJ, Sekhar LN. High-Flow Bypass and Clip Trapping of a Giant Fusiform Middle Cerebral Artery (M1) Aneurysm: Technical Case Instruction. Oper Neurosurg (Hagerstown) 2023; 25:e183-e187. [PMID: 37307021 DOI: 10.1227/ons.0000000000000785] [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: 01/27/2023] [Accepted: 04/06/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Giant intracranial aneurysms have a poor natural history with mortality rates of 68% and 80% over 2-year and 5-year, respectively. Cerebral revascularization can provide flow preservation while treating complex aneurysms requiring parent artery sacrifice. In this report, we describe the microsurgical clip trapping and high-flow bypass revascularization for a giant middle cerebral artery (MCA) aneurysm. CLINICAL PRESENTATION A 19-year-old man was diagnosed with a giant left MCA aneurysm after he suffered a left hemispheric capsular stroke 6 months ago. Since then, the patient recovered from the right hemiparesis and dysarthria with residual symptoms. Neuroimaging demonstrated a giant fusiform aneurysm encompassing the entire M1 segment. The bilobed aneurysm measured 37 × 16 × 15 mm. Endovascular treatment options included partial coiling of the aneurysm followed by deployment of flow-diverting stent spanning from the M2 branch-through the aneurysm neck-into the internal carotid artery. Because of the high risk of lenticulostriate artery stroke with endovascular treatment, the patient opted for microsurgical clip trapping and bypass. The patient consented to the procedure. High-flow bypass from internal carotid artery to M2 MCA was performed using radial artery graft, followed by aneurysm clip trapping using 3 clips. CONCLUSION We demonstrate the successful microsurgical treatment for a complex case of giant M1 MCA aneurysm with fusiform morphology. High-flow revascularization using radial artery graft helped in achieving good clinical outcome with complete aneurysm occlusion with flow preservation despite the challenging morphology and location. Cerebral bypass continues to be a useful tool to tackle complex intracranial aneurysms.
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Affiliation(s)
- Varadaraya Satyanarayan Shenoy
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Co-Motion, University of Washington, Seattle, Washington, USA
| | - Charles Miller
- Department of Neurosurgery, Walter Reed National Military Medical Center, Washington District of Columbia, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Malia McAvoy
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Andrew Montoure
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
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6
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Yuwapattanawong K, Chanthima P, Thamjamrassri T, Keen J, Qiu Q, Fong C, Robinson EF, Dhulipala VB, Walters AM, Athiraman U, Kim LJ, Vavilala MS, Levitt MR, Lele AV. The Association Between Illness Severity Scores and In-hospital Mortality After Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2023; 35:299-306. [PMID: 35297396 DOI: 10.1097/ana.0000000000000840] [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: 10/27/2021] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the association with in-hospital mortality of 8 illness severity scores in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS In a retrospective cohort study, we investigated the association with in-hospital mortality of admission Hunt and Hess (HH) score, Fisher grade, severity of illness and risk of mortality scores, and serial Glasgow coma scale (GCS) score in patients with aSAH. We also explored the changes in GCS between admission and discharge using a multivariate model adjusting for age, clinical vasospasm, and external ventricular drain status. RESULTS Data from 480 patients with aSAH, of which 383 (79.8%) aneurysms were in the anterior circulation, were included in analysis. Patients were female (n=340, 70.8%) with a median age of 56 (interquartile range: 48 to 66) years. The majority (n=332, 69.2%) had admission HH score 3 to 5, Fisher grade 3 to 4 (n=437, 91%), median severity of illness 3 (range: 1 to 4), median risk of mortality 3 (range: 1 to 4), and median admission GCS of 13 (interquartile range: 7 to 15). Overall, 406 (84.6%) patients received an external ventricular drain, 469 (97.7%) underwent aneurysm repair, and 60 died (12.5%). Compared with admission HH score, GCS 24 hours after admission (area under the curve: 0.84, 95% confidence interval [CI]: 0.79-0.88) and 24 hours after aneurysm repair (area under the curve: 0.87, 95% CI: 0.82-0.90) were more likely to be associated with in-hospital mortality. Among those who died, the greatest decline in GCS was noted between 24 hours after aneurysm repair and discharge (-3.38 points, 95% CI: -4.17, -2.58). CONCLUSIONS Compared with admission HH score, GCS 24 hours after admission (or 24 h after aneurysm repair) is more likely to be associated with in-hospital mortality after aSAH.
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Affiliation(s)
| | | | | | | | - Qian Qiu
- Harborview Injury Prevention and Research Center
| | - Christine Fong
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | | | | | | | | | - Monica S Vavilala
- Harborview Injury Prevention and Research Center
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | - Abhijit V Lele
- Harborview Injury Prevention and Research Center
- Departments of Neurological Surgery
- Anesthesiology and Pain Medicine, Harborview Medical Center
- Neurocritical Service, Harborview Medical Center, Seattle, WA
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7
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Walker E, Srienc AI, Guniganti RR, Brinjikji W, Chen CJ, Abecassis IJ, Levitt MR, Durnford A, Polifka AJ, Derdeyn CP, Samaniego EA, Kwasnicki AM, Alaraj A, Potgieser AR, Sur S, Tada Y, Winkler EA, Lai R, Du R, Abla AA, Satomi J, Starke RM, Van Dijk MC, Amin-Hanjani S, Hayakawa M, Gross BA, Fox WC, Butlers D, Kim LJ, Sheehan JP, Lanzino G, Osbun JW, Zipfel GJ. 483 Partial Treatment as a Risk Factor in Up-Conversion of Type 1 dAVFs. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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8
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Bass DI, Marsh LMM, Fillingham P, Lim D, Chivukula VK, Kim LJ, Aliseda A, Levitt MR. Modeling the Mechanical Microenvironment of Coiled Cerebral Aneurysms. J Biomech Eng 2023; 145:041005. [PMID: 36193892 PMCID: PMC9791668 DOI: 10.1115/1.4055857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/09/2022] [Indexed: 12/30/2022]
Abstract
Successful occlusion of cerebral aneurysms using coil embolization is contingent upon stable thrombus formation, and the quality of the thrombus depends upon the biomechanical environment. The goal of this study was to investigate how coil embolization alters the mechanical micro-environment within the aneurysm dome. Inertialess particles were injected in three-dimensional, computational simulations of flow inside patient aneurysms using patient-specific boundary conditions. Coil embolization was simulated as a homogenous porous medium of known permeability and inertial constant. Lagrangian particle tracking was used to calculate the residence time and shear stress history for particles in the flow before and after treatment. The percentage of particles entering the aneurysm dome correlated with the neck surface area before and after treatment (pretreatment: R2 = 0.831, P < 0.001; post-treatment: R2 = 0.638, P < 0.001). There was an inverse relationship between the change in particles entering the dome and coil packing density (R2 = 0.600, P < 0.001). Following treatment, the particles with the longest residence times tended to remain within the dome even longer while accumulating lower shear stress. A significant correlation was observed between the treatment effect on residence time and the ratio of the neck surface area to porosity (R2 = 0.390, P = 0.007). The results of this study suggest that coil embolization triggers clot formation within the aneurysm dome via a low shear stress-mediated pathway. This hypothesis links independently observed findings from several benchtop and clinical studies, furthering our understanding of this treatment strategy.
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Affiliation(s)
- David I. Bass
- Department of Neurological Surgery, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104
| | - Laurel M. M. Marsh
- Department of Mechanical Engineering, University of Washington, 3900 East Stevens Way NE, Box 352600, Seattle, WA 98195
| | - Patrick Fillingham
- Department of Neurological Surgery, Stroke & Applied Neuroscience Center, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104
| | - Do Lim
- Department of Neurological Surgery, Stroke & Applied Neuroscience Center, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104
| | - V. Keshav Chivukula
- Department of Biomedical and Chemical Engineering and Sciences, Florida Institute of Technology, 150 West University Building, Melbourne, FL 32901
| | - Louis J. Kim
- Department of Neurological Surgery, Stroke & Applied Neuroscience Center, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104; Department of Radiology, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104
| | - Alberto Aliseda
- Department of Mechanical Engineering, Stroke & Applied Neuroscience Center, University of Washington, 3900 East Stevens Way NE, Box 352600, Seattle, WA 98195; Department of Neurological Surgery, Stroke & Applied Neuroscience Center, University of Washington, 3900 East Stevens Way NE, Box 352600, Seattle, WA 98195
| | - Michael R. Levitt
- Department of Neurological Surgery, Stroke & Applied Neuroscience Center, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104; Department of Radiology, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104; Department of Mechanical Engineering, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104
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9
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Salem MM, Srinivasan VM, Tonetti DA, Ravindran K, Taussky P, Yang K, Karahalios K, Raygor KP, Naylor RM, Catapano JS, Tavakoli-Sabour S, Abdelsalam A, Chen SH, Grandhi R, Jankowitz BT, Baskaya MK, Mascitelli JR, Van Gompel JJ, Cherian J, Couldwell WT, Kim LJ, Cohen-Gadol AA, Starke RM, Kan P, Dehdashti AR, Abla AA, Lawton MT, Burkhardt JK. Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience. Neurosurgery 2023; 92:205-212. [PMID: 36519864 DOI: 10.1227/neu.0000000000002196] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/15/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports. OBJECTIVE To report a multicenter experience assessing microsurgery safety/efficacy. METHODS Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021). RESULTS Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%. CONCLUSION Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Krishnan Ravindran
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Kaiyun Yang
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Katherine Karahalios
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kunal P Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Samon Tavakoli-Sabour
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Jacob Cherian
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | | | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Aaron A Cohen-Gadol
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
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10
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Zhang J, Li X, Zhao B, Zhang J, Sun B, Wang L, Tian J, Mossa-Basha M, Kim LJ, Yan J, Wan J, Xu J, Zhou Y, Zhao H, Zhu C. Irregular pulsation of aneurysmal wall is associated with symptomatic and ruptured intracranial aneurysms. J Neurointerv Surg 2023; 15:91-96. [PMID: 35169029 DOI: 10.1136/neurintsurg-2021-018381] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/23/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Irregular pulsation of aneurysmal wall detected by four-dimensional CT angiography (4D-CTA) has been described as a novel imaging feature of aneurysm vulnerability. Our study aimed to investigate whether irregular pulsation is associated with symptomatic and ruptured intracranial aneurysms (IAs). METHODS This retrospective study included consecutive patients with IAs who underwent 4D-CTA from January 2018 to July 2021. IAs were categorized as asymptomatic, symptomatic or ruptured. The presence of irregular pulsation (defined as a temporary focal protuberance ≥1 mm on more than three successive frames) was identified on 4D-CTA movies. Univariate and multivariate analyses were used to identify the parameters associated with aneurysm symptomatic or ruptured status. RESULTS Overall, 305 patients with 328 aneurysms (37 ruptured, 60 symptomatic, 231 asymptomatic) were included. Ruptured and symptomatic IAs were significantly larger in size compared with asymptomatic IAs (median (IQR) 6.5 (5.1-8.3) mm, 7.0 (5.5-9.7) mm vs 4.7 (3.8-6.3) mm, p=0.001 and p<0.001, respectively) and had more irregular pulsations (70.3%, 78.3% vs 28.1%, p<0.05). Irregular pulsation (OR 5.03, 95% CI 2.83 to 8.92; p<0.001) was independently associated with aneurysm symptomatic/ruptured status in the whole population. With unruptured IAs, both irregular pulsation (OR 6.31, 95% CI 3.02 to 13.20; p<0.001) and size (OR 1.17, 95% CI 1.03 to 1.32; p=0.015) were independently associated with the symptoms. The combination of irregular pulsation and size increased the accuracy over size alone in identifying symptomatic aneurysms (AUC 0.81 vs 0.77, p=0.007) in unruptured IAs. CONCLUSION In a large cohort of patients with IAs detected by 4D-CTA, the presence of irregular pulsation was independently associated with aneurysm symptomatic and ruptured status.
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Affiliation(s)
- Jianjian Zhang
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Li
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Zhao
- Department of Neurosurgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin Zhang
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Beibei Sun
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lingling Wang
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiaqi Tian
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jing Yan
- Research Collaboration, Canon Medical Systems (China) Co., LTD, Shanghai, China
| | - Jieqing Wan
- Department of Neurosurgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianrong Xu
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Zhou
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huilin Zhao
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, Washington, USA
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11
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Mandrycky CJ, Abel AN, Levy S, Marsh LM, Chassagne F, Chivukula VK, Barczay SE, Kelly CM, Kim LJ, Aliseda A, Levitt MR, Zheng Y. Endothelial Responses to Curvature-Induced Flow Patterns in Engineered Cerebral Aneurysms. J Biomech Eng 2023; 145:011001. [PMID: 35838329 PMCID: PMC9445320 DOI: 10.1115/1.4054981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 07/05/2022] [Indexed: 11/08/2022]
Abstract
Hemodynamic factors have long been associated with clinical outcomes in the treatment of cerebral aneurysms. Computational studies of cerebral aneurysm hemodynamics have provided valuable estimates of the mechanical environment experienced by the endothelium in both the parent vessel and aneurysmal dome walls and have correlated them with disease state. These computational-clinical studies have recently been correlated with the response of endothelial cells (EC) using either idealized or patient-specific models. Here, we present a robust workflow for generating anatomic-scale aneurysm models, establishing luminal cultures of ECs at physiological relevant flow profiles, and comparing EC responses to curvature mediated flow. We show that flow patterns induced by parent vessel curvature produce changes in wall shear stress (WSS) and wall shear stress gradients (WSSG) that are correlated with differences in cell morphology and cellular protein localization. Cells in higher WSS regions align better with the flow and display strong Notch1-extracellular domain (ECD) polarization, while, under low WSS, differences in WSSG due to curvature change were associated with less alignment and attenuation of Notch1-ECD polarization in ECs of the corresponding regions. These proof-of-concept results highlight the use of engineered cellularized aneurysm models for connecting computational fluid dynamics to the underlying endothelial biology that mediates disease.
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Affiliation(s)
- Christian J. Mandrycky
- Bioengineering, University of Washington, Seattle, WA 98105; Institute for Stem Cell and Regenerative Medicine, Seattle, WA 98109
| | - Ashley N. Abel
- Neurological Surgery, University of Washington, Seattle, WA 98195
| | - Samuel Levy
- Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98104
| | - Laurel M. Marsh
- Mechanical Engineering, University of Washington, Seattle, WA 98195
| | | | | | - Sari E. Barczay
- Mechanical Engineering, University of Washington, Seattle, WA 98195
| | - Cory M. Kelly
- Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98104
| | - Louis J. Kim
- Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98104; Radiology, University of Washington, Seattle, WA 98195
| | - Alberto Aliseda
- Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98104; Mechanical Engineering, University of Washington, Seattle, WA 98195
| | - Michael R. Levitt
- Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98104; Mechanical Engineering, University of Washington, Seattle, WA 98195; Radiology, University of Washington, Seattle, WA 98195
| | - Ying Zheng
- Bioengineering, University of Washington, Seattle, WA 98105Institute for Stem Cell and Regenerative Medicine, Seattle, WA 98109; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98104
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12
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Muacevic A, Adler JR, Wahlster S, Keen J, Walters AM, Fong CT, Dhulipala VB, Athiraman U, Moore A, Vavilala MS, Kim LJ, Levitt MR. Associations Between Transcranial Doppler Vasospasm and Clinical Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Observational Study. Cureus 2022; 14:e31789. [PMID: 36569681 PMCID: PMC9777349 DOI: 10.7759/cureus.31789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective is to examine the relationship between transcranial Doppler cerebral vasospasm (TCD-vasospasm), and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). METHODS In a retrospective cohort study, using univariate and multivariate analysis, we examined the association between TCD-vasospasm (defined as Lindegaard ratio >3) and patient's ability to ambulate without assistance, the need for tracheostomy and gastrostomy tube placement, and the likelihood of being discharged home from the hospital. RESULTS We studied 346 patients with aSAH; median age 55 years (Interquartile range IQR 46,64), median Hunt and Hess 3 [IQR 1-5]. Overall, 68.6% (n=238) had TCD-vasospasm, and 28% (n=97) had delayed cerebral ischemia. At hospital discharge, 54.3% (n=188) were able to walk without assistance, 5.8% (n=20) had received a tracheostomy, and 12% (n=42) had received a gastrostomy tube. Fifty-three percent (n=183) were discharged directly from the hospital to their home. TCD-vasospasm was not associated with ambulation without assistance at discharge (adjusted odds ratio, aOR 0.54, 95% 0.19,1.45), tracheostomy placement (aOR 2.04, 95% 0.23,18.43), gastrostomy tube placement (aOR 0.95, 95% CI 0.28,3.26), discharge to home (aOR 0.36, 95% CI 0.11,1.23). CONCLUSION This single-center retrospective study finds that TCD-vasospasm is not associated with clinical outcomes such as ambulation without assistance, discharge to home from the hospital, tracheostomy, and gastrostomy feeding tube placement. Routine screening for cerebral vasospasm and its impact on vasospasm diagnostic and therapeutic interventions and their associations with improved clinical outcomes warrant an evaluation in large, prospective, case-controlled, multi-center studies.
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13
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Young CC, Bass DI, Cruz MJ, Carroll K, Vanent KN, Lee C, Sen RD, Feroze AH, Williams JR, Levy S, McCray D, Kelly CM, Barber J, Kim LJ, Levitt MR. Clopidogrel hyper-response increases peripheral hemorrhagic complications without increasing intracranial complications in endovascular aneurysm treatments requiring dual antiplatelet therapy. J Clin Neurosci 2022; 105:66-72. [PMID: 36113244 DOI: 10.1016/j.jocn.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/09/2022] [Accepted: 09/03/2022] [Indexed: 10/31/2022]
Abstract
Clinical significance of increased clopidogrel response measured by VerifyNow P2Y12 assay is unclear; management guidelines are lacking in the context of neuroendovascular intervention. Our objective was to assess whether increased clopidogrel response predicts complications from endovascular aneurysm treatment requiring dual antiplatelet therapy. A single-institution, 9-year retrospective study of patients undergoing endovascular treatments for ruptured and unruptured aneurysms requiring aspirin and clopidogrel was conducted. Patients were grouped according to preoperative platelet inhibition in response to clopidogrel measured by the VerifyNow P2Y12 assay (VNP; P2Y12 reactivity units, PRU). Demographic and clinical features were compared across groups. Hemorrhagic complication rates (intracranial, major extracranial, minor extracranial) and thromboembolic complications (in-stent stenosis, stroke/transient ischemic attack) were compared, controlling for potential confounders and multiple comparisons. Data were collected from 284 patients across 317 procedures. Pre-operative VNP assays identified 9 % Extreme Responders (PRU ≤ 15), 13 % Hyper-Responders (PRU 16-60), 62 % Therapeutic Responders (PRU 61-214), 16 % Hypo-Responders (PRU ≥ 215). Increased response to clopidogrel was associated with increased risk of any hemorrhagic complication (≤60 PRU vs > 60 PRU; 39 % vs 24 %, P = 0.050); all intracranial hemorrhages occurred in patients with PRU > 60. Thromboembolic complications were similar between therapeutic and subtherapeutic patients (<215 PRU vs ≥ 215 PRU; 15 % vs 16 %, P = 0.835). Increased preoperative clopidogrel response is associated with increased rate of extracranial hemorrhagic complications in endovascular aneurysm treatments. Hyper-responders (16-60 PRU) and Extreme Responders (≤15 PRU) were not associated with intracranial hemorrhagic or thrombotic complications. Hypo-responders who underwent adjustment of antiplatelet therapy and neurointerventions did not experience higher rates of complications.
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Affiliation(s)
- Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - David I Bass
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Michael J Cruz
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Kate Carroll
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Kevin N Vanent
- School of Medicine, University of Washington, Seattle, WA 98104, USA
| | - Chungeun Lee
- School of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Abdullah H Feroze
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - John R Williams
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Samuel Levy
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Denzel McCray
- Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA; Department of Radiology, University of Washington, Seattle, WA 98104, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA; Department of Radiology, University of Washington, Seattle, WA 98104, USA; Department of Mechanical Engineering, University of Washington, Seattle, WA 98104, USA.
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14
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Kim LJ, Bozinov O, Huang J, Lanzino G. Introduction. Arteriovenous malformations in 2022: a state of the art. Neurosurg Focus 2022; 53:E1. [DOI: 10.3171/2022.4.focus22244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Louis J. Kim
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Oliver Bozinov
- Department of Neurosurgery at Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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15
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Sen RD, Nistal D, McGrath M, Barros G, Shenoy VS, Sekhar LN, Levitt MR, Kim LJ. De novo epilepsy after microsurgical resection of brain arteriovenous malformations. Neurosurg Focus 2022; 53:E6. [DOI: 10.3171/2022.4.focus2288] [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: 02/28/2022] [Accepted: 04/12/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Seizures are the second most common presenting symptom of brain arteriovenous malformations (bAVMs) after hemorrhage. Risk factors for preoperative seizures and subsequent seizure control outcomes have been well studied. There is a paucity of literature on postoperative, de novo seizures in initially seizure-naïve patients who undergo resection. Whereas this entity has been documented after craniotomy for a wide variety of neurosurgically treated pathologies including tumors, trauma, and aneurysms, de novo seizures after bAVM resection are poorly studied. Given the debilitating nature of epilepsy, the purpose of this study was to elucidate the incidence and risk factors associated with de novo epilepsy after bAVM resection.
METHODS
A retrospective review of patients who underwent resection of a bAVM over a 15-year period was performed. Patients who did not present with seizure were included, and the primary outcome was de novo epilepsy (i.e., a seizure disorder that only manifested after surgery). Demographic, clinical, and radiographic characteristics were compared between patients with and without postoperative epilepsy. Subgroup analysis was conducted on the ruptured bAVMs.
RESULTS
From a cohort of 198 patients who underwent resection of a bAVM during the study period, 111 supratentorial ruptured and unruptured bAVMs that did not present with seizure were included. Twenty-one patients (19%) developed de novo epilepsy. One-year cumulative rates of developing de novo epilepsy were 9% for the overall cohort and 8.5% for the cohort with ruptured bAVMs. There were no significant differences between the epilepsy and no-epilepsy groups overall; however, the de novo epilepsy group was younger in the cohort with ruptured bAVMs (28.7 ± 11.7 vs 35.1 ± 19.9 years; p = 0.04). The mean time between resection and first seizure was 26.0 ± 40.4 months, with the longest time being 14 years. Subgroup analysis of the ruptured and endovascular embolization cohorts did not reveal any significant differences. Of the patients who developed poorly controlled epilepsy (defined as Engel class III–IV), all had a history of hemorrhage and half had bAVMs located in the temporal lobe.
CONCLUSIONS
De novo epilepsy after bAVM resection occurs at an annual cumulative risk of 9%, with potentially long-term onset. Younger age may be a risk factor in patients who present with rupture. The development of poorly controlled epilepsy may be associated with temporal lobe location and a delay between hemorrhage and resection.
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Affiliation(s)
| | | | | | | | | | | | - Michael R. Levitt
- Departments of Neurological Surgery,
- Radiology, and
- Mechanical Engineering; and
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Louis J. Kim
- Departments of Neurological Surgery,
- Radiology, and
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington
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16
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Barros G, Sen RD, McGrath M, Nistal D, Sekhar LN, Kim LJ, Levitt MR. Frailty predicts postoperative functional outcomes after microsurgical resection of ruptured brain arteriovenous malformations in older patients. World Neurosurg 2022; 164:e844-e851. [DOI: 10.1016/j.wneu.2022.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
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17
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Abecassis IJ, Meyer RM, Levitt MR, Sheehan JP, Chen CJ, Gross BA, Smith J, Fox WC, Giordan E, Lanzino G, Starke RM, Sur S, Potgieser ARE, van Dijk JMC, Durnford A, Bulters D, Satomi J, Tada Y, Kwasnicki A, Amin-Hanjani S, Alaraj A, Samaniego EA, Hayakawa M, Derdeyn CP, Winkler E, Abla A, Lai PMR, Du R, Guniganti R, Kansagra AP, Zipfel GJ, Kim LJ. Recurrence after cure in cranial dural arteriovenous fistulas: a collaborative effort by the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). J Neurosurg 2022; 136:981-989. [PMID: 34507283 DOI: 10.3171/2021.1.jns202033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranial dural arteriovenous fistulas (dAVFs) are often treated with endovascular therapy, but occasionally a multimodality approach including surgery and/or radiosurgery is utilized. Recurrence after an initial angiographic cure has been reported, with estimated rates ranging from 2% to 14.3%, but few risk factors have been identified. The objective of this study was to identify risk factors associated with recurrence of dAVF after putative cure. METHODS The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) data were retrospectively reviewed. All patients with angiographic cure after treatment and subsequent angiographic follow-up were included. The primary outcome was recurrence, with risk factor analysis. Secondary outcomes included clinical outcomes, morbidity, and mortality associated with recurrence. Risk factor analysis was performed comparing the group of patients who experienced recurrence with those with durable cure (regardless of multiple recurrences). Time-to-event analysis was performed using all collective recurrence events (multiple per patients in some cases). RESULTS Of the 1077 patients included in the primary CONDOR data set, 457 met inclusion criteria. A total of 32 patients (7%) experienced 34 events of recurrence at a mean of 368.7 days (median 192 days). The recurrence rate was 4.5% overall. Kaplan-Meier analysis predicted long-term recurrence rates approaching 11% at 3 years. Grade III dAVFs treated with endovascular therapy were statistically significantly more likely to experience recurrence than those treated surgically (13.3% vs 0%, p = 0.0001). Tentorial location, cortical venous drainage, and deep cerebral venous drainage were all risk factors for recurrence. Endovascular intervention and radiosurgery were associated with recurrence. Six recurrences were symptomatic, including 2 with hemorrhage, 3 with nonhemorrhagic neurological deficit, and 1 with progressive flow-related symptoms (decreased vision). CONCLUSIONS Recurrence of dAVFs after putative cure can occur after endovascular treatment. Risk factors include tentorial location, cortical venous drainage, and deep cerebral drainage. Multimodality therapy can be used to achieve cure after recurrence. A delayed long-term angiographic evaluation (at least 1 year from cure) may be warranted, especially in cases with risk factors for recurrence.
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Affiliation(s)
| | | | - Michael R Levitt
- Departments of1Neurological Surgery
- 4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Jason P Sheehan
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bradley A Gross
- 6Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Jessica Smith
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - W Christopher Fox
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Giuseppe Lanzino
- Departments of8Neurosurgery and
- 9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert M Starke
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Samir Sur
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Adriaan R E Potgieser
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - J Marc C van Dijk
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Andrew Durnford
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Diederik Bulters
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Junichiro Satomi
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Amanda Kwasnicki
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | | | - Ali Alaraj
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Edgar A Samaniego
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Minako Hayakawa
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Ethan Winkler
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Adib Abla
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Pui Man Rosalind Lai
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Rose Du
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | | | - Akash P Kansagra
- Departments of18Neurological Surgery
- 20Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Louis J Kim
- Departments of1Neurological Surgery
- 2Radiology, and
- 4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
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18
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Barros G, Kim LJ. Editorial. Perspective on flow diverting stents for posterior circulation aneurysms. J Neurosurg 2022; 137:1-2. [PMID: 35276649 DOI: 10.3171/2021.12.jns212760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Louis J Kim
- 1Departments of Neurological Surgery and
- 2Radiology, and
- 3Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
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19
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Meyer RM, McAvoy M, Lim D, Prijoles K, Walker M, Bonow RH, Kim LJ, Levitt MR. 471 Prospective Comparison of CT and Digital Subtraction Angiography to Diagnose Penetrating Cerebrovascular Injuries: Preliminary Data. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_471] [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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20
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McAvoy M, Karasozen Y, Parada C, Busald T, Osbun JW, Ruzevick JJ, Emerson S, Nistal DA, Tyrtova E, Eaton JC, Swaminathan S, Levitt MR, Gonzalez-Cuyar L, Hale C, Byers P, Kim LJ, Dorschner M, Ferreira M. 416 Low Allele Frequency Somatic Variants in Sporadic Saccular “Berry” Cerebral Aneurysms. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_416] [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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Sen RD, Abecassis IJ, Barber J, Levitt MR, Kim LJ, Ellenbogen RG, Sekhar LN. Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations. J Neurosurg 2021; 137:1-8. [PMID: 34861649 DOI: 10.3171/2021.8.jns211075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. METHODS The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. RESULTS A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. CONCLUSIONS Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.
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Affiliation(s)
- Rajeev D Sen
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 3Department of Radiology, University of Washington, Seattle, Washington
- 4Department of Mechanical Engineering, University of Washington, Seattle, Washington; and
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Louis J Kim
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 3Department of Radiology, University of Washington, Seattle, Washington
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Richard G Ellenbogen
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Laligam N Sekhar
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
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22
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Bass DI, Young CC, Park MS, Cruz MJ, Carroll KT, Vanent KN, Lee C, Sen RD, Angiolillo DJ, Cattaneo M, Kim LJ, Levitt MR. Severe, Intolerable Fatigue Associated with Hyperresponse to Clopidogrel. World Neurosurg 2021; 156:e374-e380. [PMID: 34563718 DOI: 10.1016/j.wneu.2021.09.075] [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: 06/10/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Clopidogrel is a commonly used antiplatelet agent for the prevention of thromboembolic complications following neuroendovascular procedures, but anecdotal data have raised concern for the possibility that clopidogrel may induce severe, intolerable fatigue. The purpose of this study is to systematically investigate this phenomenon. METHODS We performed a dual-institution, 9-year, retrospective study of patients undergoing clopidogrel therapy for neuroendovascular procedures. Patients were included only if their response to clopidogrel was assessed by platelet function testing using the VerifyNow P2Y12 (VNP) assay. Hyperresponse to clopidogrel was defined as P2Y12 reaction units ≤60. Patients were considered to have had clopidogrel-induced severe fatigue if the onset of symptoms followed the initiation of clopidogrel therapy; symptoms improved following a reduction in the dose of clopidogrel; and symptoms could not be attributed to any other medical explanation. RESULTS Data were collected on 349 patients. Five patients (1.4%) met criteria for clopidogrel-induced severe fatigue. All 5 patients were female, ages 39-68. VNP assessments obtained while patients were symptomatic revealed hyperresponse to clopidogrel (0-22 P2Y12 reaction units). Symptoms improved in all 5 patients when the dose of clopidogrel was reduced by half. Notably, 30% of patients (n = 103) demonstrated a hyperresponse to clopidogrel on at least 1 VNP assessment, but 98 of these patients did not suffer from severe fatigue. CONCLUSIONS A syndrome of severe fatigue and other constitutional symptoms is a rare but clinically significant side effect of hyperresponse to clopidogrel in patients undergoing neuroendovasular intervention.
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Affiliation(s)
- David I Bass
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Michael J Cruz
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Kate T Carroll
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Kevin N Vanent
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Chungeun Lee
- School of Medicine, Washington State University, Spokane, Washington, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Marco Cattaneo
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington, USA; Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington, USA; Department of Radiology, University of Washington, Seattle, Washington, USA; Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA.
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23
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Guniganti R, Giordan E, Chen CJ, Abecassis IJ, Levitt MR, Durnford A, Smith J, Samaniego EA, Derdeyn CP, Kwasnicki A, Alaraj A, Potgieser ARE, Sur S, Chen SH, Tada Y, Winkler E, Phelps RRL, Lai PMR, Du R, Abla A, Satomi J, Starke RM, van Dijk JMC, Amin-Hanjani S, Hayakawa M, Gross BA, Fox WC, Bulters D, Kim LJ, Sheehan J, Lanzino G, Piccirillo JF, Kansagra AP, Zipfel GJ. Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR): rationale, design, and initial characterization of patient cohort. J Neurosurg 2021; 136:951-961. [PMID: 34507282 DOI: 10.3171/2021.1.jns202790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cranial dural arteriovenous fistulas (dAVFs) are rare lesions, hampering efforts to understand them and improve their care. To address this challenge, investigators with an established record of dAVF investigation formed an international, multicenter consortium aimed at better elucidating dAVF pathophysiology, imaging characteristics, natural history, and patient outcomes. This report describes the design of the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) and includes characterization of the 1077-patient cohort. METHODS Potential collaborators with established interest in the field were identified via systematic review of the literature. To ensure uniformity of data collection, a quality control process was instituted. Data were retrospectively obtained. RESULTS CONDOR comprises 14 centers in the United States, the United Kingdom, the Netherlands, and Japan that have pooled their data from 1077 dAVF patients seen between 1990 and 2017. The cohort includes 359 patients (33%) with Borden type I dAVFs, 175 (16%) with Borden type II fistulas, and 529 (49%) with Borden type III fistulas. Overall, 852 patients (79%) presented with fistula-related symptoms: 427 (40%) presented with nonaggressive symptoms such as tinnitus or orbital phenomena, 258 (24%) presented with intracranial hemorrhage, and 167 (16%) presented with nonhemorrhagic neurological deficits. A smaller proportion (224 patients, 21%), whose dAVFs were discovered incidentally, were asymptomatic. Many patients (85%, 911/1077) underwent treatment via endovascular embolization (55%, 587/1077), surgery (10%, 103/1077), radiosurgery (3%, 36/1077), or multimodal therapy (17%, 184/1077). The overall angiographic cure rate was 83% (758/911 treated), and treatment-related permanent neurological morbidity was 2% (27/1467 total procedures). The median time from diagnosis to follow-up was 380 days (IQR 120-1038.5 days). CONCLUSIONS With more than 1000 patients, the CONDOR registry represents the largest registry of cranial dAVF patient data in the world. These unique, well-annotated data will enable multiple future analyses to be performed to better understand dAVFs and their management.
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Affiliation(s)
| | - Enrico Giordan
- Departments of4Neurological Surgery and.,5Radiology, Mayo Clinic, Rochester, Minnesota
| | - Ching-Jen Chen
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Michael R Levitt
- 7Department of Neurological Surgery and.,8Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Andrew Durnford
- 9Department of Neurosurgery, University of Southampton, University Hospital Southampton, United Kingdom
| | - Jessica Smith
- 10Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Edgar A Samaniego
- Departments of12Neurology and.,13Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- Departments of12Neurology and.,13Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amanda Kwasnicki
- 14Department of Neurological Surgery, University of Illinois at Chicago, Illinois
| | - Ali Alaraj
- 14Department of Neurological Surgery, University of Illinois at Chicago, Illinois
| | - Adriaan R E Potgieser
- 15Department of Neurological Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Samir Sur
- 16Department of Neurological Surgery and Radiology, University of Miami, Florida
| | - Stephanie H Chen
- 16Department of Neurological Surgery and Radiology, University of Miami, Florida
| | - Yoshiteru Tada
- 17Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School, Tokushima, Japan
| | - Ethan Winkler
- 18Weill Institute for Neurosciences, Department of Neurosurgery, University of California, San Francisco, California
| | - Ryan R L Phelps
- 18Weill Institute for Neurosciences, Department of Neurosurgery, University of California, San Francisco, California
| | - Pui Man Rosalind Lai
- 19Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rose Du
- 19Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adib Abla
- 18Weill Institute for Neurosciences, Department of Neurosurgery, University of California, San Francisco, California
| | - Junichiro Satomi
- 17Department of Neurosurgery, Institute of Biomedical Biosciences, Tokushima University Graduate School, Tokushima, Japan
| | - Robert M Starke
- 16Department of Neurological Surgery and Radiology, University of Miami, Florida
| | - J Marc C van Dijk
- 15Department of Neurological Surgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Sepideh Amin-Hanjani
- 14Department of Neurological Surgery, University of Illinois at Chicago, Illinois
| | - Minako Hayakawa
- Departments of12Neurology and.,13Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Bradley A Gross
- 11Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - W Christopher Fox
- 10Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Diederik Bulters
- 9Department of Neurosurgery, University of Southampton, University Hospital Southampton, United Kingdom
| | - Louis J Kim
- 7Department of Neurological Surgery and.,8Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Jason Sheehan
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Giuseppe Lanzino
- Departments of4Neurological Surgery and.,5Radiology, Mayo Clinic, Rochester, Minnesota
| | - Jay F Piccirillo
- 3Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 1Department of Neurological Surgery.,2Mallinckrodt Institute of Radiology, and
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24
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Samaniego EA, Roa JA, Hayakawa M, Chen CJ, Sheehan JP, Kim LJ, Abecassis IJ, Levitt MR, Guniganti R, Kansagra AP, Lanzino G, Giordan E, Brinjikji W, Bulters D, Durnford A, Fox WC, Polifka AJ, Gross BA, Amin-Hanjani S, Alaraj A, Kwasnicki A, Starke RM, Sur S, van Dijk JMC, Potgieser ARE, Satomi J, Tada Y, Abla A, Winkler E, Du R, Lai PMR, Zipfel GJ, Derdeyn CP. Dural arteriovenous fistulas without cortical venous drainage: presentation, treatment, and outcomes. J Neurosurg 2021; 136:942-950. [PMID: 34507278 DOI: 10.3171/2021.1.jns202825] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current evidence suggests that intracranial dural arteriovenous fistulas (dAVFs) without cortical venous drainage (CVD) have a benign clinical course. However, no large study has evaluated the safety and efficacy of current treatments and their impact over the natural history of dAVFs without CVD. METHODS The authors conducted an analysis of the retrospectively collected multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database. Patient demographics and presenting symptoms, angiographic features of the dAVFs, and treatment outcomes of patients with Borden type I dAVFs were reviewed. Clinical and radiological follow-up information was assessed to determine rates of new intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND), worsening of venous hyperdynamic symptoms (VHSs), angiographic recurrence, and progression or spontaneous regression of dAVFs over time. RESULTS A total of 342 patients/Borden type I dAVFs were identified. The mean patient age was 58.1 ± 15.6 years, and 62% were women. The mean follow-up time was 37.7 ± 54.3 months. Of 230 (67.3%) treated dAVFs, 178 (77%) underwent mainly endovascular embolization, 11 (4.7%) radiosurgery alone, and 4 (1.7%) open surgery as the primary modality. After the first embolization, most dAVFs (47.2%) achieved only partial reduction in early venous filling. Multiple complementary interventions increased complete obliteration rates from 37.9% after first embolization to 46.7% after two or more embolizations, and 55.2% after combined radiosurgery and open surgery. Immediate postprocedural complications occurred in 35 dAVFs (15.2%) and 6 (2.6%) with permanent sequelae. Of 127 completely obliterated dAVFs by any therapeutic modality, 2 (1.6%) showed angiographic recurrence/recanalization at a mean of 34.2 months after treatment. Progression to Borden-Shucart type II or III was documented in 2.2% of patients and subsequent development of a new dAVF in 1.6%. Partial spontaneous regression was found in 22 (21.4%) of 103 nontreated dAVFs. Multivariate Cox regression analysis demonstrated that older age, NHND, or severe venous-hyperdynamic symptoms at presentation and infratentorial location were associated with worse prognosis. Kaplan-Meier curves showed no significant difference for stable/improved symptoms survival probability in treated versus nontreated dAVFs. However, estimated survival times showed better trends for treated dAVFs compared with nontreated dAVFs (288.1 months vs 151.1 months, log-rank p = 0.28). This difference was statistically significant for treated dAVFs with 100% occlusion (394 months, log-rank p < 0.001). CONCLUSIONS Current therapeutic modalities for management of dAVFs without CVD may provide better symptom control when complete angiographic occlusion is achieved.
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Affiliation(s)
- Edgar A Samaniego
- Departments of1Neurology.,3Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jorge A Roa
- Departments of1Neurology.,2Neurosurgery, and
| | - Minako Hayakawa
- 3Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Ching-Jen Chen
- 4Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- 4Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Louis J Kim
- 5Department of Neurosurgery, University of Washington, Seattle, Washington
| | | | - Michael R Levitt
- 5Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Ridhima Guniganti
- 6Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 6Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Enrico Giordan
- 7Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | | | - Diederik Bulters
- 8Department of Neurosurgery, University of Southampton, United Kingdom
| | - Andrew Durnford
- 8Department of Neurosurgery, University of Southampton, United Kingdom
| | - W Christopher Fox
- 9Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Adam J Polifka
- 9Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Bradley A Gross
- 10Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | | | - Ali Alaraj
- 11Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Amanda Kwasnicki
- 11Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | | | - Samir Sur
- 12Department of Neurosurgery, University of Miami, Florida
| | - J Marc C van Dijk
- 13Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Adriaan R E Potgieser
- 13Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Junichiro Satomi
- 14Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 14Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Adib Abla
- 15Department of Neurosurgery, University of California, San Francisco, California; and
| | - Ethan Winkler
- 15Department of Neurosurgery, University of California, San Francisco, California; and
| | - Rose Du
- 16Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pui Man Rosalind Lai
- 16Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregory J Zipfel
- 6Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Colin P Derdeyn
- 3Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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25
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Chen CJ, Buell TJ, Ding D, Guniganti R, Kansagra AP, Lanzino G, Giordan E, Kim LJ, Levitt MR, Abecassis IJ, Bulters D, Durnford A, Fox WC, Polifka AJ, Gross BA, Hayakawa M, Derdeyn CP, Samaniego EA, Amin-Hanjani S, Alaraj A, Kwasnicki A, van Dijk JMC, Potgieser ARE, Starke RM, Sur S, Satomi J, Tada Y, Abla AA, Winkler EA, Du R, Lai PMR, Zipfel GJ, Sheehan JP. Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study. J Neurosurg 2021; 136:962-970. [PMID: 34608140 DOI: 10.3171/2021.1.jns202799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The risk-to-benefit profile of treating an unruptured high-grade dural arteriovenous fistula (dAVF) is not clearly defined. The aim of this multicenter retrospective cohort study was to compare the outcomes of different interventions with observation for unruptured high-grade dAVFs. METHODS The authors retrospectively reviewed dAVF patients from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with unruptured high-grade (Borden type II or III) dAVFs were included and categorized into four groups (observation, embolization, surgery, and stereotactic radiosurgery [SRS]) based on the initial management. The primary outcome was defined as the modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were good outcome (mRS scores 0-2) at final follow-up, symptomatic improvement, all-cause mortality, and dAVF obliteration. The outcomes of each intervention group were compared against those of the observation group as a reference, with adjustment for differences in baseline characteristics. RESULTS The study included 415 dAVF patients, accounting for 29, 324, 43, and 19 in the observation, embolization, surgery, and SRS groups, respectively. The mean radiological and clinical follow-up durations were 21 and 25 months, respectively. Functional outcomes were similar for embolization, surgery, and SRS compared with observation. With observation as a reference, obliteration rates were higher after embolization (adjusted OR [aOR] 7.147, p = 0.010) and surgery (aOR 33.803, p < 0.001) and all-cause mortality was lower after embolization (imputed, aOR 0.171, p = 0.040). Hemorrhage rates per 1000 patient-years were 101 for observation versus 9, 22, and 0 for embolization (p = 0.022), surgery (p = 0.245), and SRS (p = 0.077), respectively. Nonhemorrhagic neurological deficit rates were similar between each intervention group versus observation. CONCLUSIONS Embolization and surgery for unruptured high-grade dAVFs afforded a greater likelihood of obliteration than did observation. Embolization also reduced the risk of death and dAVF-associated hemorrhage compared with conservative management over a modest follow-up period. These findings support embolization as the first-line treatment of choice for appropriately selected unruptured Borden type II and III dAVFs.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 18Department of Neurosurgery, University of Louisville, Kentucky
| | - Ridhima Guniganti
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri.,15Mallinckrodt Institute of Radiology and.,16Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Enrico Giordan
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Louis J Kim
- 4Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- 4Department of Neurosurgery, University of Washington, Seattle, Washington
| | | | - Diederik Bulters
- 5Department of Neurosurgery, University of Southampton, United Kingdom
| | - Andrew Durnford
- 5Department of Neurosurgery, University of Southampton, United Kingdom
| | - W Christopher Fox
- 6Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Adam J Polifka
- 6Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Bradley A Gross
- 7Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Minako Hayakawa
- 8Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Colin P Derdeyn
- 8Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | | | - Ali Alaraj
- 9Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Amanda Kwasnicki
- 9Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - J Marc C van Dijk
- 10Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Adriaan R E Potgieser
- 10Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Robert M Starke
- 11Department of Neurosurgery, University of Miami, Florida.,17Department of Radiology, University of Miami, Florida; and
| | - Samir Sur
- 11Department of Neurosurgery, University of Miami, Florida
| | - Junichiro Satomi
- 12Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 12Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Adib A Abla
- 13Department of Neurosurgery, University of California, San Francisco, California
| | - Ethan A Winkler
- 13Department of Neurosurgery, University of California, San Francisco, California
| | - Rose Du
- 14Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pui Man Rosalind Lai
- 14Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregory J Zipfel
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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26
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Abecassis IJ, Meyer RM, Levitt MR, Sheehan JP, Chen CJ, Gross BA, Lockerman A, Fox WC, Brinjikji W, Lanzino G, Starke RM, Chen SH, Potgieser ARE, van Dijk JMC, Durnford A, Bulters D, Satomi J, Tada Y, Kwasnicki A, Amin-Hanjani S, Alaraj A, Samaniego EA, Hayakawa M, Derdeyn CP, Winkler E, Abla A, Lai PMR, Du R, Guniganti R, Kansagra AP, Zipfel GJ, Kim LJ. Assessing the rate, natural history, and treatment trends of intracranial aneurysms in patients with intracranial dural arteriovenous fistulas: a Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) investigation. J Neurosurg 2021; 136:971-980. [PMID: 34507300 DOI: 10.3171/2021.1.jns202861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a reported elevated risk of cerebral aneurysms in patients with intracranial dural arteriovenous fistulas (dAVFs). However, the natural history, rate of spontaneous regression, and ideal treatment regimen are not well characterized. In this study, the authors aimed to describe the characteristics of patients with dAVFs and intracranial aneurysms and propose a classification system. METHODS The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database from 12 centers was retrospectively reviewed. Analysis was performed to compare dAVF patients with (dAVF+ cohort) and without (dAVF-only cohort) concomitant aneurysm. Aneurysms were categorized based on location as a dAVF flow-related aneurysm (FRA) or a dAVF non-flow-related aneurysm (NFRA), with further classification as extra- or intradural. Patients with traumatic pseudoaneurysms or aneurysms with associated arteriovenous malformations were excluded from the analysis. Patient demographics, dAVF anatomical information, aneurysm information, and follow-up data were collected. RESULTS Of the 1077 patients, 1043 were eligible for inclusion, comprising 978 (93.8%) and 65 (6.2%) in the dAVF-only and dAVF+ cohorts, respectively. There were 96 aneurysms in the dAVF+ cohort; 10 patients (1%) harbored 12 FRAs, and 55 patients (5.3%) harbored 84 NFRAs. Dural AVF+ patients had higher rates of smoking (59.3% vs 35.2%, p < 0.001) and illicit drug use (5.8% vs 1.5%, p = 0.02). Sixteen dAVF+ patients (24.6%) presented with aneurysm rupture, which represented 16.7% of the total aneurysms. One patient (1.5%) had aneurysm rupture during follow-up. Patients with dAVF+ were more likely to have a dAVF located in nonconventional locations, less likely to have arterial supply to the dAVF from external carotid artery branches, and more likely to have supply from pial branches. Rates of cortical venous drainage and Borden type distributions were comparable between cohorts. A minority (12.5%) of aneurysms were FRAs. The majority of the aneurysms underwent treatment via either endovascular (36.5%) or microsurgical (15.6%) technique. A small proportion of aneurysms managed conservatively either with or without dAVF treatment spontaneously regressed (6.2%). CONCLUSIONS Patients with dAVF have a similar risk of harboring a concomitant intracranial aneurysm unrelated to the dAVF (5.3%) compared with the general population (approximately 2%-5%) and a rare risk (0.9%) of harboring an FRA. Only 50% of FRAs are intradural. Dural AVF+ patients have differences in dAVF angioarchitecture. A subset of dAVF+ patients harbor FRAs that may regress after dAVF treatment.
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Affiliation(s)
| | | | - Michael R Levitt
- Departments of1Neurological Surgery.,4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Jason P Sheehan
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bradley A Gross
- 6Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ashley Lockerman
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - W Christopher Fox
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Waleed Brinjikji
- Departments of8Neurosurgery and.,9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Giuseppe Lanzino
- Departments of8Neurosurgery and.,9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert M Starke
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Stephanie H Chen
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Adriaan R E Potgieser
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - J Marc C van Dijk
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Andrew Durnford
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Diederik Bulters
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Junichiro Satomi
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Amanda Kwasnicki
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | | | - Ali Alaraj
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Edgar A Samaniego
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Minako Hayakawa
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Ethan Winkler
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Adib Abla
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Pui Man Rosalind Lai
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Rose Du
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | | | - Akash P Kansagra
- Departments of18Neurological Surgery.,20Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Louis J Kim
- Departments of1Neurological Surgery.,2Radiology, and.,4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
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27
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Chassagne F, Barbour MC, Chivukula VK, Machicoane N, Kim LJ, Levitt MR, Aliseda A. The effect of Dean, Reynolds, and Womersley number on the flow in a spherical cavity on a curved round pipe. Part 1. Fluid mechanics in the cavity as a canonical flow representing intracranial aneurysms. J Fluid Mech 2021; 915:A123. [PMID: 34024939 PMCID: PMC8136084 DOI: 10.1017/jfm.2020.1114] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Flow in side-wall cerebral aneurysms can be ideally modelled as the combination of flow over a spherical cavity and flow in a curved circular pipe, two canonical flows. Flow in a curved pipe is known to depend on the Dean number De, combining the effects of Reynolds number, Re, and of the curvature along the pipe centreline, κ. Pulsatility in the flow introduces a dependency on the Womersley number Wo. Using stereo PIV measurements, this study investigated the effect of these three key non-dimensional parameters, by modifying pipe curvature (De), flow-rate (Re), and pulsatility frequency (Wo), on the flow patterns in a spherical cavity. A single counter-rotating vortex was observed in the cavity for all values of pipe curvature κ and Re, for both steady and pulsatile inflow conditions. Increasing the pipe curvature impacted both the flow patterns in the pipe and the cavity, by shifting the velocity profile towards the cavity opening and increasing the flow rate into the cavity. The circulation in the cavity was found to collapse well with only the Dean number, for both steady and pulsatile inflows. For pulsatile inflow, the counter-rotating vortex was unstable and the location of its centre over time was impacted by the curvature of the pipe, as well as the Re and the Wo in the freestream. The circulation in the cavity was higher for steady inflow than for the equivalent average Reynolds and Dean number pulsatile inflow, with very limited impact of the Womersley in the range studied.
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Affiliation(s)
- Fanette Chassagne
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98105, USA
| | - Michael C. Barbour
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98105, USA
| | - Venkat K. Chivukula
- Biomedical and Chemical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL 32901, USA
| | | | - Louis J. Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
- Department of Radiology, University of Washington, Seattle, WA 98107, USA
| | - Michael R. Levitt
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98105, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
- Department of Radiology, University of Washington, Seattle, WA 98107, USA
| | - Alberto Aliseda
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98105, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
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28
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Barbour MC, Chassagne F, Chivukula VK, Machicoane N, Kim LJ, Levitt MR, Aliseda A. The effect of Dean, Reynolds and Womersley numbers on the flow in a spherical cavity on a curved round pipe. Part 2. The haemodynamics of intracranial aneurysms treated with flow-diverting stents. J Fluid Mech 2021; 915:A124. [PMID: 34658417 PMCID: PMC8519511 DOI: 10.1017/jfm.2020.1115] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The flow in a spherical cavity on a curved round pipe is a canonical flow that describes well the flow inside a sidewall aneurysm on an intracranial artery. Intracranial aneurysms are often treated with a flow-diverting stent (FDS), a low-porosity metal mesh that covers the entrance to the cavity, to reduce blood flow into the aneurysm sac and exclude it from mechanical stresses imposed by the blood flow. Successful treatment is highly dependent on the degree of reduction of flow inside the cavity, and the resulting altered fluid mechanics inside the aneurysm following treatment. Using stereoscopic particle image velocimetry, we characterize the fluid mechanics in a canonical configuration representative of an intracranial aneurysm treated with a FDS: a spherical cavity on the side of a curved round pipe covered with a metal mesh formed by an actual medical FDS. This porous mesh coverage is the focus of Part 2 of the paper, characterizing the effects of parent vessel Re, De and pulsatility, Wo, on the fluid dynamics, compared with the canonical configuration with no impediments to flow into the cavity that is described in Part 1 (Chassagne et al., J. Fluid Mech., vol. 915, 2021, A123). Coverage with a FDS markedly reduces the flow Re in the aneurysmal cavity, creating a viscous-dominated flow environment despite the parent vessel Re > 100. Under steady flow conditions, the topology that forms inside the cavity is shown to be a function of the parent vessel De. At low values of De, flow enters the cavity at the leading edge and remains attached to the wall before exiting at the trailing edge, a novel behaviour that was not found under any conditions of the high-Re, unimpeded cavity flow described in Part 1. Under these conditions, flow in the cavity co-rotates with the direction of the free-stream flow, similar to Stokes flow in a cavity. As De increases, the flow along the leading edge begins to separate, and the recirculation zone grows with increasing De, until, above De ≈ 180, the flow inside the cavity is fully recirculating, counter-rotating with respect to the free-stream flow. Under pulsatile flow conditions, the vortex inside the cavity progresses through the same cycle - switching from attached and co-rotating with the free-stream flow at the beginning of the cycle (low velocity and positive acceleration) to separated and counter-rotating as De reaches a critical value. The location of separation within the harmonic cycle is shown to be a function of both De and Wo. The values of aneurysmal cavity Re based on both the average velocity and the circulation inside the cavity are shown to increase with increasing values of De, while Wo is shown to have little influence on the time-averaged metrics. As De increases, the strength of the secondary flow in the parent vessel grows, due to the inertial instability in the curved pipe, and the flow rate entering the cavity increases. Thus, the effectiveness of FDS treatment to exclude the aneurysmal cavity from the haemodynamic stresses is compromised for aneurysms located on high-curvature arteries, i.e. vessels with high De, and this can be a fluid mechanics criterion to guide treatment selection.
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Affiliation(s)
- Michael C. Barbour
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
| | - Fanette Chassagne
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
| | - Venkat K. Chivukula
- Biomedical and Chemical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL 32901, USA
| | | | - Louis J. Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
- Department of Radiology, University of Washington, Seattle, WA 98107, USA
| | - Michael R. Levitt
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
- Department of Radiology, University of Washington, Seattle, WA 98107, USA
| | - Alberto Aliseda
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
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29
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Chivukula VK, Marsh L, Chassagne F, Barbour MC, Kelly CM, Levy S, Geindreau C, Roscoat SRD, Kim LJ, Levitt MR, Aliseda A. Lagrangian Trajectory Simulation of Platelets and Synchrotron Microtomography Augment Hemodynamic Analysis of Intracranial Aneurysms Treated With Embolic Coils. J Biomech Eng 2021; 143:1102198. [PMID: 33665669 DOI: 10.1115/1.4050375] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Indexed: 11/08/2022]
Abstract
As frequency of endovascular treatments for intracranial aneurysms increases, there is a growing need to understand the mechanisms for coil embolization failure. Computational fluid dynamics (CFD) modeling often simplifies modeling the endovascular coils as a homogeneous porous medium (PM), and focuses on the vascular wall endothelium, not considering the biomechanical environment of platelets. These assumptions limit the accuracy of computations for treatment predictions. We present a rigorous analysis using X-ray microtomographic imaging of the coils and a combination of Lagrangian (platelet) and Eulerian (endothelium) metrics. Four patient-specific, anatomically accurate in vitro flow phantoms of aneurysms are treated with the same patient-specific endovascular coils. Synchrotron tomography scans of the coil mass morphology are obtained. Aneurysmal hemodynamics are computationally simulated before and after coiling, using patient-specific velocity/pressure measurements. For each patient, we analyze the trajectories of thousands of platelets during several cardiac cycles, and calculate residence times (RTs) and shear exposure, relevant to thrombus formation. We quantify the inconsistencies of the PM approach, comparing them with coil-resolved (CR) simulations, showing the under- or overestimation of key hemodynamic metrics used to predict treatment outcomes. We fully characterize aneurysmal hemodynamics with converged statistics of platelet RT and shear stress history (SH), to augment the traditional wall shear stress (WSS) on the vascular endothelium. Incorporating microtomographic scans of coil morphology into hemodynamic analysis of coiled intracranial aneurysms, and augmenting traditional analysis with Lagrangian platelet metrics improves CFD predictions, and raises the potential for understanding and clinical translation of computational hemodynamics for intracranial aneurysm treatment outcomes.
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Affiliation(s)
| | - Laurel Marsh
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195
| | - Fanette Chassagne
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195
| | - Michael C Barbour
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98195
| | - Samuel Levy
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98195
| | - Christian Geindreau
- Laboratoire 3SR, Université Grenoble Alpes, 1270 Rue de la Piscine, Gières 38610, France
| | | | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98195; Department of Radiology, University of Washington, Seattle, WA 98195
| | - Michael R Levitt
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195; Department of Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98195; Department of Radiology, University of Washington, Seattle, WA 98195
| | - Alberto Aliseda
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195; Department of Neurological Surgery, University of Washington, Seattle, WA 98195; Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA 98195
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30
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Li Y, Chen SH, Guniganti R, Kansagra AP, Piccirillo JF, Chen CJ, Buell T, Sheehan JP, Ding D, Lanzino G, Brinjikji W, Kim LJ, Levitt MR, Abecassis IJ, Bulters DO, Durnford A, Fox WC, Polifka AJ, Gross BA, Sur S, McCarthy DJ, Yavagal DR, Peterson EC, Hayakawa M, Derdeyn C, Samaniego EA, Amin-Hanjani S, Alaraj A, Kwasnicki A, Charbel FT, van Dijk JMC, Potgieser AR, Satomi J, Tada Y, Abla A, Phelps R, Du R, Lai PMR, Zipfel GJ, Starke RM. Onyx embolization for dural arteriovenous fistulas: a multi-institutional study. J Neurointerv Surg 2021; 14:neurintsurg-2020-017109. [PMID: 33632883 DOI: 10.1136/neurintsurg-2020-017109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/05/2021] [Accepted: 02/10/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance. OBJECTIVE To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs. METHODS From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models. RESULTS A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes. CONCLUSIONS In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.
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Affiliation(s)
- Yangchun Li
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Ridhima Guniganti
- Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Akash P Kansagra
- Department of Neurological Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Jay F Piccirillo
- Department of Neurological Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas Buell
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Andrew Durnford
- Department of Neurosurgery, University of Southampton, Southampton, Hampshire, UK
| | - W Christopher Fox
- Department of Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samir Sur
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami, Miami, Florida, USA
| | - Eric C Peterson
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Minako Hayakawa
- Division of Neurointerventional Surgery, Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Colin Derdeyn
- Department of Radiology and Interventional Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amanda Kwasnicki
- Department of Neurosurgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - J Marc C van Dijk
- Department of Neurosurgery, Universitair Medisch Centrum Groningen, Groningen, Groningen, Netherlands
| | - Adriaan Re Potgieser
- Department of Neurosurgery, University of Groningen, Groningen, Groningen, Netherlands
| | - Junichiro Satomi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yoshiteru Tada
- Department of Neurosurgery, Tokushima University, Tokushima, Tokushima, Japan
| | - Adib Abla
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Ryan Phelps
- Department of Neurosurgery, UCSF, San Francisco, California, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University, St Louis, Missouri, USA.,Department of Neurological Surgery, Washington University, St Louis, Missouri, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA .,Department of Radiology, University of Miami School of Medicine, Miami, Florida, USA
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Amin-Hanjani S, Stapleton CJ, See AP, Bambakidis NC, Etminan N, Charbel FT, Kim LJ, Lanzino G, Nakaji P, Raabe A, Siddiqui AH, Woo HH, Welch BG, Zipfel GJ, Ghogawala Z. Wisdom of the Crowd? Results from the Retrospective Expert Panel Review of Unruptured Intracranial Aneurysms (REPaiR-UIA) Study. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_276] [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: 11/13/2022] Open
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Abecassis IJ, Meyer RM, Levitt MR, Sheehan JP, Chen CJ, Gross BA, Lockerman A, Fox WC, Giordan E, Lanzino G, Starke RM, Chen SH, Potgieser ARE, van Dijk J, Durnford A, Bulters DO, Satomi J, Tada Y, Kwasnicki AM, Amin-Hanjani S, Alaraj A, Samaniego EA, Hayakawa M, Derdeyn CP, Winkler EA, Abla AA, Lai PMR, Du R, Guniganti RR, Kansagra AP, Zipfel GJ, Kim LJ. Assessing the Rate, Natural History, and Treatment Trends of Intracranial Aneurysms in Patients with Cranial Dural Arteriovenous Fistulae (dAVF); A CONDOR Investigation. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sen RD, Abecassis IJ, Barber J, Nistal DA, Abecassis ZA, Levitt MR, Kim LJ, Sekhar LN. Ruptured Brain Arteriovenous Malformation Presenting in Extremis. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_365] [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: 11/13/2022] Open
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Sen RD, Abecassis IJ, Barber J, Nistal DA, Abecassis ZA, Levitt MR, Kim LJ, Sekhar LN. Impact of Acute Microsurgical Resection for Ruptured Brain Arteriovenous Malformations on Hospital Length of Stay and Clinical Outcomes. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_323] [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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35
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Mascitelli JR, Levitt MR, Griessenauer CJ, Kim LJ, Gross B, Abla A, Winkler E, Jankowitz B, Grandhi R, Goren O, Schirmer CM. Transcirculation approach for stent-assisted coiling of intracranial aneurysms: a multicenter study. J Neurointerv Surg 2020; 13:711-715. [PMID: 33203763 DOI: 10.1136/neurintsurg-2020-016899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND The transcirculation approach (TCA) for stent-assisted coiling (SAC) of intracranial aneurysms may be useful for certain wide-neck bifurcation aneurysms as well as those with acute-angle efferent branches. OBJECTIVE To describe a multicenter experience using the TCA for SAC. METHODS A multicenter, retrospective study (2016-2020) of aneurysm treatment using SAC via the TCA. Angiographic outcome was scored using the Raymond Scale (adequate occlusion 1 and 2), and clinical outcome was scored using a modified Rankin Scale (good outcome 0-2) RESULTS: Twenty-nine patients with 29 aneurysms were included (62.1% female; average age 61; 89.7% unruptured; 13.8% previously treated; average dome size 6.4 mm; average neck 4.4 mm). Aneurysm locations included internal carotid artery-fetal posterior cerebral artery (n=4), internal carotid artery terminus (n=4), anterior communicating artery (n=8), vertebral artery-posterior inferior cerebellar artery (n=2), and basilar tip (n=11). The TCA used communicating arteries (93.1%; average 1.6 mm), intermediate catheters (51.7%), jailing technique (62.1%), and staged procedures (10.3%). The most common stent was the Neuroform Atlas (Stryker; 69%). Immediate adequate occlusion was obtained in 75.9%, and five patients with inadequate occlusion progressed to adequate occlusion at follow-up. One (3.4%) procedural complication occurred: a watershed stroke in the setting of baseline four-vessel extracranial disease. Two patients had a poor outcome unrelated to the TCA. The majority of patients (86.4%) had a good clinical outcome. One case of in-stent stenosis due to non-compliance with medication was seen, which resolved with medication resumption. CONCLUSIONS The TCA for SAC can be performed for a variety of aneurysms with a low complication rate and good clinical outcomes.
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Affiliation(s)
- Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Louis J Kim
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Bradley Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adib Abla
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ethan Winkler
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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Arthur AS, Abecassis IJ, Abi-Aad KR, Albuquerque FC, Almefty RO, Aoun RJN, Barrow DL, Bederson J, Bendok BR, Ducruet AF, Fanous AA, Fennell VS, Flores BC, Griessenauer CJ, Kim LJ, Levitt MR, Mack WJ, Mascitelli J, Min E, Mocco J, Morr S, Nerva JD, Richards AE, Schirmer CM, See AP, Snyder KV, Tian F, Walcott BP, Welz ME. Vascular. Oper Neurosurg (Hagerstown) 2020; 17:S76-S118. [PMID: 31099843 DOI: 10.1093/ons/opz088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - I Josh Abecassis
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Karl R Abi-Aad
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rami O Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rami James N Aoun
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Ophthalmalogy, Emory University School of Medicine, Atlanta, Georgia.,Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Joshua Bederson
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew A Fanous
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Vernard S Fennell
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Bruno C Flores
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, Pennsylvania
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington.,Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington.,Department of Radiology, University of Washington School of Medicine, Seattle, Washington.,Department of Mechanical Engineering, University of Washington School of Medicine, Seattle, Washington
| | - William J Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Justin Mascitelli
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Elliott Min
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Simon Morr
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - John D Nerva
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | | | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, Pennsylvania
| | - Alfred P See
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Fucheng Tian
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Brian P Walcott
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matthew E Welz
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
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Pandey AS, Ringer AJ, Rai AT, Kan P, Jabbour P, Siddiqui AH, Levy EI, Snyder KV, Riina H, Tanweer O, Levitt MR, Kim LJ, Veznedaroglu E, Binning MJ, Arthur AS, Mocco J, Schirmer C, Thompson BG, Langer D. Minimizing SARS-CoV-2 exposure when performing surgical interventions during the COVID-19 pandemic. J Neurointerv Surg 2020; 12:643-647. [PMID: 32434798 PMCID: PMC7298685 DOI: 10.1136/neurintsurg-2020-016161] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Infection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences. METHODS We assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment. RESULTS Patients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas. CONCLUSION Based on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff.
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Affiliation(s)
- Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew J Ringer
- Neurosurgery, Mayfield Clinic, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Elad I Levy
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kenneth V Snyder
- Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Neurosurgery and Neurology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Howard Riina
- Department of Neurosurgery, New York University - Langone Medical Center, New York, New York, USA
| | - Omar Tanweer
- Department of Neurosurgery, New York University - Langone Medical Center, New York, New York, USA
| | - Michael R Levitt
- Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Erol Veznedaroglu
- Drexel Neuroscience Institute and GNI, Philadelphia, Pennsylvania, USA
| | - Mandy J Binning
- Drexel Neurosciences Institute, Philadelphia, Pennsylvania, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - J Mocco
- The Mount Sinai Health System, New York, New York, USA
| | - Clemens Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, USA
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | | | - David Langer
- Neurosurgery, Lenox Hill Hospital, New York, New York, USA
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38
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Walker M, Kim LJ, Levitt MR, Ghodke B. Spasm, stenosis and shelves: balloon-assisted tracking techniques in endovascular interventions. J Cerebrovasc Endovasc Neurosurg 2020; 22:26-30. [PMID: 32596141 PMCID: PMC7307611 DOI: 10.7461/jcen.2020.22.1.26] [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] [Received: 09/02/2019] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/01/2022] Open
Abstract
The technique of balloon-assisted tracking (BAT) has been demonstrated in transradial cardio-angiographic procedures. Using three commonly encountered clinical scenarios, we outline the technical details of BAT for managing peripheral and cerebral interventions with challenging vascular access. We describe methods used to overcome vasospasm, stenosis and vascular shelves during interventions for acute ischemic stroke, but these issues are not unique to neuroendovascular cases and the techniques can be applied across all endovascular interventions. We present three acute stroke interventions where anatomic challenges were overcome with the use of endovascular BAT. This article describes a novel application for BAT techniques in endovascular interventions to assist with access in peripheral, cervical and intracranial vessels. These methods can also be used to improve access during diagnostic cerebral angiography. BAT is a useful adjunct when navigating catheters through vasospasm, tortuous anatomy, vascular step-offs or intraluminal plaques.
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Affiliation(s)
- Melanie Walker
- Department of Neurological Surgery and Stroke and Applied Neurosciences Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Louis J Kim
- Department of Neurological Surgery and Stroke and Applied Neurosciences Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurological Surgery and Stroke and Applied Neurosciences Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Basavaraj Ghodke
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
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39
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Burkhardt JK, Srinivasan V, Srivatsan A, Albuquerque F, Ducruet AF, Hendricks B, Gross BA, Jankowitz BT, Thomas AJ, Ogilvy CS, Maragkos GA, Enriquez-Marulanda A, Crowley RW, Levitt MR, Kim LJ, Griessenauer CJ, Schirmer CM, Dalal S, Piper K, Mokin M, Winkler EA, Abla AA, McDougall C, Birnbaum L, Mascitelli J, Litao M, Tanweer O, Riina H, Johnson J, Chen S, Kan P. Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms. AJNR Am J Neuroradiol 2020; 41:1037-1042. [PMID: 32467183 DOI: 10.3174/ajnr.a6581] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent. MATERIALS AND METHODS On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up. RESULTS Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03). CONCLUSIONS This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.
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Affiliation(s)
- J-K Burkhardt
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - V Srinivasan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - A Srivatsan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - F Albuquerque
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - A F Ducruet
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - B Hendricks
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - B A Gross
- Department of Neurological Surgery (B.A.G.), University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania
| | - B T Jankowitz
- Department of Neurosurgery (B.T.J.), Cooper University, Camden, New Jersey
| | - A J Thomas
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | - C S Ogilvy
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | - G A Maragkos
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | | | - R W Crowley
- Department of Neurosurgery (R.W.C.), Rush Medical College, Chicago, Illinois
| | - M R Levitt
- Department of Neurological Surgery (M.R.L., L.J.K.), University of Washington, Seattle, Washington
| | - L J Kim
- Department of Neurological Surgery (M.R.L., L.J.K.), University of Washington, Seattle, Washington
| | - C J Griessenauer
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania.,Research Institute of Neurointervention (C.J.G., C.M.S.), Paracelsus Medical University, Salzburg, Austria
| | - C M Schirmer
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania.,Research Institute of Neurointervention (C.J.G., C.M.S.), Paracelsus Medical University, Salzburg, Austria
| | - S Dalal
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania
| | - K Piper
- Department of Neurosurgery (K.P., M.M.), University of Southern Florida College of Public Health, Tampa, Florida
| | - M Mokin
- Department of Neurosurgery (K.P., M.M.), University of Southern Florida College of Public Health, Tampa, Florida
| | - E A Winkler
- Department of Neurological Surgery (E.A.W., A.A.A.), University of California, San Francisco, San Francisco, California
| | - A A Abla
- Department of Neurological Surgery (E.A.W., A.A.A.), University of California, San Francisco, San Francisco, California
| | - C McDougall
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - L Birnbaum
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - J Mascitelli
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - M Litao
- Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - O Tanweer
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - H Riina
- Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - J Johnson
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - S Chen
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - P Kan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
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Pandey AS, Ringer AJ, Rai A, Kan PT, Jabbour PM, Siddiqui A, Levy E, Snyder KV, Riina HA, Tanweer O, Levitt MR, Kim LJ, Veznedaroglu E, Binning M, Arthur AS, Mocco J, Schirmer CM, Thompson BG, Langer D. Letter: Considerations for Performing Emergent Neurointerventional Procedures in a COVID-19 Environment. Neurosurgery 2020; 87:E203-E206. [PMID: 32358606 PMCID: PMC7197580 DOI: 10.1093/neuros/nyaa173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Aditya S Pandey
- Department of Neurosurgery and Radiology University of Michigan Ann Arbor, Michigan
| | | | - Ansaar Rai
- Department of Neuroradiology West Virginia University Morgantown, West Virginia
| | - Peter T Kan
- Department of Neurosurgery Baylor College of Medicine Houston, Texas
| | - Pascal M Jabbour
- Department of Neurosurgery Thomas Jefferson University Hospital Philadelphia, Pennsylvania
| | - Adnan Siddiqui
- Department of Neurosurgery Jacobs School of Medicine University at Buffalo Buffalo, New York
| | - Elad Levy
- Department of Neurosurgery Jacobs School of Medicine University at Buffalo Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery Jacobs School of Medicine University at Buffalo Buffalo, New York
| | - Howard A Riina
- Department of Neurosurgery New York University Langone Health New York, New York
| | - Omar Tanweer
- Department of Neurosurgery New York University Langone Health New York, New York
| | - Michael R Levitt
- Department of Neurological Surgery University of Washington Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery University of Washington Seattle, Washington
| | - Erol Veznedaroglu
- Department of Neurosurgery Drexel University College of Medicine Philadelphia, Pennsylvania
| | - Mandy Binning
- Department of Neurosurgery Drexel University College of Medicine Philadelphia, Pennsylvania
| | - Adam S Arthur
- Department of Neurosurgery Semmes Murphy Clinic University of Tennessee Memphis, Tennessee
| | - J Mocco
- Department of Neurosurgery Mount Sinai New York, New York
| | - Clemens M Schirmer
- Department of Neurosurgery Geisinger Health System Danville, Pennsylvania
| | - B Gregory Thompson
- Department of Neurosurgery and Radiology University of Michigan Ann Arbor, Michigan
| | - David Langer
- Department of Neurosurgery Lenox Hill Hospital New York, New York
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Abstract
Cerebrovascular diseases manifest as abnormalities of and disruption to the intracranial vasculature and its capacity to carry blood to the brain. However, the pathogenesis of many cerebrovascular diseases begins in the vessel wall. Traditional luminal and perfusion imaging techniques do not provide adequate information regarding the differentiation, onset, or progression of disease. Intracranial high-resolution MR vessel wall imaging (VWI) has emerged as an invaluable technique for understanding and evaluating cerebrovascular diseases. The location and pattern of contrast enhancement in intracranial VWI provides new insight into the inflammatory etiology of cerebrovascular diseases and has potential to permit earlier diagnosis and treatment. In this report, technical considerations of VWI are discussed and current applications of VWI in vascular malformations, blunt cerebrovascular injury/dissection, and steno-occlusive cerebrovascular vasculopathies are reviewed.
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Affiliation(s)
| | | | | | | | - Louis J. Kim
- Departments of 1Neurological Surgery,
- 2Radiology, and
- 4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Michael R. Levitt
- Departments of 1Neurological Surgery,
- 2Radiology, and
- 3Mechanical Engineering, and
- 4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
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Marsh LMM, Barbour MC, Chivukula VK, Chassagne F, Kelly CM, Levy SH, Kim LJ, Levitt MR, Aliseda A. Platelet Dynamics and Hemodynamics of Cerebral Aneurysms Treated with Flow-Diverting Stents. Ann Biomed Eng 2019; 48:490-501. [PMID: 31549329 DOI: 10.1007/s10439-019-02368-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/13/2019] [Indexed: 02/06/2023]
Abstract
Flow-diverting stents (FDS) are used to treat cerebral aneurysms. They promote the formation of a stable thrombus within the aneurysmal sac and, if successful, isolate the aneurysmal dome from mechanical stresses to prevent rupture. Platelet activation, a mechanism necessary for thrombus formation, is known to respond to biomechanical stimuli, particularly to the platelets' residence time and shear stress exposure. Currently, there is no reliable method for predicting FDS treatment outcomes, either a priori or after the procedure. Eulerian computational fluid dynamic (CFD) studies of aneurysmal flow have searched for predictors of endovascular treatment outcome; however, the hemodynamics of thrombus formation cannot be fully understood without considering the platelets' trajectories and their mechanics-triggered activation. Lagrangian analysis of the fluid mechanics in the aneurysmal vasculature provides novel metrics by tracking the platelets' residence time (RT) and shear history (SH). Eulerian and Lagrangian parameters are compared for 19 patient-specific cases, both pre- and post-treatment, to assess the degree of change caused by the FDS and subsequent treatment efficacy.
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Affiliation(s)
- Laurel M M Marsh
- Mechanical Engineering, University of Washington, 4000 15th Ave NE, Box 352600, Seattle, WA, 98195, USA
| | - Michael C Barbour
- Mechanical Engineering, University of Washington, 4000 15th Ave NE, Box 352600, Seattle, WA, 98195, USA
| | - Venkat Keshav Chivukula
- Mechanical Engineering, University of Washington, 4000 15th Ave NE, Box 352600, Seattle, WA, 98195, USA
| | - Fanette Chassagne
- Mechanical Engineering, University of Washington, 4000 15th Ave NE, Box 352600, Seattle, WA, 98195, USA
| | - Cory M Kelly
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Stroke & Applied NeuroScience Center, University of Washington, Seattle, WA, USA
| | - Samuel H Levy
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Stroke & Applied NeuroScience Center, University of Washington, Seattle, WA, USA
| | - Louis J Kim
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Stroke & Applied NeuroScience Center, University of Washington, Seattle, WA, USA.,Radiology, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Mechanical Engineering, University of Washington, 4000 15th Ave NE, Box 352600, Seattle, WA, 98195, USA.,Neurological Surgery, University of Washington, Seattle, WA, USA.,Stroke & Applied NeuroScience Center, University of Washington, Seattle, WA, USA.,Radiology, University of Washington, Seattle, WA, USA
| | - Alberto Aliseda
- Mechanical Engineering, University of Washington, 4000 15th Ave NE, Box 352600, Seattle, WA, 98195, USA. .,Neurological Surgery, University of Washington, Seattle, WA, USA. .,Stroke & Applied NeuroScience Center, University of Washington, Seattle, WA, USA.
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43
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Osbun JW, Patel B, Levitt MR, Yahanda AT, Shah A, Dlouhy KM, Thatcher JP, Chicoine MR, Kim LJ, Zipfel GJ. Transradial intraoperative cerebral angiography: a multicenter case series and technical report. J Neurointerv Surg 2019; 12:170-175. [PMID: 31484699 DOI: 10.1136/neurintsurg-2019-015207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 06/17/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Use of the radial artery as an access site for neurointerventional procedures is gaining popularity after several studies in interventional cardiology have demonstrated superior patient safety, decreased length of stay, and patient preference compared with femoral artery access. The transradial approach has yet to be characterized for intraoperative cerebral angiography. OBJECTIVE To report a multicenter experience on the use of radial artery access in intraoperative cerebral angiography, including case series and discussion of technical nuances. METHODS 27 patients underwent attempted transradial cerebral angiography betweenMay 2017 and May 2019. Data were collected regarding technique, patient positioning, vessels selected, technical success rate, and access site complications. RESULTS 24 of the 27 patients (88.8%) underwent successful transradial intraoperative cerebral angiography. 18 patients (66.7%) were positioned supine, 6 patients (22.2%) were positioned prone, 1 patient (3.7%) was positioned lateral, and 2 patients (7.4%) were positioned three-quarters prone. A total of 31 vessels were selected including 13 right carotid arteries (8 common, 1 external, 4 internal), 11 left carotid arteries (9 common and 2 internal), and 6 vertebral arteries (5 right and 1 left). Two patients (7.4%) required conversion to femoral access in order to complete the intraoperative angiogram (1 due to arterial vasospasm and 1 due to inadvertent venous catheterization). One procedure (3.7%) was aborted because of inability to obtain the appropriate fluoroscopic views due to patient positioning. No patient experienced stroke, arterial dissection, or access site complication. CONCLUSIONS Transradial intraoperative cerebral angiography is safe and feasible with potential for improved operating room workflow ergonomics, faster patient mobility in the postoperative period, and reduced costs.
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Affiliation(s)
- Joshua W Osbun
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Michael R Levitt
- Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Alexander T Yahanda
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Amar Shah
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Kathleen M Dlouhy
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Joshua P Thatcher
- Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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44
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Alexander MD, Hippe DS, Cooke DL, Hallam DK, Hetts SW, Kim H, Lawton MT, Sekhar LN, Kim LJ, Ghodke BV. Targeted Embolization of Aneurysms Associated With Brain Arteriovenous Malformations at High Risk for Surgical Resection: A Case-Control Study. Neurosurgery 2019; 82:343-349. [PMID: 28419337 DOI: 10.1093/neuros/nyx167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/10/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High-risk components of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of lesion rupture. OBJECTIVE To evaluate targeted embolization of aneurysms against other means of treatment with a case-control analysis; we previously investigated this approach associated with BAVMs. METHODS Retrospective analysis of patients with BAVMs was performed, identifying patients treated with intention to occlude only an aneurysm associated with a BAVM. For each targeted aneurysm embolization (TAE) patient identified, 4 control patients were randomly selected, controlling for rupture status, age, and Spetzler-Martin plus Lawton-Young supplemental score. Analysis was performed to compare rates of adverse events (hemorrhage, new seizure, and death) between the 2 groups. RESULTS Thirty-two patients met inclusion criteria, and 128 control patients were identified, out of 1103 patients treated during the study period. Thirty-four adverse events occurred (15 ruptures, 15 new seizures, and 11 deaths) during the follow-up period (mean 1157 d for the TAE cohort and 1036 d for the non-TAE cohort). Statistically lower associations were noted for the TAE group for any adverse event (hazard ratio 0.28, P = .037) and the composite outcome of hemorrhage or new seizure (hazard ratio 0.20, P = .029). CONCLUSION For BAVMs at high risk for surgical resection, TAE can be performed safely and effectively. Patients treated with TAE had better outcomes than matched patients undergoing other combinations of treatment. TAE can be considered for BAVMs with high operative risk prior to radiosurgery or when no other treatment options are available.
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Affiliation(s)
- Matthew D Alexander
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Daniel S Hippe
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Daniel L Cooke
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Danial K Hallam
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Steven W Hetts
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Helen Kim
- Univer-sity of California San Francisco, Depart-ment of Anesthesia and Perioperative Care, San Francisco, California
| | - Michael T Lawton
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
| | - Laligam N Sekhar
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
| | - Louis J Kim
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
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45
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Osbun JW, Karasozen Y, Parada C, Busald T, Tatman P, Gonzalez-Cuyar L, Hale C, Alcantra D, O'Driscoll M, Dobyns W, Murray M, Kim LJ, Byers P, Dorschner M, Ferreira M. Somatic Platelet Derived Growth Factor Receptor Beta Activating Variants in Fusiform Cerebral Aneurysms. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_677] [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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46
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Ironside N, Christophe B, Bruce S, Carpenter AM, Robison T, Yoh N, Cremers S, Landry D, Frey HP, Chen CJ, Hoh BL, Kim LJ, Claassen J, Connolly ES. A phase II randomized controlled trial of tiopronin for aneurysmal subarachnoid hemorrhage. J Neurosurg 2019; 133:1-9. [PMID: 31299655 DOI: 10.3171/2019.4.jns19478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a significant contributor to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). The neurotoxin 3-aminopropanal (3-AP) is upregulated in cerebral ischemia. This phase II clinical trial evaluated the efficacy of tiopronin in reducing CSF 3-AP levels in patients with aSAH. METHODS In this prospective, randomized, double-blind, placebo-controlled, multicenter clinical trial, 60 patients were assigned to receive tiopronin or placebo in a 1:1 ratio. Treatment was commenced within 96 hours after aSAH onset, administered at a dose of 3 g daily, and continued until 14 days after aSAH or hospital discharge, whichever occurred earlier. The primary efficacy outcome was the CSF 3-AP level at 7 ± 1 days after aSAH. RESULTS Of the 60 enrolled patients, 29 (97%) and 27 (93%) in the tiopronin and placebo arms, respectively, received more than one dose of the study drug or placebo. At post-aSAH day 7 ± 1, CSF samples were available in 41% (n = 12/29) and 48% (n = 13/27) of patients in the tiopronin and placebo arms, respectively. No difference in CSF 3-AP levels at post-aSAH day 7 ± 1 was observed between the study arms (11 ± 12 nmol/mL vs 13 ± 18 nmol/mL; p = 0.766). Prespecified adverse events led to early treatment cessation for 4 patients in the tiopronin arm and 2 in the placebo arm. CONCLUSIONS The power of this study was affected by missing data. Therefore, the authors could not establish or refute an effect of tiopronin on CSF 3-AP levels. Additional observational studies investigating the role of 3-AP as a biomarker for DCI may be warranted prior to its use as a molecular target in future clinical trials.Clinical trial registration no.: NCT01095731 (ClinicalTrials.gov).
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Affiliation(s)
- Natasha Ironside
- 1Department of Neurological Surgery, Columbia University Medical Center
| | | | - Samuel Bruce
- 1Department of Neurological Surgery, Columbia University Medical Center
| | | | - Trae Robison
- 1Department of Neurological Surgery, Columbia University Medical Center
| | - Nina Yoh
- 1Department of Neurological Surgery, Columbia University Medical Center
| | - Serge Cremers
- 2Division of Laboratory Medicine, Department of Pathology and Cell Biology, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center
| | - Donald Landry
- 3Department of Medicine, Columbia University Medical Center
| | - Hans-Peter Frey
- 4Department of Neurology, Columbia University Medical Center, New York, New York
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Brian L Hoh
- 6Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Louis J Kim
- 7Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jan Claassen
- 4Department of Neurology, Columbia University Medical Center, New York, New York
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47
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Abecassis IJ, Sen R, Kelly CM, Levy S, Barber J, Ghodke B, Levitt M, Kim LJ, Sekhar LN. Clinical outcomes and cost-effectiveness analysis for the treatment of basilar tip aneurysms. J Neurointerv Surg 2019; 11:1210-1215. [DOI: 10.1136/neurintsurg-2019-014747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 12/27/2022]
Abstract
BackgroundEndovascular treatment of basilar tip aneurysms is less invasive than microsurgical clipping, but requires closer follow-up.ObjectiveTo characterize the additional costs associated with endovascular treatment of basilar tip aneurysms rather than microsurgical clipping.Materials and methodsWe obtained clinical records and billing information for 141 basilar tip aneurysms treated with clip ligation (n=48) or endovascular embolization (n=93). Costs included direct and indirect costs associated with index hospitalization, as well as re-treatments, follow-up visits, imaging studies, rehabilitation, and disability. Effectiveness of treatment was quantified by converting functional outcomes (modified Rankin Scale (mRS) score) into quality-adjusted life-years (QALYs). Cost-effectiveness was performed using cost/QALY ratios.ResultsAverage index hospitalization costs were significantly higher for patients with unruptured aneurysms treated with clip ligation ($71 400 ± $47 100) compared with coil embolization ($33 500 ± $22 600), balloon-assisted coiling ($26 200 ± $11 600), and stent-assisted coiling ($38 500 ± $20 900). Multivariate predictors for higher index hospitalization cost included vasospasm requiring endovascular intervention, placement of a ventriculoperitoneal shunt, longer length of stay, larger aneurysm neck and width, higher Hunt-Hess grade, and treatment-associated complications. At 1 year, endovascular treatment was associated with lower cost/QALY than clip ligation in unruptured aneurysms ($52 000/QALY vs $137 000/QALY, respectively, p=0.006), but comparable rates in ruptured aneurysms ($193 000/QALY vs $233 000/QALY, p=0.277). Multivariate predictors for higher cost/QALY included worse mRS score at discharge, procedural complications, and larger aneurysm width.ConclusionsCoil embolization of basilar tip aneurysms is associated with a lower cost/QALY. This effect is sustained during follow-up. Clinical condition at discharge is the most significant predictor of overall cost/QALY at 1 year.
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48
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Karasozen Y, Osbun JW, Parada CA, Busald T, Tatman P, Gonzalez-Cuyar LF, Hale CJ, Alcantara D, O'Driscoll M, Dobyns WB, Murray M, Kim LJ, Byers P, Dorschner MO, Ferreira M. Somatic PDGFRB Activating Variants in Fusiform Cerebral Aneurysms. Am J Hum Genet 2019; 104:968-976. [PMID: 31031011 PMCID: PMC6506794 DOI: 10.1016/j.ajhg.2019.03.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 03/15/2019] [Indexed: 12/20/2022] Open
Abstract
The role of somatic genetic variants in the pathogenesis of intracranial-aneurysm formation is unknown. We identified a 23-year-old man with progressive, right-sided intracranial aneurysms, ipsilateral to an impressive cutaneous phenotype. The index individual underwent a series of genetic evaluations for known connective-tissue disorders, but the evaluations were unrevealing. Paired-sample exome sequencing between blood and fibroblasts derived from the diseased areas detected a single novel variant predicted to cause a p.Tyr562Cys (g.149505130T>C [GRCh37/hg19]; c.1685A>G) change within the platelet-derived growth factor receptor β gene (PDGFRB), a juxtamembrane-coding region. Variant-allele fractions ranged from 18.75% to 53.33% within histologically abnormal tissue, suggesting post-zygotic or somatic mosaicism. In an independent cohort of aneurysm specimens, we detected somatic-activating PDGFRB variants in the juxtamembrane domain or the kinase activation loop in 4/6 fusiform aneurysms (and 0/38 saccular aneurysms; Fisher's exact test, p < 0.001). PDGFRB-variant, but not wild-type, patient cells were found to have overactive auto-phosphorylation with downstream activation of ERK, SRC, and AKT. The expression of discovered variants demonstrated non-ligand-dependent auto-phosphorylation, responsive to the kinase inhibitor sunitinib. Somatic gain-of-function variants in PDGFRB are a novel mechanism in the pathophysiology of fusiform cerebral aneurysms and suggest a potential role for targeted therapy with kinase inhibitors.
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Affiliation(s)
- Yigit Karasozen
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Joshua W Osbun
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Carolina Angelica Parada
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Tina Busald
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Philip Tatman
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Luis F Gonzalez-Cuyar
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Christopher J Hale
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Diana Alcantara
- Genome Damage and Stability Centre, University of Sussex, Falmer, Brighton BN1 9RH, UK
| | - Mark O'Driscoll
- Genome Damage and Stability Centre, University of Sussex, Falmer, Brighton BN1 9RH, UK
| | - William B Dobyns
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 98195, USA; Department of Neurology, University of Washington School of Medicine, Seattle, Washington 98195, USA; Center for Integrative Brain Research, Seattle Children's Hospital, Seattle, Washington 98105, USA
| | - Mitzi Murray
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington 98195, USA; Department of Medicine, Division of Genetics, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Louis J Kim
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Peter Byers
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington 98195, USA; Department of Genome Sciences, University of Washington School of Medicine, Seattle, Washington 98195, USA; Department of Medicine, Division of Genetics, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Michael O Dorschner
- Department of Pathology, University of Washington School of Medicine, Seattle, Washington 98195, USA; Department of Genome Sciences, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Manuel Ferreira
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, Washington 98195, USA.
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49
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Levitt MR, Mandrycky C, Abel A, Kelly CM, Levy S, Chivukula VK, Zheng Y, Aliseda A, Kim LJ. Genetic correlates of wall shear stress in a patient-specific 3D-printed cerebral aneurysm model. J Neurointerv Surg 2019; 11:999-1003. [PMID: 30979845 DOI: 10.1136/neurintsurg-2018-014669] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 12/14/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To study the correlation between wall shear stress and endothelial cell expression in a patient-specific, three-dimensional (3D)-printed model of a cerebral aneurysm. MATERIALS AND METHODS A 3D-printed model of a cerebral aneurysm was created from a patient's angiogram. After populating the model with human endothelial cells, it was exposed to media under flow for 24 hours. Endothelial cell morphology was characterized in five regions of the 3D-printed model using confocal microscopy. Endothelial cells were then harvested from distinct regions of the 3D-printed model for mRNA collection and gene analysis via quantitative polymerase chain reaction (qPCR.) Cell morphology and mRNA measurement were correlated with computational fluid dynamics simulations. RESULTS The model was successfully populated with endothelial cells, which survived under flow for 24 hours. Endothelial morphology showed alignment with flow in the proximal and distal parent vessel and aneurysm neck, but disorganization in the aneurysm dome. Genetic analysis of endothelial mRNA expression in the aneurysm dome and distal parent vessel was compared with the proximal parent vessels. ADAMTS-1 and NOS3 were downregulated in the aneurysm dome, while GJA4 was upregulated in the distal parent vessel. Disorganized morphology and decreased ADAMTS-1 and NOS3 expression correlated with areas of substantially lower wall shear stress and wall shear stress gradient in computational fluid dynamics simulations. CONCLUSIONS Creating 3D-printed models of patient-specific cerebral aneurysms populated with human endothelial cells is feasible. Analysis of these cells after exposure to flow demonstrates differences in both cell morphology and genetic expression, which correlate with areas of differential hemodynamic stress.
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Affiliation(s)
- Michael R Levitt
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Radiology, University of Washington, Seattle, WA, USA.,Mechanical Engineering, University of Washington, Seattle, WA, USA.,Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | | | - Ashley Abel
- Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Cory M Kelly
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Samuel Levy
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | | | - Ying Zheng
- Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA, USA.,Bioengineering, University of Washington, Seattle, WA, USA
| | - Alberto Aliseda
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Mechanical Engineering, University of Washington, Seattle, WA, USA.,Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Louis J Kim
- Neurological Surgery, University of Washington, Seattle, WA, USA.,Radiology, University of Washington, Seattle, WA, USA.,Stroke and Applied Neuroscience Center, University of Washington, Seattle, WA, USA
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Abecassis IJ, Sen RD, Barber J, Shetty R, Kelly CM, Ghodke BV, Hallam DK, Levitt MR, Kim LJ, Sekhar LN. Predictors of Recurrence, Progression, and Retreatment in Basilar Tip Aneurysms: A Location-Controlled Analysis. Oper Neurosurg (Hagerstown) 2019; 16:435-444. [PMID: 29905850 DOI: 10.1093/ons/opy132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Endovascular treatment of intracranial aneurysms is associated with higher rates of recurrence and retreatment, though contemporary rates and risk factors for basilar tip aneurysms (BTAs) are less well-described. OBJECTIVE To characterize progression, retreatement, and retreated progression of BTAs treated with microsurgical or endovascular interventions. METHODS We retrospectively reviewed records for 141 consecutive BTA patients. We included 158 anterior communicating artery (ACoA) and 118 middle cerebral artery (MCA) aneurysms as controls. Univariate and multivariate analyses were used to calculate rates of progression (recurrence of previously obliterated aneurysms and progression of known residual aneurysm dome or neck), retreatment, and retreated progression. Kaplan-Meier analysis was used to characterize 24-mo event rates for primary outcome prediction. RESULTS Of 141 BTA patients, 62.4% were ruptured and 37.6% were unruptured. Average radiographical follow-up was 33 mo. Among ruptured aneurysms treated with clipping, there were 2 rehemorrhages due to recurrence (6.1%), and none in any other cohorts. Overall rates of progression (28.9%), retreatment (28.9%), and retreated progression (24.7%) were not significantly different between surgical and endovascular subgroups, though ruptured aneurysms had higher event rates. Multivariate modeling confirmed rupture status (P = .003, hazard ratio = 0.14) and aneurysm dome width (P = .005, hazard ratio = 1.23) as independent predictors of progression requiring retreatment. In a separate multivariate analysis with ACoA and MCA aneurysms, basilar tip location was an independent predictor of progression, retreatment, and retreated progression. CONCLUSION BTAs have higher rates of progression and retreated progression than other aneurysm locations, independent of treatment modality. Rupture status and dome width are risk factors for progression requiring retreatment.
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Affiliation(s)
- Isaac Josh Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Rakshith Shetty
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Danial K Hallam
- Department of Radiology, University of Washington, Seattle, Washington
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle, Washington.,Department of Mechanical Engineering, University of Washington, Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Department of Radiology, University of Washington, Seattle, Washington
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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