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Elguindy MM, Haddad AF, Lu A, Savastano LE. Minimally Invasive Endoscopic Evacuation of Cerebellar Intracerebral Hemorrhage: An Illustrative Case Report. Stroke 2024; 55:e144-e147. [PMID: 38511319 DOI: 10.1161/strokeaha.123.045924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Affiliation(s)
- Mahmoud M Elguindy
- Department of Neurological Surgery, University of California, San Francisco
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco
| | - Alex Lu
- Department of Neurological Surgery, University of California, San Francisco
| | - Luis E Savastano
- Department of Neurological Surgery, University of California, San Francisco
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Ramesh R, Haddad AF, Letchuman V, Lee YM, Rinaldo L, Abla AA, Savastano LE, Raper DMS. Patient-reported outcome measures in cerebrovascular neurosurgery. J Neurosurg 2024; 140:1357-1368. [PMID: 38000069 DOI: 10.3171/2023.9.jns231067] [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: 05/15/2023] [Accepted: 09/05/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE The object of this study was to describe the use of patient-reported outcome measures (PROMs) in cerebrovascular neurosurgery and to outline a framework for incorporating them into future cerebrovascular research. METHODS Following the standardized PRISMA guidelines, the authors performed a search of the PubMed and Embase databases in February 2023 using filters to investigate six specific cerebrovascular pathologies/procedures: subarachnoid hemorrhage (SAH), intracranial hemorrhage, ischemic stroke, arteriovenous malformation, chronic subdural hematoma, and carotid artery stenosis. PROMs in the identified articles were distinguished and classified as generic, symptom specific, or disease specific. RESULTS A total of 259 studies including 51 PROMs were eligible for inclusion in the review. Most of the PROMs were generic or symptom specific. Only 5 PROMs were disease specific, and all of these pertained to stroke or SAH. CONCLUSIONS There are only a limited number of disease-specific PROMs available for cerebrovascular pathologies and outcomes. Further validation of existing measures in independent cohorts, expanded incorporation of disease-specific PROMs in prospective trials, and the development of new PROMs specific to cerebrovascular conditions are critical to a better understanding of the impact of cerebrovascular diseases and novel therapies on patient lives.
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Affiliation(s)
- Rithvik Ramesh
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Young M Lee
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Lorenzo Rinaldo
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Luis E Savastano
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California
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3
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Nogueira RG, Pinheiro A, Brinjikji W, Abbasi M, Al-Bayati AR, Mohammaden MH, Souza Viana L, Ferreira F, Abdelhamid H, Bhatt NR, Kvamme P, Layton KF, Delgado Almandoz JE, Hanel RA, Mendes Pereira V, Almekhlafi MA, Yoo AJ, Jahromi BS, Gounis MJ, Patel B, Arturo Larco JL, Fitzgerald S, Mereuta OM, Doyle K, Savastano LE, Cloft HJ, Thacker IC, Kayan Y, Copelan A, Aghaebrahim A, Sauvageau E, Demchuk AM, Bhuva P, Soomro J, Nazari P, Cantrell DR, Puri AS, Entwistle J, Polley EC, Frankel MR, Kallmes DF, Haussen DC. Clot composition and recanalization outcomes in mechanical thrombectomy. J Neurointerv Surg 2024; 16:466-470. [PMID: 37419694 DOI: 10.1136/jnis-2023-020117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/24/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has become standard for large vessel occlusions, but rates of complete recanalization are suboptimal. Previous reports correlated radiographic signs with clot composition and a better response to specific techniques. Therefore, understanding clot composition may allow improved outcomes. METHODS Clinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin-eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of first-pass effect (FPE, modified Thrombolysis in Cerebral Infarction 2c/3) and the number of passes. RESULTS A total of 1430 patients of mean±SD age 68.4±13.5 years (median (IQR) baseline National Institutes of Health Stroke Scale score 17.2 (10.5-23), IV-tPA use 36%, stent-retrievers (SR) 27%, contact aspiration (CA) 27%, combined SR+CA 43%) were included. The median (IQR) number of passes was 1 (1-2). FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for red blood cell (RBC)-rich (P<0.0001), platelet-rich (P=0.003), and mixed (P<0.0001) clots. Fibrin-rich and platelet-rich clots required a higher number of passes than RBC-rich and mixed clots (median 2 and 1.5 vs 1, respectively; P=0.02). CA showed a trend towards a higher number of passes with fibrin-rich clots (2 vs 1; P=0.12). By gross appearance, mixed/heterogeneous clots had lower FPE rates than red and white clots. CONCLUSIONS Despite the lack of correlation between clot histology and FPE, our study adds to the growing evidence supporting the notion that clot composition influences recanalization treatment strategy outcomes.
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Affiliation(s)
| | | | | | - Mehdi Abbasi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | | | | - Nirav R Bhatt
- UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Peter Kvamme
- Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Kennith F Layton
- NeuroInterventional Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Ricardo A Hanel
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Mohammed A Almekhlafi
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Babak S Jahromi
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Biraj Patel
- Radiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
- Radiology, Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | | | | | - Oana Madalina Mereuta
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
- CÚRAM-SFI Research Centre for Medical Devices and Physiology Department, National University of Ireland Galway, Galway, Ireland
| | - Karen Doyle
- Physiology, CURAM, National University of Ireland Galway, Galway, Ireland
| | | | | | - Ike C Thacker
- NeuroInterventional Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Interventional Neuroradiology, Abbot Northwestern Hospital, 55435, Minnesota, USA
| | - Alexander Copelan
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Health System, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- University of Calgary, Calgary, Alberta, Canada
| | - Parita Bhuva
- Neuroendovascular Surgery, Texas Stroke Institute, Plano, Texas, USA
| | - Jazba Soomro
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Pouya Nazari
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Neurosurgery and Radiology, Northwestern University, Chicago, Illinois, USA
| | | | - Ajit S Puri
- Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - John Entwistle
- Radiology, Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | | | - Michael R Frankel
- Department of Neurology, Emory University Atlanta, Atlanta, Georgia, USA
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Diogo C Haussen
- Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Savastano LE, Morreale RF, Eliasoph PI, Forcht-Dagi T, Nijensohn DE. The "Michelangelo Code": The Quest for Universal Truth. Neuroscientist 2024; 30:157-172. [PMID: 35866556 DOI: 10.1177/10738584221096642] [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] [Indexed: 11/15/2022]
Abstract
Michelangelo's unparalleled frescoes in the Sistine Chapel have been traditionally construed to represent the traditional, Roman Catholic interpretation of the Seven Days of Creation in the Book of Genesis and the Last Judgement. Indeed, in September 2018, Pope Francis I offered a benediction for the Vatican's art treasures and for "those who contributed to the Church's history through art." A number of studies have suggested that Michelangelo concealed anatomic information about the human brain in his renderings of God and biblical prophets and saints. Was the anatomic content of these images purposeful or coincidental? Was the anatomy intentionally concealed? Is there a common pattern with symbolic connotations in the anatomic representations? Was Michelangelo sending an encoded message? In this study, we analyze the imagery in the Sistine frescoes in light of the literature surrounding Michelangelo's artistry with a particular interest in the relationship between the certain purported anatomic depictions and details demonstrable using scientific and anatomic techniques available during the High Renaissance.
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Affiliation(s)
- Luis E Savastano
- University of Michigan, MI, USA
- Mayo Clinic, Rochester, MN, USA
- University of California San Francisco, CA, USA
| | | | - Philip I Eliasoph
- Fairfield University College of Arts and Sciences, Fairfield, CT, USA
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5
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Cohen-Cohen S, Jabal MS, Rinaldo L, Savastano LE, Lanzino G, Cloft H, Brinjikji W. Middle meningeal artery embolization for chronic subdural hematoma: A single-center experience and predictive modeling of outcomes. Neuroradiol J 2024; 37:192-198. [PMID: 38147825 DOI: 10.1177/19714009231224431] [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] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction. MATERIAL AND METHODS A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score. RESULTS A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included. CONCLUSION MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.
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Benson JC, Shahid A, Larson A, Brinjikji W, Nasr D, Saba L, Lanzino G, Savastano LE. Carotid Artery Tortuosity and Internal Carotid Artery Plaque Composition. Clin Neuroradiol 2023; 33:1017-1021. [PMID: 37286876 DOI: 10.1007/s00062-023-01302-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/27/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Little is known about the association between carotid artery tortuosity and internal carotid artery atherosclerosis. This study sought to evaluate the associations between various types of arterial tortuosity and vulnerable plaque components on magnetic resonance angiography (MRA). MATERIAL AND METHODS A retrospective review was completed of 102 patients who had undergone MRA neck imaging, with intraplaque hemorrhage (IPH) present in one or both cervical internal carotid arteries (ICA). Each ICA was assessed for two categories of tortuosity: variant arterial pathway(s) (retrojugular and/or retropharyngeal) and abnormal curvature (kinks, loops, and/or coils). All ICA plaques were assessed for the presence or absence of intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), ulceration, and enhancement, as well as the volume of IPH and degree of luminal stenosis. RESULTS The mean age of included patients was 73.5 years (SD = 9.0 years) and 88 (86.3%) subjects were male. The left carotid plaque was significantly more likely to have IPH (68.6% vs. 47.1%; p = 0.02). The left ICA was more likely to have a retrojugular course (22% vs. 9.9%; p = 0.002) and any variant arterial course (26.5% versus 14.67%, p = 0.01). On the right there was an association between the presence of a LRNC and retropharyngeal and/or retrojugular arterial pathway (p = 0.03). On the left there was an association between the presence of any abnormal arterial curvature and IPH volume (p = 0.03). Neither association met the adjusted statistical threshold after Bonferroni correction, with alpha set at 0.0028. CONCLUSION ICA tortuosity is not associated with carotid artery plaque composition, and likely does not play a role in the development of high-risk plaques.
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Affiliation(s)
- John C Benson
- Department of Radiology, Mayo Clinic, 200 1st St. SW Rochester, 55905, Rochester, MN, USA.
| | - Adnan Shahid
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Anthony Larson
- Department of Radiology, Mayo Clinic, 200 1st St. SW Rochester, 55905, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 1st St. SW Rochester, 55905, Rochester, MN, USA
| | - Deena Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Luca Saba
- Department of Medical Imaging, Azienda Ospedaliero Universitaria of Cagliari-Polo di Monserrato, Cagliari, Italy
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Arturo Larco JL, Madhani SI, Liu Y, Abbasi M, Lylyk PN, Benike A, Shahid A, Tekin B, Quinton R, Savastano LE. Evaluation of an in vivo preclinical model for human middle meningeal artery embolization using the posterior intercostal artery of the swine. J Neurointerv Surg 2023; 15:924-930. [PMID: 35999050 DOI: 10.1136/jnis-2022-019105] [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: 05/02/2022] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Embolization of the middle meningeal artery (MMA) is a promising minimally invasive technique that is gaining traction in the treatment of chronic subdural hematoma. Unfortunately, the human meninges and associated arteries are significantly larger than those of conventional laboratory animals, making the development of a clinically relevant animal model for testing of embolization agents elusive. OBJECTIVE To introduce the posterior intercostal artery (PIA) model in swine and provide anatomical, angiographic, histological, and procedural data to validate its relevance in modeling the human MMA. METHODS In human cadaveric specimens, 3D angiograms of the internal maxillary arteries (n=6) were obtained and the dura with MMA were harvested and histologically processed. Angiographic and histologic data of the human MMA were compared with the swine PIA (three animals). Then, embolization of the PIA (n=48 arteries) was conducted with liquid embolization agent (Onyx, Medtronic), and angiographic and histological results were assessed acutely (four animals) and after 30 days (two animals). RESULTS The human MMA has equivalent diameter, length, branching pattern, 3D trajectory, and wall structure to those of swine PIAs. Each swine has 12 to 14 PIAs (6-7 per side) suitable for acute or chronic embolization, which can be performed with high fidelity using the same devices, agents, and techniques currently used to embolize the MMA. The arterial wall structure and the acute and chronic histological findings in PIAs after embolization are comparable to those of humans. CONCLUSIONS This PIA model in swine could be used for research and development; objective benchmarking of agents, devices, and techniques; and in the training of neurointerventionalists.
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Affiliation(s)
| | | | - Yang Liu
- Global Institute of Future Technology, Shanghai Jiao Tong University, Shanghai, China
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Pedro N Lylyk
- Department of Interventional Neuroradiology, Clinica Sagrada Familia, Buenos Aires, CABA, Argentina
| | - Amy Benike
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Adnan Shahid
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Burak Tekin
- Department of Pathology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Reade Quinton
- Department of Pathology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, UCSF, San Francisco, California, USA
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Nicolai EN, Larco JA, Madhani SI, Asirvatham SJ, Chang SY, Ludwig KA, Savastano LE, Worrell GA. Vagus nerve stimulation using an endovascular electrode array. J Neural Eng 2023; 20:046008. [PMID: 37276858 DOI: 10.1088/1741-2552/acdb9b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/05/2023] [Indexed: 06/07/2023]
Abstract
Objective. Vagus nerve stimulation (VNS), which involves a surgical procedure to place electrodes directly on the vagus nerve (VN), is approved clinically for the treatment of epilepsy, depression, and to facilitate rehabilitation in stroke. VNS at surgically implanted electrodes is often limited by activation of motor nerve fibers near and within the VN that cause neck muscle contraction. In this study we investigated endovascular VNS that may allow activation of the VN at locations where the motor nerve fibers are not localized.Approach. We used endovascular electrodes within the nearby internal jugular vein (IJV) to electrically stimulate the VN while recording VN compound action potentials (CAPs) and neck muscle motor evoked potentials (MEPs) in an acute intraoperative swine experiment.Main Results. We show that the stimulation electrode position within the IJV is critical for efficient activation of the VN. We also demonstrate use of fluoroscopy (cone beam CT mode) and ultrasound to determine the position of the endovascular stimulation electrode with respect to the VN and IJV. At the most effective endovascular stimulation locations tested, thresholds for VN activation were several times higher than direct stimulation of the nerve using a cuff electrode; however, this work demonstrates the feasibility of VNS with endovascular electrodes and provides tools to optimize endovascular electrode positions for VNS.Significance. This work lays the foundation to develop endovascular VNS strategies to stimulate at VN locations that would be otherwise too invasive and at VN locations where structures such as motor nerve fibers do not exist.
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Affiliation(s)
- Evan N Nicolai
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, United States of America
| | - Jorge Arturo Larco
- Department of Radiology, Mayo Clinic, Rochester, MN, United States of America
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States of America
| | - Sarosh I Madhani
- Department of Neurosurgery, University of California-San Francisco, San Francisco, CA, United States of America
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Su-Youne Chang
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States of America
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States of America
| | - Kip A Ludwig
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States of America
- Wisconsin Institute for Translational Neuroengineering (WITNe), University of Wisconsin-Madison, Madison, WI, United States of America
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Luis E Savastano
- Department of Neurosurgery, University of California-San Francisco, San Francisco, CA, United States of America
| | - Gregory A Worrell
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States of America
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
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Oushy S, Borg N, Madhani SI, Brinjikji W, Savastano LE. Endovascular revascularization of chronically occluded common carotid artery for symptomatic cerebral hypoperfusion. Interv Neuroradiol 2023:15910199231187293. [PMID: 37438978 DOI: 10.1177/15910199231187293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
Endovascular recanalization is increasingly being utilized in symptomatic patients with chronically occluded carotid arteries.1 In carefully selected patients, endovascular recanalization has shown to lower the risk of ischemic events when compared to medical management alone.1 However, successful endovascular revascularization is technically challenging and not without risk.1, 2 In this video, we demonstrate a case of a 64-year-old woman who presented with recurrent transient ischemic attacks. On imaging she was found to have a chronic total occlusion of the common carotid artery from the arch. After obtaining informed consent, the patient underwent a successful endovascular recanalization and stenting of a chronically occluded left common carotid artery with aid from an intravascular guided re-entry catheter. Post operatively the patient developed a neck hematoma which improved and she returned to her neurological baseline. She reported no further symptoms on her three month follow up.
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Affiliation(s)
- Soliman Oushy
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nicholas Borg
- Department of Neurological Surgery, University of Nebraska, Omaha, NE, USA
| | - Sarosh Irfan Madhani
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | | | - Luis E Savastano
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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10
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Benson JC, Shahid A, Larson AS, Brinjikji W, Nasr D, Saba L, Lanzino G, Savastano LE. Intraplaque hemorrhage on magnetic resonance angiography: How often do signal abnormalities persist on follow-up imaging? Clin Neurol Neurosurg 2023; 229:107744. [PMID: 37119658 DOI: 10.1016/j.clineuro.2023.107744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND AND PURPOSE Intraplaque hemorrhage (IPH) in carotid atherosclerosis demonstrates increased signal on magnetic resonance angiography images. Little remains known about how this signal changes on subsequent examinations. MATERIALS AND METHODS A retrospective observational study was completed of patients that had IPH on a neck MRA between 1/1/2016 and 3/25/2021, defined as ≥ 200 % signal intensity of the sternocleidomastoid muscle on MPRAGE images. Examinations were excluded if the patients had undergone carotid endarterectomy between examinations or had poor quality imaging. IPH volumes were calculated by manually outlining IPH components. Up to 2 subsequent MRAs, if available, were assessed for both the presence and volume of IPH. RESULTS 102 patients were included, of which 90 (86.5 %) were male. IPH was on the right in 48 patients (average volume = 174.0 mm3), and on the left in 70 patients (average volume 186.9 mm3). 22 had at least one follow-up (average 444.7 days between exams), and 6 had two follow-up MRAs (average 489.5 days between exams). On the first follow-up, 19 (86.4 %) plaques had persistent hyperintense signal in the region of IPH. The second follow-up showed persistent signal in 5/6 plaques (88.3 %). Combined volume of IPH from right and left carotid arteries did not significantly decrease on the first follow-up exam (p = 0.08). CONCLUSIONS IPH usually retains hyperintense signal on follow-up MRAs, possibly representing recurrent hemorrhage or degraded blood products.
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Affiliation(s)
- John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| | - Adnan Shahid
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Deena Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Luca Saba
- Department of Medical Imaging, Azienda Ospedaliero Universitaria of Cagliari-Polo di Monserrato, Cagliari, Italy
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Oushy S, Flemming KD, Cloft H, Savastano LE. Use of intravascular optical coherence tomography to confirm the diagnosis of a carotid web in a patient with recurrent ipsilateral embolic strokes and evaluate the response to stenting. Interv Neuroradiol 2023; 29:217-221. [PMID: 35451886 PMCID: PMC10152817 DOI: 10.1177/15910199221080878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 11/15/2022] Open
Abstract
A Carotid web (CaW) is defined as a focal shelf-like projection of non-atheromatous, fibrous tissue along the posterior wall of the carotid bulb. CaW are rare and commonly overlooked lesions increasingly recognized as a cause of stroke in otherwise healthy patients. Intravascular imaging modalities such as intravascular ultrasound and optical coherence tomography (OCT) have been proposed as an adjunct to digital subtraction angiography for the evaluation of CaW. However, the use of OCT in CaW has yet to be described. This report investigated the utility of OCT as an adjunct imaging modality in the evaluation of CaW morphology in a young patient with recurrent ischemic strokes.
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Affiliation(s)
- Soliman Oushy
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Luis E Savastano
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Larson AS, Klaas JP, Johnson MP, Benson JC, Shlapak D, Lanzino G, Savastano LE, Lehman VT. Vessel wall imaging features of Moyamoya disease in a North American population: patterns of negative remodelling, contrast enhancement, wall thickening, and stenosis. BMC Med Imaging 2022; 22:198. [DOI: 10.1186/s12880-022-00930-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 11/07/2022] [Indexed: 11/18/2022] Open
Abstract
Abstract
Background
This study characterized vessel wall imaging (VWI) features of Moyamoya disease (MMD) in a predominantly adult population at a North American center.
Methods
Consecutive patients with VWI were included. Twelve arterial segments were analyzed for wall thickening, degree and pattern of contrast enhancement, and remodeling.
Results
Overall, 286 segments were evaluated in 24 patients (mean age = 36.0 years [range = 1–58]). Of 172 affected segments, 163 (95%) demonstrated negative remodeling. Complete vessel wall obliteration was most frequent in the proximal M1 (17/48, 35%). Affected segments enhanced in 72/172 (42%) (n = 15 for grade II; n = 54 for concentric and n = 18 for eccentric); 20 of 24 (83%) patients had at least one enhancing segment. Both enhancing and non-enhancing segments were present in 19/20 (95%) patients. Vessel wall enhancement was most common in the proximal segments and correlated to the degree of stenosis (p < 0.001), and outer wall diameter (p < 0.001), but not disease duration (p = 0.922) or Suzuki score (p = 0.477). Wall thickening was present in 82/172 (48%) affected segments and was associated with contrast enhancement (p < 0.001), degree of stenosis (p < 0.001), and smaller outer wall diameter (p = 0.004).
Conclusion
This study presents VWI findings in North American patients with MMD. Negative remodeling was the most common finding. Most patients had both enhancing and non-enhancing abnormal segments. Vessel wall enhancement was most common in proximal segments, variable in pattern or degree and was correlated to the degree of stenosis and smaller outer wall diameter.
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13
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Larco JA, Abbasi M, Kadirvel R, Kallmes DF, Savastano LE, Brinjikji W. Intra-procedural cerebral sinus thrombosis during endovascular treatment of idiopathic intracranial hypertension. Neuroradiol J 2022; 35:654-657. [PMID: 35488380 PMCID: PMC9513914 DOI: 10.1177/19714009221096837] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Stenting of the intracranial venous sinuses has shown promising results in patients who are refractory to medical treatment of idiopathic intracranial hypertension (IIH). Among the reported complications associated with this procedure, in-stent thrombosis is an unreported one. We present a case of cerebral sinus thrombosis during endovascular treatment of IIH. A 33-year-old man with multiple comorbidities was presented with non-specific vision changes and headaches. Initial workup revealed a diagnosis of idiopathic intracranial hypertension which was treated medically but with no improvement. Therefore, cerebral sinus stenting was pursued. During the procedure, an in-stent thrombus was identified which was retrieved mechanically and was sent for histological and immunohistochemical evaluation. The retrieved thrombus was predominantly composed of RBCs (57.8%) followed by fibrin (30.78%), platelet (6.4%), and WBCs (5.95%), with high expression of CitH3 (neutrophil extra cellular traps specific marker) (10.9%), and CD66 (11.35%).
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Affiliation(s)
- Jorge Arturo Larco
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Luis E Savastano
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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14
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Oushy S, Clarke M, Savastano LE, Brinjikji W, Klaas JP. Dynamic Vertebral Artery Compression by Solitary Osteochondroma Presenting With Recurrent Posterior Circulation Strokes. Stroke 2022; 53:e379-e380. [PMID: 35620990 DOI: 10.1161/strokeaha.122.039124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Soliman Oushy
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN. (S.O., M.C., L.E.S.)
| | - Michelle Clarke
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN. (S.O., M.C., L.E.S.)
| | - Luis E Savastano
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN. (S.O., M.C., L.E.S.)
| | | | - James P Klaas
- Department of Neurology, Mayo Clinic, Rochester, MN. (J.P.K.)
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15
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Yuen J, Jabal MS, Savastano LE, Kallmes DF. Bibliometric Trends in Open Surgical and Endovascular Cerebrovascular Research. Cureus 2022; 14:e25204. [PMID: 35747015 PMCID: PMC9211035 DOI: 10.7759/cureus.25204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 11/05/2022] Open
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16
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Holmes DR, Alkhouli MA, Klaas JP, Brinjikji W, Savastano LE, Lanzino G, Benson JC. Change of Heart: The Underexplored Role of Plaque Hemorrhage in the Evaluation of Stroke of Undetermined Etiology. J Am Heart Assoc 2022; 11:e025323. [PMID: 35475334 PMCID: PMC9238607 DOI: 10.1161/jaha.122.025323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the evaluation of embolic strokes of undetermined source, great emphasis is often placed on cardiovascular disease, namely on atrial fibrillation. Other pathophysiologic mechanisms, however, may also be involved. Carotid artery intraplaque hemorrhage (IPH)—the presence of blood components within an atheromatous plaque—has become increasingly recognized as a possible etiologic mechanism in some cryptogenic strokes. IPH is a marker of plaque instability and is associated with ipsilateral neurologic ischemic events, even in nonstenotic carotid plaques. As recognition of carotid IPH as an etiology of embolic strokes has grown, so too has the complexity with which such patients are evaluated and treated, particularly because overlaps exist in the risk factors for atrial fibrillation and IPH. In this article, we review what is currently known about carotid IPH and how this clinical entity should be approached in the context of the evaluation of embolic strokes of undetermined source.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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17
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Brinjikji W, Abbasi M, Mereuta OM, Fitzgerald S, Larco JA, Dai D, Kadirvel R, Nogueira RG, Kvamme P, Layton KF, Delgado JE, Hanel RA, Pereira VM, Almekhlafi MA, Yoo AJ, Jahromi BS, Gounis MJ, Patel BM, Savastano LE, Cloft HJ, Haussen DC, Al-Bayati A, Mohammaden M, Pisani L, Rodrigues G, Thacker IC, Kayan Y, Copelan AZ, Aghaebrahim A, Sauvageau E, Demchuk AM, Bhuva P, Soomro J, Nazari P, Cantrell DR, Puri AS, Doyle KM, Entwistle J, Kallmes DF. Histological composition of retrieved emboli in acute ischemic stroke is independent of pre-thrombectomy alteplase use. J Stroke Cerebrovasc Dis 2022; 31:106376. [PMID: 35183984 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106376] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/23/2022] [Accepted: 01/26/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Given recent evidence suggesting the clot composition may be associated with revascularization outcomes and stroke etiology, clot composition research has been a topic of growing interest. It is currently unclear what effect, if any, pre-thrombectomy thrombolysis has on clot composition. Understanding this association is important as it is a potential confounding variable in clot composition research. We retrospectively evaluated the composition of retrieved clots from ischemic stroke patients who did and did not receive pre-treatment tPA to study the effect of tPA on clot composition. MATERIALS AND METHODS Consecutive patients enrolled in the Stroke Thromboembolism Registry of Imaging and Pathology (STRIP) were included in this study. All patients underwent mechanical thrombectomy and retrieved clots were sent to a central core lab for processing. Histological analysis was performed using Martius Scarlett Blue (MSB) staining and area of the clot was also measured on the gross photos. Student's t test was used for continuous variables and chi-squared test for categorical variables. RESULTS A total of 1430 patients were included in this study. Mean age was 68.4±13.5 years. Overall rate of TICI 2c/3 was 67%. A total of 517 patients received tPA (36%) and 913 patients did not (64%). Mean RBC density for the tPA group was 42.97±22.62% compared to 42.80±23.18% for the non-tPA group (P=0.89). Mean WBC density for the tPA group was 3.74±2.60% compared to 3.42±2.21% for the non-tPA group (P=0.012). Mean fibrin density for the tPA group was 26.52±15.81% compared to 26.53±15.34% for the non-tPA group (P=0.98). Mean platelet density for the tPA group was 26.22±18.60% compared to 26.55±19.47% for the non-tPA group (P=0.75). tPA group also had significantly smaller clot area compared to non-tPA group. CONCLUSIONS Our study 1430 retrieved emboli and ischemic stroke patients shows no interaction between tPA administration and clot composition. These findings suggest that tPA does not result in any histological changes in clot composition.
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Affiliation(s)
- Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Oana Madalina Mereuta
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Physiology and CURAM-SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Seán Fitzgerald
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Physiology and CURAM-SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | | | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Raul G Nogueira
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, Georgia, USA
| | - Peter Kvamme
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Kennith F Layton
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Josser E Delgado
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Vitor M Pereira
- Departments of Medical Imaging and Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Babak S Jahromi
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, IL, USA
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Biraj M Patel
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, VA, USA
| | - Luis E Savastano
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Diogo C Haussen
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, Georgia, USA
| | - Alhamza Al-Bayati
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, Georgia, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, Georgia, USA
| | - Leonardo Pisani
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, Georgia, USA
| | - Gabriel Rodrigues
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, Georgia, USA
| | - Ike C Thacker
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Alexander Z Copelan
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Amin Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Parita Bhuva
- Department of Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Jazba Soomro
- Department of Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Pouya Nazari
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, IL, USA
| | | | - Ajit S Puri
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Karen M Doyle
- Department of Physiology and CURAM-SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - John Entwistle
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, VA, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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18
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Nardi V, Benson JC, Larson AS, Brinjikji W, Saba L, Meyer FB, Lanzino G, Lerman A, Savastano LE. Carotid artery endarterectomy in patients with symptomatic non-stenotic carotid artery disease. Stroke Vasc Neurol 2022; 7:251-257. [PMID: 35241631 PMCID: PMC9240461 DOI: 10.1136/svn-2021-000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/08/2021] [Indexed: 11/09/2022] Open
Abstract
Object We sought to determine the safety and efficacy in secondary stroke prevention of carotid endarterectomy (CEA) in patients with symptomatic non-stenotic carotid artery disease (SyNC). Methods This was a single-centre retrospective case series. All patients who underwent CEA for unilateral anterior circulation cerebrovascular events with ipsilateral <50% carotid stenosis from 2002 to 2020 were included. Imaging hallmarks including the degree of luminal stenosis and the presence of various vulnerable plaque characteristics (eg, intraplaque haemorrhage (IPH) on MR angiography, ulceration or low-density plaque on CT angiography) were assessed. The presence of vulnerable plaque characteristics was compared between arteries ipsilateral to the ischaemic event and contralateral arteries. The prevalence of perioperative/intraoperative complications, as well as recurrent ischaemic events at follow-up was determined. Results Thirty-two patients were included in the analysis, of which 25.0% were female. Carotid arteries ipsilateral to an ischaemic event had a significantly higher prevalence of IPH when compared with contralateral arteries (80.0% vs 0.0%; p<0.001). There were no intraoperative complications. One patient (3.1%) developed symptoms of transient ipsilateral ischaemia 1 day following CEA which resolved without treatment. In a median follow-up of 18.0 months (IQR 5.0–36.0), only one patient (3.1%) experienced a transient neurologic deficit with complete resolution (annualised rate of recurrent stroke after CEA of 1.5% for a total follow-up of 788 patient-months following CEA). All other patients (31/32, 96.9%) were free of recurrent ischaemic events. Conclusion CEA appears to be safe and well-tolerated in patients with SyNC. Additional studies with larger cohorts and longer follow-up intervals are needed in order to determine the role of CEA in this patient population.
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Affiliation(s)
- Valentina Nardi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Luca Saba
- Radiology, Azienda Ospedaliero Universitaria, Cagliari, Italy
| | | | | | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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19
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Shahid A, Abbasi M, Madhani S, Larco JA, Liu Y, Robertson C, Chiang CC, Savastano LE. 433 Efficacy and Safety of Surgical Decompression for Migraine: A Systematic Review. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_433] [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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Borg N, Cutsforth-Gregory J, Oushy S, Huynh T, Savastano LE, Cloft HJ, Lanzino G, Brinjikji W. Anatomy of Spinal Venous Drainage for the Neurointerventionalist: From Puncture Site to Intervertebral Foramen. AJNR Am J Neuroradiol 2022; 43:517-525. [PMID: 35086801 PMCID: PMC8993202 DOI: 10.3174/ajnr.a7409] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
CSF-venous fistula is a relatively novel entity that is increasingly being recognized as a cause for spontaneous intracranial hypotension. Recently, our group published the first series of transvenous embolization of CSF-venous fistulas in this journal. Having now performed the procedure in 60 patients, we have garnered increasing familiarity with the anatomy and how to navigate our way through the venous system to any intervertebral foramen in the cervical, thoracic, and lumbar spine. The first part of this review summarizes the organization of spinal venous drainage as described in classic anatomy and interventional radiology texts, the same works that we studied when attempting our first cases. In the second part, we draw mostly on our own experience to provide a practical roadmap from the puncture site to the foramen. On the basis of these 2 parts, we hope this article will serve to collate the relevant anatomic knowledge and give confidence to colleagues who wish to embark on transvenous spinal procedures.
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Affiliation(s)
- N Borg
- From the Departments of Neurologic Surgery (N.B., S.O., L.E.S., G.L.)
| | | | - S Oushy
- From the Departments of Neurologic Surgery (N.B., S.O., L.E.S., G.L.)
| | - T Huynh
- Department of Neurologic Surgery (T.H.), Mayo Clinic, Jacksonville, Florida
| | - L E Savastano
- From the Departments of Neurologic Surgery (N.B., S.O., L.E.S., G.L.)
| | - H J Cloft
- Radiology (H.J.C., W.B.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Departments of Neurologic Surgery (N.B., S.O., L.E.S., G.L.)
| | - W Brinjikji
- Radiology (H.J.C., W.B.), Mayo Clinic, Rochester, Minnesota
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21
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Nardi V, Benson J, Bois MC, Saba L, Larson AS, Özcan I, Ahmad A, Morse DW, Meyer FB, Brinjikji W, Lanzino G, Lerman LO, Savastano LE, Lerman A. Carotid Plaques From Symptomatic Patients With Mild Stenosis Is Associated With Intraplaque Hemorrhage. Hypertension 2022; 79:271-282. [PMID: 34878895 DOI: 10.1161/hypertensionaha.121.18128] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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] [Indexed: 11/16/2022]
Abstract
Carotid plaque vulnerability features beyond the degree of stenosis may play a key role in the pathogenesis and recurrence of ischemic cerebrovascular events. This study sought to compare intraplaque hemorrhage (IPH) as a marker of plaque vulnerability in symptomatic patients with mild (<50%), moderate (50%-69%), and severe (≥70%) carotid artery stenosis. We included patients who experienced ischemic cerebrovascular events with no other identifiable sources and underwent carotid endarterectomy for mild (n=32), moderate (n=47), and severe (n=58) carotid artery stenosis. The degree of stenosis and imaging hallmarks were assessed by computed tomography angiography or magnetic resonance angiography. Plaque specimens were stained with hematoxylin and eosin and Movat pentachrome staining. Carotid plaques of patients with mild stenosis had a higher extent of IPH (%) on tissue analysis compared with patients with moderate (mild, 15.7% [interquartile range, 7.8%-26.7%]; moderate, 3.9% [0.0%-9.2%]; P<0.001) and severe carotid artery stenosis (mild, 15.7% [interquartile range, 7.8%-26.7%]; severe, 2.5% [interquartile range, 0.0%-11.2%]; P<0.001). When considering the degree of carotid artery stenosis as a continuous variable, a lower lumen narrowing was associated with higher extent of IPH (P<0.001; R, -0.329). Our major finding is the association of IPH with mild carotid artery stenosis based on histological analysis. The current study may suggest that IPH potentially plays a role in the mechanism of stroke in patients with nonobstructive carotid stenosis.
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Affiliation(s)
- Valentina Nardi
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - John Benson
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology (M.C.B.), Mayo Clinic, Rochester, MN
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria, Cagliari, Italy (L.S.)
| | - Anthony S Larson
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Ilke Özcan
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - Ali Ahmad
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - David W Morse
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
| | - Fredric B Meyer
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Waleed Brinjikji
- Department of Radiology (J.C.B., A.S.L., W.B.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- Department of Nephrology and Hypertension (L.O.L.), Mayo Clinic, Rochester, MN
| | - Luis E Savastano
- Department of Neurologic Surgery (F.B.M., G.L., L.E.S.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine (V.N., I.Ö., A.A., D.W.M., A.L.), Mayo Clinic, Rochester, MN
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22
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Abstract
The sympathetic nervous system has been implicated in various physiological and pathological processes, including regulation of homeostatic functions, maintenance of the circadian rhythms, and neuronal disruption and recovery after injury. Of special interest is focus on the role of the superior cervical ganglion (SCG) in regulating the daily changes in pineal function. Removal of the superior cervical ganglion (SCGx) and decentralization have served as valuable microsurgical models to investigate the effects of surgical denervation on this gland or organ. In this chapter, we offer information about methodologies for performing SCGx along with decentralization and denervation procedures, including details about recommended equipment as well as tips that can improve these techniques.
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Affiliation(s)
- Sarosh Irfan Madhani
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - David C Klein
- Section on Neuroendocrinology, Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Estela M Muñoz
- Laboratory of Neurobiology: Section of Chronobiology, Institute of Histology and Embryology of Mendoza (IHEM), National University of Cuyo, National Scientific and Technical Research Council (CONICET), Mendoza, Argentina
| | - Luis E Savastano
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA.
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23
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Bhambri A, Adapa AR, Liu Y, Boeckh-Behrens T, Procházka V, Hernández-Fernández F, Barbella-Aponte RA, Hashimoto T, Savastano LE, Gemmete JJ, Chaudhary N, Shih AJ, Pandey AS. Thrombus Histology as It Relates to Mechanical Thrombectomy: A Meta-Analysis and Systematic Review. Neurosurgery 2021; 89:1122-1131. [PMID: 34634805 DOI: 10.1093/neuros/nyab366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/06/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Appropriate thrombus-device interaction is critical for recanalization. Histology can serve as a proxy for mechanical properties, and thus inform technique selection. OBJECTIVE To investigate the value of histologic characterization, we conducted a systematic review and meta-analysis on the relationship between thrombus histology and recanalization, technique, etiology, procedural efficiency, and imaging findings. METHODS In this meta-analysis, we identified studies published between March 2010 and March 2020 reporting findings related to the histologic composition of thrombi in large vessel occlusion stroke. Studies with at least 10 patients who underwent mechanical thrombectomy using stent retriever or aspiration were considered. Only studies in which retrieved thrombi were histologically processed were included. Patient-level data were requested when data could not be directly extracted. The primary outcome assessed was the relationship between thrombus histology and angiographic outcome. RESULTS A total of 22 studies encompassing 1623 patients met inclusion criteria. Clots associated with good angiographic outcome had higher red blood cell (RBC) content (mean difference [MD] 9.60%, 95% CI 3.85-15.34, P = .008). Thrombi retrieved by aspiration had less fibrin (MD -11.39, 95% CI -22.50 to -0.27, P = .046) than stent-retrieved thrombi. Fibrin/platelet-rich clots were associated with longer procedure times (MD 13.20, 95% CI 1.30-25.10, P = .037). Hyperdense artery sign was associated with higher RBC content (MD 14.17%, 95% CI 3.07-25.27, P = .027). No relationship was found between composition and etiology. CONCLUSION RBC-rich thrombi were associated with better recanalization outcomes and shorter procedure times, suggesting that preinterventional compositional characterization may yield important prognostic and therapeutic guidance.
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Affiliation(s)
- Ankur Bhambri
- College of Medicine, Central Michigan University, Saginaw, Michigan, USA
| | | | - Yang Liu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Václav Procházka
- Department of Imaging Methods, University of Ostrava, Ostrava, Czech Republic
| | - Francisco Hernández-Fernández
- Interventional Neuroradiology Unit, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Tetsuya Hashimoto
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Albert J Shih
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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Chiang CC, Shahid AH, Harriott AM, Tietjen GE, Savastano LE, Klaas JP, Lanzino G. Evaluation and treatment of headache associated with moyamoya disease - a narrative review. Cephalalgia 2021; 42:542-552. [PMID: 34786968 DOI: 10.1177/03331024211056250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Headache in patients with moyamoya disease is an under-addressed topic in the medical literature. Delay in the diagnosis of moyamoya disease or inappropriate treatment of headache could lead to devastating cerebrovascular outcome. With the evolving understanding of moyamoya disease, migraine pathophysiology, and various migraine-specific medications that have become available, it is crucial to provide an updated overview on this topic. METHODS We searched PubMed for keywords including moyamoya disease, moyamoya syndrome, headache in moyamoya, surgical revascularization, surgical bypass, migraine and moyamoya, and calcitonin gene-related peptide (CGRP). We summarized the literature and provide a comprehensive review of the headache presentation, possible mechanisms, the impact of various surgical revascularizations on headache in patients with moyamoya disease, and the medical management of headache incorporating novel migraine-specific treatments.Results and conclusion: The most common headache phenotype is migraine; tension-type headache, hemiplegic migraine, and cluster headache have also been reported. Most patients experience improvement of headache after surgical revascularization, though some patients report worsening, or new-onset headache after surgery. Given the complexity of moyamoya disease, careful consideration of different types of medical therapy for headache is necessary to improve the quality of life while not increasing the risk of adverse cerebrovascular events. More prospective studies are warranted to better understand and manage headache in patients with moyamoya disease.
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Affiliation(s)
- Chia-Chun Chiang
- Department of Neurology, 6915Mayo Clinic, Mayo Clinic, Rochester, MN
| | | | | | | | | | - James P Klaas
- Department of Neurology, 6915Mayo Clinic, Mayo Clinic, Rochester, MN
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Liu Y, Larco JLA, Madhani SI, Shahid AH, Quinton RA, Kadirvel R, Kallmes DF, Brinjikji W, Savastano LE. A Thrombectomy Model Based on Ex Vivo Whole Human Brains. AJNR Am J Neuroradiol 2021; 42:1968-1972. [PMID: 34556479 PMCID: PMC8583258 DOI: 10.3174/ajnr.a7291] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/08/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The persistent challenges in thrombectomy for large-vessel occlusion, such as suboptimal complete recanalization and first-pass effect imply an insufficient understanding of the artery-clot-device interaction. In this study, we present a thrombectomy model using fresh human brains, which can capture the artery-clot-device interaction through concurrent transmural and angiographic visualizations. MATERIALS AND METHODS Fresh nonfrozen whole adult human brains were collected and connected to a customized pump system tuned to deliver saline flow at a physiologic flow rate and pressure. Angiography was performed to verify the flow in the anterior-posterior and vertebrobasilar circulations and collaterals. Large-vessel occlusion was simulated by embolizing a radiopaque clot analog. Thrombectomy was tested, and the artery-clot-device interactions were recorded by transmural and angiographic videos. RESULTS Baseline cerebral angiography revealed excellent penetration of contrast in the anterior-posterior and vertebrobasilar circulations without notable arterial cutoffs and with robust collaterals. Small branches (<0.5 mm) and perforating arteries were consistently opacified with good patency. Three device passes were performed to achieve recanalization, with failure modes including elongation, fragmentation, and distal embolization. CONCLUSIONS This model enables concurrent transmural and angiographic analysis of artery-clot-device interaction in a human brain and provides critical insights into the action mechanism and failure modes of current and upcoming thrombectomy devices.
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Affiliation(s)
- Y Liu
- From the Departments of Radiology (Y.L., R.K., D.F.K., W.B.)
| | - J L A Larco
- Neurosurgery (J.L.A.L., S.I.M., A.H.S., L.E.S.)
| | - S I Madhani
- Neurosurgery (J.L.A.L., S.I.M., A.H.S., L.E.S.)
| | - A H Shahid
- Neurosurgery (J.L.A.L., S.I.M., A.H.S., L.E.S.)
| | - R A Quinton
- Division of Anatomic Pathology (R.A.Q.), Mayo Clinic, Rochester, Minnesota
| | - R Kadirvel
- From the Departments of Radiology (Y.L., R.K., D.F.K., W.B.)
| | - D F Kallmes
- From the Departments of Radiology (Y.L., R.K., D.F.K., W.B.)
| | - W Brinjikji
- From the Departments of Radiology (Y.L., R.K., D.F.K., W.B.)
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26
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Abstract
Asystole or bradycardia is a relatively uncommon side effect seen in patients undergoing endovascular embolization using dimethylsulfoxide based liquid embolic agents. We present a case of a patient who underwent dural arteriovenous fistula embolization and experienced bradycardia during Onyx injection but was stabilized and the procedure was completed successfully.
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Arturo Larco J, Abbasi M, Liu Y, Madhani SI, Shahid AH, Kadirvel R, Brinjikji W, Savastano LE. Per-pass analysis of recanalization and good neurological outcome in thrombectomy for stroke: Systematic review and meta-analysis. Interv Neuroradiol 2021; 28:358-363. [PMID: 34229523 DOI: 10.1177/15910199211028342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND AIM First pass effect (FPE) is defined as achieving a complete recanalization with a single thrombectomy device pass. Although clinically desired, FPE is reached in less than 30% of thrombectomy procedures. Multiple device passes are often necessary to achieve successful or complete recanalization. We performed a systematic review and meta-analysis to determine the recanalization rate after each pass of mechanical thrombectomy and its association with good neurological outcome. METHODS A literature search was performed for studies reporting the number of device passes required for either successful (mTICI 2b or higher) or complete (mTICI 2c or higher) recanalization. Using random-effect meta-analysis, we evaluated the likelihood of recanalization and good neurological outcome (measured with the modified Rankin Score <2 at 90 days) after each device pass. RESULTS Thirteen studies comprising 4197 patients were included. Among cases with failed first pass, 24% of them achieved final complete recanalization and 45% of them achieved final successful recanalization. Independently to the total number of previously failed attempts, the likelihood of achieving successful recanalization was 30% per pass, and the likelihood to achieve complete recanalization was about 20% per pass. The likelihood of good neurological outcome in patients with final successful recanalization decreased after each device pass: 55% after the first pass, 48% after the second pass, 42% after the third pass, 36% after the fourth pass, and 26% for 5 passes or more. CONCLUSION Each pass is associated with a stable likelihood of recanalization but a decreased likelihood of good neurological outcome.
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Affiliation(s)
| | - Mehdi Abbasi
- Department of Neurosurgery, Mayo Clinic, Rochester, USA.,Department of Radiology, Mayo Clinic, Rochester, USA
| | - Yang Liu
- Department of Neurosurgery, Mayo Clinic, Rochester, USA.,Department of Radiology, Mayo Clinic, Rochester, USA
| | | | | | | | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, Rochester, USA.,Department of Radiology, Mayo Clinic, Rochester, USA
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28
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Abbasi M, Dai D, Liu Y, Fitzgerald S, Kadirvel R, Savastano LE, Cloft H, Kallmes DF, Brinjikji W. Iatrogenic Foreign Materials Associated with Retrieved Clot Tissue via Mechanical Thrombectomy. AJNR Am J Neuroradiol 2021; 42:1239-1249. [PMID: 34255735 DOI: 10.3174/ajnr.a7106] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Hydrophilic polymers and polytetrafluoroethylene liners, commonly used in the construction of endovascular devices, occasionally separate from devices with subsequent embolization. We determined the frequency of such materials in thrombus specimens retrieved by mechanical thrombectomy in patients with stroke. MATERIALS AND METHODS We retrospectively reviewed H&E-stained thrombus sections for presence and types of foreign materials. We identified 4 types of foreign materials-Type I: material was light green with refraction and had a homogeneous texture; type II: material was light gray and/or dark gray, thin, and loose or attenuated in texture; type III: material was light green with refraction, solitary in texture, irregular in shape, and was often associated with round or oval bubblelike particles and/or diffuse black particles; and type IV: material had homogeneous texture and was light pink or red. In addition, polymer materials from different layers of used mechanical thrombectomy catheters were compared with the foreign materials found in thrombus specimens. RESULTS A total of 101 thrombi were evaluated. Foreign materials were found in 53 (52.5%) thrombus samples. The most common type was type I (92%), followed by type II (30%). The histopathologic features of the polymer materials from mechanical thrombectomy catheters were similar to the foreign materials found in thrombus specimens. The inner polytetrafluoroethylene liner and coating layer of catheters resembled type I and type II of the foreign materials, respectively. CONCLUSIONS Foreign polymer materials are present in approximately half of retrieved thrombi, most commonly polytetrafluoroethylene from catheter liners and less from hydrophilic coatings.
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Affiliation(s)
- M Abbasi
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
| | - D Dai
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
| | - Y Liu
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
| | - S Fitzgerald
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
| | - R Kadirvel
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
| | - L E Savastano
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
- Neurosurgery (L.E.S.), Mayo Clinic, Rochester, Minnesota
| | - H Cloft
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
| | - D F Kallmes
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
| | - W Brinjikji
- Departments of Radiology (M.A., D.D., Y.L., S.F., R.K., L.E.S., H.C., D.F.K. W.B.)
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29
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Liu Y, Gebrezgiabhier D, Reddy AS, Davis E, Zheng Y, Arturo Larco JL, Shih AJ, Pandey AS, Savastano LE. Failure modes and effects analysis of mechanical thrombectomy for stroke discovered in human brains. J Neurosurg 2021; 136:197-204. [PMID: 34087793 DOI: 10.3171/2020.11.jns203684] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite advancement of thrombectomy technologies for large-vessel occlusion (LVO) stroke and increased user experience, complete recanalization rates linger around 50%, and one-third of patients who have undergone successful recanalization still experience poor neurological outcomes. To enhance the understanding of the biomechanics and failure modes, the authors conducted an experimental analysis of the interaction of emboli/artery/devices in the first human brain test platform for LVO stroke described to date. METHODS In 12 fresh human brains, 105 LVOs were recreated by embolizing engineered emboli analogs and recanalization was attempted using aspiration catheters and/or stent retrievers. The complex mechanical interaction between diverse emboli (elastic, stiff, and fragment prone), arteries (anterior and posterior circulation), and thrombectomy devices were observed, analyzed, and categorized. The authors systematically evaluated the recanalization process through failure modes and effects analysis, and they identified where and how thrombectomy devices fail and the impact of device failure. RESULTS The first-pass effect (34%), successful (71%), and complete (60%) recanalization rates in this model were consistent with those in the literature. Failure mode analysis of 184 passes with thrombectomy devices revealed the following. 1) Devices loaded the emboli with tensile forces leading to elongation and intravascular fragmentation. 2) In the presence of anterograde flow, small fragments embolize to the microcirculation and large fragments result in recurrent vessel occlusion. 3) Multiple passes are required due to recurrent (15%) and residual (73%) occlusions, or both (12%). 4) Residual emboli remained in small branching and perforating arteries in cases of alleged complete recanalization (28%). 5) Vacuum caused arterial collapse at physiological pressures (27%). 6) Device withdrawal caused arterial traction (41%), and severe traction provoked avulsion of perforating and small branching arteries. CONCLUSIONS Biomechanically superior thrombectomy technologies should prevent unrestrained tensional load on emboli, minimize intraluminal embolus fragmentation and release, improve device/embolus integration, recanalize small branching and perforating arteries, prevent arterial collapse, and minimize traction.
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Affiliation(s)
- Yang Liu
- Departments of1Mechanical Engineering and.,Departments of2Radiology and
| | - Daniel Gebrezgiabhier
- 3Neurosurgery, University of Michigan, Ann Arbor, Michigan.,4UC Berkeley-UCSF Graduate Program in Bioengineering, San Francisco, California; and
| | | | - Evan Davis
- Departments of1Mechanical Engineering and
| | - Yihao Zheng
- Departments of1Mechanical Engineering and.,5Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | | | | | | | - Luis E Savastano
- 3Neurosurgery, University of Michigan, Ann Arbor, Michigan.,6Neurosurgery, Mayo Clinic, Rochester, Minnesota
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30
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Larson AS, Lehman VT, Savastano LE, Lanzino G, Campeau NG, Welker KM, Klaas JP. Implementation and Rationale for a Unified Clinical and Imaging Protocol for Evaluation and Treatment of Moyamoya Angiopathy: A Single Institutional Experience. Front Neurol 2021; 12:662393. [PMID: 34079514 PMCID: PMC8165224 DOI: 10.3389/fneur.2021.662393] [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: 02/01/2021] [Accepted: 04/21/2021] [Indexed: 11/13/2022] Open
Abstract
Moyamoya disease (MMD) is a complex and incompletely-understood cerebrovascular pathological entity that requires thorough clinical and imaging evaluation. Moyamoya is rare, thereby making the establishment of an effective, thorough and interdisciplinary patient evaluation protocol challenging, even within specialized referral centers. Nevertheless, implementation of such a protocol is crucial in order to provide the best possible evaluation and treatment for MMD patients. Here, we describe our institution's implementation of, rationale for, and experience with a comprehensive multidisciplinary collaboration and evaluation strategy for adult patients with moyamoya. This evaluation course consists of, first of all, a thorough clinical and laboratory evaluation with a vascular neurologist. This is followed by a comprehensive imaging assessment which evaluates angiographic and parenchymal features, in addition to cerebrovascular functionality. Finally, appropriate referrals are made to consulting services as indicated, which includes vascular neurosurgery. These steps are described in detail herein.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | | | - Kirk M Welker
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - James P Klaas
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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31
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Naylor RM, Topinka B, Rinaldo L, Jacobi J, Neth B, Flemming KD, Savastano LE. Progressive Myelopathy From a Craniocervical Junction Dural Arteriovenous Fistula. Stroke 2021; 52:e278-e281. [PMID: 33940952 DOI: 10.1161/strokeaha.120.032552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan M Naylor
- Department of Neurological Surgery (R.M.N., L.R., L.E.S.), Mayo Clinic, Rochester, MN
| | - Britney Topinka
- Department of Neurology (B.T., J.J., B.N., K.D.F.), Mayo Clinic, Rochester, MN
| | - Lorenzo Rinaldo
- Department of Neurological Surgery (R.M.N., L.R., L.E.S.), Mayo Clinic, Rochester, MN
| | - Jaclyn Jacobi
- Department of Neurology (B.T., J.J., B.N., K.D.F.), Mayo Clinic, Rochester, MN
| | - Bryan Neth
- Department of Neurology (B.T., J.J., B.N., K.D.F.), Mayo Clinic, Rochester, MN
| | - Kelly D Flemming
- Department of Neurology (B.T., J.J., B.N., K.D.F.), Mayo Clinic, Rochester, MN
| | - Luis E Savastano
- Department of Neurological Surgery (R.M.N., L.R., L.E.S.), Mayo Clinic, Rochester, MN
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32
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Abbasi M, Kvamme P, Layton KF, Hanel RA, Almekhlafi MA, Delgado JE, Pereira VM, Patel BM, Jahromi BS, Yoo AJ, Nogueira RG, Gounis MJ, Fitzgerald S, Mereuta OM, Dai D, Kadirvel R, Kallmes DF, Doyle KM, Savastano LE, Cloft HJ, Liu Y, Thacker IC, Aghaebrahim A, Sauvageau E, Demchuk AM, Kayan Y, Copelan AZ, Entwistle J, Nazari P, Cantrell DR, Bhuva P, Soomro J, Haussen DC, Al-Bayati A, Mohammaden M, Pisani L, Rodrigues G, Puri AS, Brinjikji W. Per pass analysis of thrombus composition retrieved by mechanical thrombectomy. Interv Neuroradiol 2021; 27:815-820. [PMID: 33823621 DOI: 10.1177/15910199211009119] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND AIM Mechanical thrombectomy (MT) for large vessel occlusion often requires multiple passes to retrieve the entire thrombus load. In this multi-institutional study we sought to examine the composition of thrombus fragments retrieved with each pass during MT. METHODS Patients who required multiple passes during thrombectomy were included. Histopathological evaluation of thrombus fragments retrieved from each pass was performed using Martius Scarlet Blue staining and the composition of each thrombus component including RBC, fibrin and platelet was determined using image analysis software. RESULTS 154 patients underwent MT and 868 passes was performed which resulted in 263 thrombus fragments retrieval. The analysis of thrombus components per pass showed higher RBC, lower fibrin and platelet composition in the pass 1 and 2 when compared to pass 3 and passes 4 or more combined (P values <0.05). There were no significant differences between thrombus fragments retrieved in pass 1 and pass 2 in terms of RBC, WBC, fibrin, and platelet composition (P values >0.05). Similarly, when each composition of thrombus fragments retrieved in pass 3 and passes 4 or more combined were compared with each other, no significant difference was noted (P values >0.05). CONCLUSION Our findings confirm that thrombus fragments retrieved with each pass differed significantly in histological content. Fragments in the first passes were associated with lower fibrin and platelet composition compared to fragments retrieved in passes three and four or higher. Also, thrombus fragments retrieved after failed pass were associated with higher fibrin and platelet components.
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Affiliation(s)
- Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Peter Kvamme
- Department of Radiology, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Kennith F Layton
- Department of Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, FL, USA
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Josser E Delgado
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Vitor M Pereira
- Departments of Medical Imaging and Surgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Biraj M Patel
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, VA, USA
| | - Babak S Jahromi
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, IL, USA
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Plano, TX, USA
| | - Raul G Nogueira
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Seán Fitzgerald
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Physiology and CURAM-SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Oana M Mereuta
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Physiology and CURAM-SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Karen M Doyle
- Department of Physiology and CURAM-SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Luis E Savastano
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Yang Liu
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ike C Thacker
- Department of Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Amin Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, FL, USA
| | - Eric Sauvageau
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, FL, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Yasha Kayan
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Alexander Z Copelan
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - John Entwistle
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, VA, USA
| | - Pouya Nazari
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, IL, USA
| | | | - Parita Bhuva
- Department of Neurointervention, Texas Stroke Institute, Plano, TX, USA
| | - Jazba Soomro
- Department of Neurointervention, Texas Stroke Institute, Plano, TX, USA
| | - Diogo C Haussen
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | - Alhamza Al-Bayati
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | - Leonardo Pisani
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | - Gabriel Rodrigues
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | - Ajit S Puri
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, MA, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Essibayi MA, Cloft H, Savastano LE, Brinjikji W. Safety and efficacy of Angio-Seal device for transfemoral neuroendovascular procedures: A systematic review and meta-analysis. Interv Neuroradiol 2021; 27:703-711. [PMID: 33601976 DOI: 10.1177/1591019921996100] [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] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Angio-Seal is a commonly used device for femoral hemostasis in neuroendovascular procedures. This meta-analysis investigates of the safety and efficacy of Angio-Seal in patients undergoing endovascular neurointerventional procedures. METHODS A systematic review and meta-analysis on all studies evaluating the Angio-Seal device in neurointerventional procedures from inception through 2020 were performed. We studied rates of groin hematoma, retroperitoneal hematoma, pseudoaneurysm, ipsilateral DVT, and ischemic complications. Meta-analysis was performed using the random-effects model. RESULTS 13 studies were included in our analysis. 2250 patients with 104 complications were found {4.5% (95% CI, 2.7%-6.3%)}. Of these complications, groin hematoma was the most common with a rate of 2.4% (95% CI, 1.1%-3.6%). Retroperitoneal hematoma {0.3% (95% CI, 0%-0.5%)}, pseudo-aneurysm {0.5% (95% CI, 0.2%-0.8%), and ipsilateral DVT {0.3% (95% CI, 0.1%-0.7%) were also not in negligible rate. The rate of other complications were as follows: vessel occlusion/stenosis; 0.2% (95% CI, 0%-0.4%), vascular surgery; 0.2% (95% CI, 0%-0.5%), and infection; 0.2% (95% CI, 0%-0.5%). One patient died as result of hemorrhagic complications {0.1% (95% CI, 0%-0.3%)}. Use of anticoagulant/antiplatelet therapy was found to be positively correlated with high risk of any groin complication and groin hematoma (p ≤ .05). Female gender was associated with high risk of ipsilateral DVT (p ≤ .05). Interestingly, large sheath size was associated with low risk of groin hematoma (p ≤ .05). CONCLUSION The safety and efficacy rate of Angio-Seal was approximately 95%. The most common complication was groin hematoma. Serious complications including retroperitoneal hematoma and femoral artery occlusion were rare.
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Affiliation(s)
| | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.,Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Brinjikji W, Savastano LE, Atkinson JLD, Garza I, Farb R, Cutsforth-Gregory JK. A Novel Endovascular Therapy for CSF Hypotension Secondary to CSF-Venous Fistulas. AJNR Am J Neuroradiol 2021; 42:882-887. [PMID: 33541895 DOI: 10.3174/ajnr.a7014] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/30/2020] [Indexed: 11/07/2022]
Abstract
We report a consecutive case series of patients who underwent transvenous embolization of the paraspinal vein, which was draining the CSF-venous fistula, for treatment of spontaneous intracranial hypotension. These are the first-ever reported cases of this treatment for CSF-venous fistulas. All patients underwent spinal venography following catheterization of the azygous vein and then selective catheterization of the paraspinal vein followed by embolization of the vein with Onyx. All patients had improvement of clinical and radiologic findings with 4 patients having complete resolution of headaches and 1 patient having 50% reduction in headache symptoms. Pachymeningeal enhancement resolved in 4 patients and improved but did not resolve in 1 patient. Brain sag resolved in 4 patients and improved but did not resolve in 1 patient. There were no cases of permanent neurologic complications. All patients were discharged home on the day of the procedure.
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Affiliation(s)
- W Brinjikji
- Department of Interventional Neuroradiology (W.B., L.E.S.), Mayo Clinic, Rochester, Minnesota .,Department of Neurosurgery (W.B., L.E.S., J.L.D.A.), Mayo Clinic, Rochester, Minnesota
| | - L E Savastano
- Department of Interventional Neuroradiology (W.B., L.E.S.), Mayo Clinic, Rochester, Minnesota.,Department of Neurosurgery (W.B., L.E.S., J.L.D.A.), Mayo Clinic, Rochester, Minnesota
| | - J L D Atkinson
- Department of Neurosurgery (W.B., L.E.S., J.L.D.A.), Mayo Clinic, Rochester, Minnesota
| | - I Garza
- Department of Neurology (I.G., J.K.C.-G.), Mayo Clinic, Rochester, Minnesota
| | - R Farb
- Joint Department of Medical Imaging (R.F.), Toronto Western Hospital, Toronto, Ontario, Canada
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Gebrezgiabhier D, Liu Y, Reddy AS, Davis E, Zheng Y, Shih AJ, Pandey AS, Savastano LE. A human brain test bed for research in large vessel occlusion stroke. J Neurosurg 2021; 135:1072-1080. [PMID: 33482637 DOI: 10.3171/2020.7.jns202278] [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: 06/12/2020] [Accepted: 07/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular removal of emboli causing large vessel occlusion (LVO)-related stroke utilizing suction catheter and/or stent retriever technologies or thrombectomy is a new standard of care. Despite high recanalization rates, 40% of stroke patients still experience poor neurological outcomes as many cases cannot be fully reopened after the first attempt. The development of new endovascular technologies and techniques for mechanical thrombectomy requires more sophisticated testing platforms that overcome the limitations of phantom-based simulators. The authors investigated the use of a hybrid platform for LVO stroke constructed with cadaveric human brains. METHODS A test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with cadaveric human brains, a customized hydraulic system to generate physiological flow rate and pressure, and three types of embolus analogs (elastic, stiff, and fragment-prone) engineered to match mechanically and phenotypically the emboli causing LVO strokes. LVO cases were replicated in the anterior and posterior circulation, and thrombectomy was attempted using suction catheters and/or stent retrievers. RESULTS The test bed allowed radiation-free visualization of thrombectomy for LVO stroke in real cerebrovascular anatomy and flow conditions by transmural visualization of the intraluminal elements and procedures. The authors were able to successfully replicate 105 LVO cases with 184 passes in 12 brains (51 LVO cases and 82 passes in the anterior circulation, and 54 LVO cases and 102 passes in the posterior circulation). Observed recanalization rates in this model were graded using a Recanalization in LVO (RELVO) scale analogous to other measures of recanalization outcomes in clinical use. CONCLUSIONS The human brain platform introduced and validated here enables the analysis of artery-embolus-device interaction under physiological hemodynamic conditions within the unmodified complexity of the cerebral vasculature inside the human brain.
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Affiliation(s)
- Daniel Gebrezgiabhier
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.,2UC Berkeley-UCSF Graduate Program in Bioengineering, San Francisco, California
| | - Yang Liu
- 3Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan.,4Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Adithya S Reddy
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Evan Davis
- 3Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Yihao Zheng
- 3Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan.,5Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts; and
| | - Albert J Shih
- 3Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Aditya S Pandey
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Luis E Savastano
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.,6Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Abstract
Carotid endarterectomy is considered the gold standard for primary and secondary stroke prevention in patients with asymptomatic and symptomatic carotid artery stenosis. The role of CEA has been defined by multiple randomized multicenter trials and CEA is the most studied surgical procedure. In recent years, with advances in endovascular techniques, carotid angioplasty, and stenting (CAS) has been proposed as an alternative to CEA especially in high-risk patients. In this article, we review some of the most important trials on the invasive treatment of carotid artery stenosis and summarized the most recent treatment recommendations based on current evidence. The data overwhelmingly supports revascularization of patients with symptomatic stenosis between 70-90%, with a clear preference for CEA over CAS to be done within 14 days of symptom onset is possible. However, CAS is an acceptable alternative to CEA in certain symptomatic patients such as those with severe medical comorbidities, high riding plaques, contralateral occlusion, restenosis after prior CEA, and radiation-induced stenosis. Treatment of asymptomatic patients remains controversial because of advanced of modern medical therapy and large trials are underway to define the role of invasive revascularization in these patients.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA - .,Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Savastano LE, Liu Y, Gebrezgiabhier D, Reddy A, Davis E, Zheng Y, Shih A, Pandey AS. Failure Modes of Suction Catheters and Stent Retrievers in Large Vessel Occlusion Stroke Discovered in a Human Brain Platform. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_261] [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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Larson TS, Savastano LE, Klaas J, Lanzino G. Cardiac Manifestations in a Western Moyamoya Disease Population. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_304] [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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39
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Liu Y, Reddy A, Cockrum J, Ajulufoh M, Zheng Y, Shih A, Pandey AS, Savastano LE. Fabrication, Histology, and Tensile Test of Clot Analogs Made from Human Blood with Varied Compositions. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_280] [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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40
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Larson AS, Nasr DM, Rizvi A, Alzuabi M, Seyedsaadat SM, Lanzino G, Huston J, Lehman VT, Savastano LE, Brinjikji W. Embolic Stroke of Undetermined Source: The Association With Carotid Intraplaque Hemorrhage. JACC Cardiovasc Imaging 2020; 14:506-508. [PMID: 33011125 DOI: 10.1016/j.jcmg.2020.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/29/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
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Franko LR, Pandian B, Gupta A, Savastano LE, Chen KS, Riddell J, Orringer DA. Posterior Fossa Craniotomy for Adherent Fourth Ventricle Neurocysticercosis. Oper Neurosurg (Hagerstown) 2020; 16:E154-E158. [PMID: 29905841 DOI: 10.1093/ons/opy158] [Citation(s) in RCA: 3] [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: 08/09/2017] [Accepted: 05/27/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Neurocysticercosis (NCC) is an infectious helminthic disease often presenting in patients who have immigration or travel history from areas where NCC is endemic. Fourth ventricle cysts from NCC pose a unique treatment challenge, as there is little consensus on the best treatment. This case study describes the treatment of a patient with fourth ventricle neurocysticercosis (FVNCC), examines the therapeutic decision-making, and provides a video of a posterior fossa craniotomy (PFC) resection of a degenerative cyst. CLINICAL PRESENTATION The patient presented with headache, dizziness, nausea, and memory difficulties. A fourth ventricle cyst consistent with NCC was found on magnetic resonance imaging, and serum enzyme-linked immunosorbent assay (ELISA) confirmed the diagnosis. The cyst was removed utilizing an open PFC followed by antihelminthic therapy and corticosteroids. There was resolution of symptoms at 9 mo postoperatively. CONCLUSION Several treatment modalities have been proposed for isolated cysts in the fourth ventricle, including medication, ventriculoperitoneal shunt, endoscopic removal, and PFC. The treatment decision is complex, and there is little guidance on the best treatment choices. In this article, we describe treatment via PFC for an adherent FVNCC cyst.
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Affiliation(s)
- Lynze R Franko
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Balaji Pandian
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Avneesh Gupta
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Luis E Savastano
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kevin S Chen
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - James Riddell
- Department of Internal Medicine-Infectious Diseases, University of Michigan, Ann Arbor, Michigan
| | - Daniel A Orringer
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Alawieh A, Al Kasab S, Almallouhi E, Levitt MR, Jabbour PM, Sweid A, Starke RM, Saini V, Fargen KM, Wolfe SQ, Arthur AS, Goyal N, Fragata I, Maier I, Matouk C, Howard BM, Grossberg JA, Cawley M, Kan P, Hafeez M, Singer J, Crowley RW, Joshi KC, Brinjikji W, Savastano LE, Ogilvy CS, Gomez-Paz S, Levy E, Waqas M, Mokin M, Veznedaroglu E, Binning M, Mascitelli J, Yoo AJ, Soomro J, Williamson RW, Chalhoub RM, Grande A, Crosa R, Webb S, Psychogios M, Ducruet AF, Albuquerque FC, Majmundar N, Turner R, Casagrande W, Al-Mufti F, De Leacy R, Mocco J, Fessler RD, Osanai T, Chowdhry SA, Park M, Schirmer CM, Ringer A, Spiotta AM. Letter: An International Investigation Into the COVID-19 Pandemic and Workforce Depletion in Highly Specialized Neurointerventional Units - Insights From Stroke Thrombectomy and Aneurysm Registry and Endovascular Neurosurgery Research Group. Neurosurgery 2020; 87:E697-E699. [PMID: 32893855 PMCID: PMC7499731 DOI: 10.1093/neuros/nyaa415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/26/2023] Open
Affiliation(s)
- Ali Alawieh
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia
| | - Sami Al Kasab
- Department of Neurosurgery Medical University of South Carolina Charleston, South Carolina.,Department of Neurology Medical University of South Carolina Charleston, South Carolina
| | - Eyad Almallouhi
- Department of Neurology Medical University of South Carolina Charleston, South Carolina
| | - Michael R Levitt
- Department of Neurosurgery University of Washington Seattle, Washington
| | - Pascal M Jabbour
- Department of Neurosurgery Thomas Jefferson University Hospitals Philadelphia, Pennsylvania
| | - Ahmad Sweid
- Department of Neurosurgery Thomas Jefferson University Hospitals Philadelphia, Pennsylvania
| | - Robert M Starke
- Department of Neurosurgery University of Miami Health System Miami, Florida
| | - Vasu Saini
- Department of Neurosurgery University of Miami Health System Miami, Florida
| | - Kyle M Fargen
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem, North Carolina
| | - Stacey Q Wolfe
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem, North Carolina
| | - Adam S Arthur
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis, Tennessee
| | - Nitin Goyal
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis, Tennessee.,Department of Neurology University of Tennessee Health Science Center Memphis, Tennessee
| | - Isabel Fragata
- Neuroradiology Department Hospital São José Centro Hospitalar Lisboa Central Lisboa, Portugal
| | - Ilko Maier
- Department of Neurology University Medical Center Göttingen Göttingen, Germany
| | - Charles Matouk
- Department of Neurosurgery Yale University/Yale-New Haven Hospital New Haven, Connecticut
| | - Brian M Howard
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia
| | | | - Michael Cawley
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia
| | - Peter Kan
- Department of Neurosurgery Baylor School of Medicine Houston, Texas
| | - Muhammad Hafeez
- Department of Neurosurgery Baylor School of Medicine Houston, Texas
| | - Justin Singer
- Division of Neurosurgery Spectrum Health Grand Rapids, Michigan
| | | | - Krishna C Joshi
- Department of Neurosurgery Rush University Chicago, Illinois
| | | | | | | | - Santiago Gomez-Paz
- Department of Neurosurgery Beth Israel Deaconess Hospital Boston, Massachusetts
| | - Elad Levy
- Department of Neurosurgery University at Buffalo Buffalo, New York
| | - Muhammad Waqas
- Department of Neurosurgery University at Buffalo Buffalo, New York
| | - Maxim Mokin
- Department of Neurosurgery University of South Florida Tampa, Florida
| | | | - Mandy Binning
- Global Neurosciences Institute Pennington, New Jersey
| | - Justin Mascitelli
- Department of Neurosurgery University of Texas Health Science Center at San Antonio San Antonio, Texas
| | | | | | | | - Reda M Chalhoub
- Department of Neurosurgery Medical University of South Carolina Charleston, South Carolina
| | - Andrew Grande
- Department of Neurosurgery University of Minnesota Minneapolis, Minnesota
| | - Roberto Crosa
- Department of Neurosurgery Centro Endovascular Neurologico Medica Uruguaya Montevideo, Uruguay
| | - Sharon Webb
- Department of Neurosurgery Bon Secours Greenville, South Carolina
| | | | - Andrew F Ducruet
- Department of Neurosurgery Barrow Neurological Institute Phoenix, Arizona
| | | | - Neil Majmundar
- Department of Neurosurgery Barrow Neurological Institute Phoenix, Arizona
| | | | - Walter Casagrande
- Department of Cerebrovascular and Endovascular Neurosurgery Hospital Juan Fernandez Buenos Aires, Argentina
| | - Fawaz Al-Mufti
- Department of Neurosurgery and Radiology Westchester Medical Center New York, New York
| | - Reade De Leacy
- Department of Neurosurgery Mount Sinai Health System New York, New York
| | - J Mocco
- Department of Neurosurgery Mount Sinai Health System New York, New York
| | | | | | - Shakeel A Chowdhry
- Department of Neurosurgery NorthShore University Health System Evanston, Illinois
| | - Min Park
- Department of Neurosurgery University of Virginia Charlottesville, Virginia
| | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute Geisinger Health System Wilkes-Barre, Pennsylvania.,Research Institute of Neurointervention Paracelsus Medical University Salzburg, Austria
| | - Andrew Ringer
- Department of Neurosurgery Mayfield Brain & Spine Cincinnati, Ohio
| | - Alejandro M Spiotta
- Department of Neurosurgery Medical University of South Carolina Charleston, South Carolina
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Liu Y, Reddy AS, Cockrum J, Ajulufoh MC, Zheng Y, Shih AJ, Pandey AS, Savastano LE. Standardized Fabrication Method of Human-Derived Emboli with Histologic and Mechanical Quantification for Stroke Research. J Stroke Cerebrovasc Dis 2020; 29:105205. [PMID: 33066901 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105205] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 02/28/2020] [Revised: 07/01/2020] [Accepted: 07/23/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND As access to patient emboli is limited, embolus analogs (EAs) have become critical to the research of large vessel occlusion (LVO) stroke and the development of thrombectomy technology. To date, techniques for fabricating standardized human blood-derived EAs are limited in the variety of compositions, and the mechanical properties relevant to thrombectomy are not quantified. METHODS EAs were made by mixing human banked red blood cells (RBCs), plasma, and platelet concentrate in 10 different volumetric percentage combinations to mimic the broad range of patient emboli causing LVO strokes. The samples underwent histologic analysis and tensile testing to mimic the pulling action of thrombectomy devices, and were compared to patient emboli. RESULTS EAs had histologic compositions of 0-96% RBCs, 0.78%-92% fibrin, and 2.1%-22% platelets, which can be correlated with the ingredients using a regression model. At fracture, EAs elongated from 81% to 136%, and the ultimate tensile stress ranged from 16 to 949 kPa. These EAs' histologic compositions and tensile properties showed great similarity to those of emboli retrieved from LVO stroke patients, indicating the validity of such EA fabrication methods. EAs with lower RBC and higher fibrin contents are more extensible and can withstand higher tensile stress. CONCLUSIONS EAs fabricated and tested using the proposed new methods provide a platform for stroke research and pre-clinical development of thrombectomy devices.
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Affiliation(s)
- Yang Liu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA.
| | - Adithya S Reddy
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
| | - Joshua Cockrum
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
| | | | - Yihao Zheng
- Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA.
| | - Albert J Shih
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA.
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
| | - Luis E Savastano
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.
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Larson AS, Brinjikji W, Savastano LE, Huston Iii J, Benson JC. Carotid Intraplaque Hemorrhage Is Associated with Cardiovascular Risk Factors. Cerebrovasc Dis 2020; 49:355-360. [PMID: 32674096 DOI: 10.1159/000508733] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/17/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Intraplaque hemorrhage (IPH) is a known predictor of symptomatic cervical carotid artery disease. However, the association between IPH and modifiable cardiovascular risk factors, patient demographics, and pertinent laboratory values has not been extensively studied. METHODS A retrospective review was performed of consecutive patients who have undergone dedicated carotid plaque imaging over a 3-year period. Patients were excluded if the MR examination did not include high-resolution carotid plaque imaging. Intraplaque hyperintense signal on carotid plaque images was presumed to represent IPH. The presence or absence of IPH was compared to various demographic and clinical variables. Multivariable regression analysis was performed in order to determine an independent association between variables and IPH. RESULTS Of 643 included patients, 114 patients (17.7%) had IPH in one or both carotids, 529 patients (82.3%) did not; 39.5% of patients with IPH had coronary artery disease compared to 23.1% of patients without (p = 0.0003). Patients with IPH also had higher proportions of hypertension (77.2 vs. 60.7%, p = 0.009), hyperlipidemia (HLD; 89.5 vs. 62.4%, p < 0.0001), diabetes mellitus (29.0 vs. 18.7%, p = 0.01), and a history of tobacco smoking (63.2 vs. 52.6%, p = 0.003). Patients without IPH had, on average, higher high-density lipoprotein levels (46.1 vs. 56.7%, p = 0.003). Factors independently associated with IPH were advanced age (odds ratio [OR]: 1.1, 95% CI: [1.0-1.05], p <0.0001), male sex (OR: 2.5, 95% CI: [1.4-4.4], p = 0.0001), presence of carotid stenosis (OR: 8.4, 95% CI: [4.6-15.3], p < 0.0001), and HLD (OR: 2.6, 95% CI: [1.3-5.2], p = 0.009). CONCLUSIONS IPH is associated with multiple cardiovascular risk factors, in particular advanced age, male sex, presence of carotid stenosis, and HLD. Such risk factors likely play a role in the development of IPH and may provide insight into the pathophysiology of unstable carotid plaques.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA, .,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA,
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John Huston Iii
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Reddy AS, Liu Y, Cockrum J, Gebrezgiabhier D, Davis E, Zheng Y, Pandey AS, Shih AJ, Savastano LE. Construction of a comprehensive endovascular test bed for research and device development in mechanical thrombectomy in stroke. J Neurosurg 2020; 134:1190-1197. [PMID: 32244204 DOI: 10.3171/2020.1.jns192732] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 10/09/2019] [Accepted: 01/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The development of new endovascular technologies and techniques for mechanical thrombectomy in stroke has greatly relied on benchtop simulators. This paper presents an affordable, versatile, and realistic benchtop simulation model for stroke. METHODS A test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with 3D-printed and commercially available cerebrovascular phantoms, a customized hydraulic system to generate physiological flow rate and pressure, and 2 types of embolus analogs (elastic and fragment-prone) capable of causing embolic occlusions under physiological flow. RESULTS The test bed was highly versatile and allowed realistic, radiation-free mechanical thrombectomy for stroke due to large-vessel occlusion with rapid exchange of geometries and phantom types. Of the transparent cerebrovascular phantoms tested, the 3D-printed phantom was the easiest to manufacture, the glass model offered the best visibility of the interaction between embolus and thrombectomy device, and the flexible model most accurately mimicked the endovascular system during device navigation. None of the phantoms modeled branches smaller than 1 mm or perforating arteries, and none underwent realistic deformation or luminal collapse from device manipulation or vacuum. The hydraulic system created physiological flow rate and pressure leading to iatrogenic embolization during thrombectomy in all phantoms. Embolus analogs with known fabrication technique, structure, and tensile strength were introduced and consistently occluded the middle cerebral artery bifurcation under physiological flow, and their interaction with the device was accurately visualized. CONCLUSIONS The test bed presented in this study is a low-cost, comprehensive, realistic, and versatile platform that enabled high-quality analysis of embolus-device interaction in multiple cerebrovascular phantoms and embolus analogs.
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Affiliation(s)
| | - Yang Liu
- 2Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | | | | | - Evan Davis
- 2Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Yihao Zheng
- 3Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts; and
| | | | - Albert J Shih
- 2Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Luis E Savastano
- Departments of1Neurosurgery and.,4Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Liu Y, Zheng Y, Reddy AS, Gebrezgiabhier D, Davis E, Cockrum J, Gemmete JJ, Chaudhary N, Griauzde JM, Pandey AS, Shih AJ, Savastano LE. Analysis of human emboli and thrombectomy forces in large-vessel occlusion stroke. J Neurosurg 2020; 134:893-901. [PMID: 32109875 DOI: 10.3171/2019.12.jns192187] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study's purpose was to improve understanding of the forces driving the complex mechanical interaction between embolic material and current stroke thrombectomy devices by analyzing the histological composition and strength of emboli retrieved from patients and by evaluating the mechanical forces necessary for retrieval of such emboli in a middle cerebral artery (MCA) bifurcation model. METHODS Embolus analogs (EAs) were generated and embolized under physiological pressure and flow conditions in a glass tube model of the MCA. The forces involved in EA removal using conventional endovascular techniques were described, analyzed, and categorized. Then, 16 embolic specimens were retrieved from 11 stroke patients with large-vessel occlusions, and the tensile strength and response to stress were measured with a quasi-static uniaxial tensile test using a custom-made platform. Embolus compositions were analyzed and quantified by histology. RESULTS Uniaxial tension on the EAs led to deformation, elongation, thinning, fracture, and embolization. Uniaxial tensile testing of patients' emboli revealed similar soft-material behavior, including elongation under tension and differential fracture patterns. At the final fracture of the embolus (or dissociation), the amount of elongation, quantified as strain, ranged from 1.05 to 4.89 (2.41 ± 1.04 [mean ± SD]) and the embolus-generated force, quantified as stress, ranged from 63 to 2396 kPa (569 ± 695 kPa). The ultimate tensile strain of the emboli increased with a higher platelet percentage, and the ultimate tensile stress increased with a higher fibrin percentage and decreased with a higher red blood cell percentage. CONCLUSIONS Current thrombectomy devices remove emboli mostly by applying linear tensile forces, under which emboli elongate until dissociation. Embolus resistance to dissociation is determined by embolus strength, which significantly correlates with composition and varies within and among patients and within the same thrombus. The dynamic intravascular weakening of emboli during removal may lead to iatrogenic embolization.
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Affiliation(s)
- Yang Liu
- 1Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Yihao Zheng
- 2Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | | | | | - Evan Davis
- 1Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | | | - Joseph J Gemmete
- Departments of3Neurosurgery and.,4Radiology, University of Michigan, Ann Arbor, Michigan; and
| | - Neeraj Chaudhary
- Departments of3Neurosurgery and.,4Radiology, University of Michigan, Ann Arbor, Michigan; and
| | | | | | - Albert J Shih
- 1Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Luis E Savastano
- Departments of3Neurosurgery and.,5Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Linzey JR, Burke JF, Nadel JL, Williamson CA, Savastano LE, Wilkinson DA, Pandey AS. Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures. J Neurosurg 2020; 131:1725-1733. [PMID: 30554183 DOI: 10.3171/2018.7.jns181226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/31/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery. METHODS This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively. RESULTS Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70-79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00. CONCLUSIONS Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.
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Affiliation(s)
| | | | | | - Craig A Williamson
- Departments of2Neurology and.,3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Luis E Savastano
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - D Andrew Wilkinson
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Aditya S Pandey
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
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Savastano LE, Gordon D, Bhambri A, Pandey A, Cockrum J, Thompson BG, Reddy A, Seibel E. Abstract WMP39: Laser Angioscopy in Carotid Artery Disease: Imaging Findings and Histopathological Correlation. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wmp39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our understanding and management of carotid artery disease has largely relied on angiography, US and MR. However, existing modalities cannot accurately identify the spectrum of thrombogenic lesions on the vascular surface or reliably detect structural markers of instability. Thus, the natural history of the different histopathological hallmarks of advanced or complicated plaques is unknown, and many patients with culprit substenotic plaques are misdiagnosed with cryptogenic stroke. An intraluminal approach to directly inspect the endovascular surfaces at unprecedented resolutions would enable detailed structural analysis of carotid plaques and the identification of the root cause of carotid-related strokes. A scanning fiber angioscope (SFA), a high-definition 1.2-mm forward-viewing camera that generates videos by spirally scanning low-power laser beams, was developed for clinical use and employed to analyze the endovascular surfaces of
ex vivo
human carotid arteries (n=95) and endarterectomized plaques (n=20). Specimens were then imaged with US and micro-CT, and all vascular diagnostic tests obtained in the patients undergoing carotid revascularization were accessed. Imaging findings in the vascular surfaces were then validated by histomorphological analysis of >300 lesions, and an angioscopic classifier for atherosclerosis was generated. Full-color videos at 30Hz and at a resolution >200,000 pixels were generated from the entire endovascular circumference in all specimens with depth-of-focus larger than 5cm in saline solution. The ability to analyze the surface anatomy with unparalleled detail allowed the identification of early, intermediate, advanced and complex atherosclerotic lesions, including ulceration of fibrotic cap, excavation of the necrotic core leading to pseudolumens, intimal flaps, exposed necrotic core to the lumen, erosions, recent and remote intimal hemorrhages, luminal thrombus, eruptive calcified nodules and calcified intimal sheaths and plates. SFA offers a direct view of the endoluminal surfaces with unparalleled resolution and has the potential to revolutionize research, diagnosis, prognosis and image-guided therapy in carotid atherosclerosis.
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Affiliation(s)
| | | | | | | | | | | | | | - Eric Seibel
- Mechanical Engineering, Univ of Washington, Seattle, WA
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Coon SL, Fu C, Hartley SW, Holtzclaw L, Mays JC, Kelly MC, Kelley MW, Mullikin JC, Rath MF, Savastano LE, Klein DC. Single Cell Sequencing of the Pineal Gland: The Next Chapter. Front Endocrinol (Lausanne) 2019; 10:590. [PMID: 31616371 PMCID: PMC6764290 DOI: 10.3389/fendo.2019.00590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022] Open
Abstract
The analysis of pineal cell biology has undergone remarkable development as techniques have become available which allow for sequencing of entire transcriptomes and, most recently, the sequencing of the transcriptome of individual cells. Identification of at least nine distinct cell types in the rat pineal gland has been made possible, allowing identification of the precise cells of origin and expression of transcripts for the first time. Here the history and current state of knowledge generated by these transcriptomic efforts is reviewed, with emphasis on the insights suggested by the findings.
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Affiliation(s)
- Steven L. Coon
- Molecular Genomics Core, Office of the Scientific Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Cong Fu
- Key Laboratory of Organ Regeneration & Transplantation of the Ministry of Education, The First Hospital of Jilin University, Changchun, China
- National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, Changchun, China
| | - Steven W. Hartley
- Comparative Genomics Analysis Unit, Cancer Genetics and Comparative Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
| | - Lynne Holtzclaw
- Microscopy and Imaging Core, Office of the Scientific Director, Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Joseph C. Mays
- Institute on Systems Genetics, New York University School of Medicine, New York, NY, United States
| | - Michael C. Kelly
- Single Cell Analysis Facility, Frederick National Lab for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Matthew W. Kelley
- Section on Developmental Neuroscience, Laboratory of Cochlear Development, Division of Intramural Research, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, United States
| | - James C. Mullikin
- National Institutes of Health Intramural Sequencing Center, National Human Genome Research Institute, National Institutes of Health, Rockville, MD, United States
| | - Martin F. Rath
- Department of Neuroscience, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Luis E. Savastano
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - David C. Klein
- Office of the Scientific Director, Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: David C. Klein
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Hollon TC, Savastano LE, Altshuler D, Barkan AL, Sullivan SE. Ventriculoscopic Surgery for Cystic Retrochiasmatic Craniopharyngiomas: Indications, Surgical Technique, and Short-Term Patient Outcomes. Oper Neurosurg (Hagerstown) 2018; 15:109-119. [PMID: 29048572 DOI: 10.1093/ons/opx220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/19/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Attempted gross-total resection for the management of cystic retrochiasmatic craniopharyngiomas can cause severe hypothalamic dysfunction and decrease overall survival. Ventriculoscopic surgery is a minimally invasive alternative; however, potential indications and technique have not been well defined. OBJECTIVE To present our indications and technique for the ventriculoscopic treatment of cystic retrochiasmatic craniopharyngiomas. METHODS We evaluated all patients with retrochiasmatic craniopharyngiomas for ventriculoscopic surgery. Indications and operative technique were developed to minimize operative morbidity, relieve mass effect, and optimize functional outcome. Cyst size and functional outcomes were statistically evaluated to determine radiographic and short-term clinical outcome. RESULTS Indications for ventriculoscopic surgery included (1) radiographic evidence of hypothalamic involvement and (2) major cystic component. Ten patients met indications, and mean follow-up was 2.5 ± 1.6 yr. The surgical technique included wide cyst fenestration at the foramen of Monro, and fenestration of inferior cyst wall/third ventriculostomy ("through-and-through" technique). Preoperative Karnofsky performance status was 70 ± 15 and was inversely correlated with preoperative cyst size (13 ± 13 cm3). A statistically significant reduction in cyst size was found on early postoperative imaging (2.1 ± 4.3 cm3). Seven patients received postoperative radiotherapy. Postoperative performance scores (81 ± 8.3) had improved; no patient suffered functional decline. Pre- and postoperative body mass indices were similar. No patient had short-term hypothalamic obesity. CONCLUSION Ventriculoscopic surgery, with or without adjuvant treatments, can reduce early postoperative tumor volume and improve short-term functional status in cystic retrochiasmatic craniopharyngiomas with hypothalamic involvement; it should be considered a minimally invasive option in the multimodal treatment of craniopharyngiomas. Further studies are needed to determine long-term efficacy.
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Affiliation(s)
- Todd C Hollon
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Luis E Savastano
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - David Altshuler
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Ariel L Barkan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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