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Hubbard ME, Pena I, Freeman D, Tummala RP. Neurosurgeons performing tracheostomies- maintaining proficiency in the modern era. Clin Neurol Neurosurg 2020; 192:105681. [PMID: 32087498 DOI: 10.1016/j.clineuro.2020.105681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Tracheostomy is a basic surgical procedure that most surgeons, regardless of specialty, learn early in their training. With improvements in intensive care medicine, the number of neurosurgical patients requiring tracheostomy has declined. As neurosurgeons advance in their training, familiarity with airway management declines and falls under the domain of other specialties. Because neurosurgeons still manage critically ill patients, they often defer the airway management to other specialists. In many institutions, neurosurgeons no longer perform tracheostomies. The purpose of this study was to evaluate complications and outcomes following tracheostomies performed by neurosurgeons. PATIENTS AND METHODS We reviewed a database of all neurosurgical procedures performed at a single institution from 9/2007 to 2/2017. We reviewed the operative and medical records of patients whose tracheostomies were performed by a neurosurgeon. RESULTS Neurosurgeons performed 72 tracheostomies over the study period. All the procedures were done in an operating room using traditional open technique. Four patients had previous tracheostomy. Five patients were on dual antiplatelet therapy. The procedure was successful in all patients. There were no immediate complications in any patient. One patient required revision for development of tracheo-cutaneous fistula. CONCLUSION Tracheostomies can be performed safely by neurosurgeons in this era of sub-specialization. There is a renewed interest in maintaining critical care proficiency in neurosurgery. Airway management is an important part of this skill-set. Neurosurgeons manage patients with brain injuries, cranial nerve deficits, and cervical spine injuries, Consequently, learning how to establish a surgical airway remains necessary in neurosurgical training.
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Affiliation(s)
- Molly E Hubbard
- Department of Neurosurgery, University of Minnesota Medical School, United States
| | | | - David Freeman
- Department of Neurosurgery, University of Minnesota Medical School, United States
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Male S, Mehta T, Khan A, Jagadeesan BD, Tummala RP. Stent-Assisted Woven EndoBridge Implantation for Treatment of Wide-Necked Aneurysm Residual: Angiographic Video. World Neurosurg 2019; 129:276. [PMID: 31226456 DOI: 10.1016/j.wneu.2019.06.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/10/2019] [Indexed: 11/26/2022]
Abstract
Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device that has recently been approved by the U.S. Food and Drug Administration (FDA) for treatment of wide-neck ruptured and unruptured aneurysms at arterial bifurcations. Successful and effective treatment of aneurysms with the WEB device requires accurate sizing. For optimal positioning of the WEB device within the aneurysm sac, the diameter of the device has to exceed by the mean diameter of the aneurysm by 1.0 mm. However, this predictably results in an increase in the height of the device. In shallow, wide-necked aneurysms, this increase in height of the WEB device could result in encroachment of the device on the parent artery or branch vessel origins. In these circumstances, the placement of an intracranial stent can prevent such encroachment. In this video, we demonstrate the operative technique of stent-assisted WEB device placement that was performed at our institution for the treatment of a recurrent basilar apex aneurysm (Video 1). This previously ruptured aneurysm had been treated initially with primary coil embolization, and the patient consented to endovascular treatment of her aneurysm recurrence. The video illustrates this procedure using a combination of fluoroscopic images, fluoroscopic cines, and digital subtraction angiograms.
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Affiliation(s)
- Shailesh Male
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Tapan Mehta
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adam Khan
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bharathi D Jagadeesan
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ramachandra P Tummala
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, Minnesota, USA
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Kim J, Male S, Damania D, Jahromi BS, Tummala RP. Comparison of Carotid Endarterectomy and Stenting for Symptomatic Internal Carotid Artery Near-Occlusion. AJNR Am J Neuroradiol 2019; 40:1207-1212. [PMID: 31171520 DOI: 10.3174/ajnr.a6085] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/22/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Carotid near-occlusion is defined as severe stenosis of the internal carotid artery with partial or full collapse of the distal vessel wall. The major studies evaluating carotid revascularization excluded patients with carotid near-occlusion. Given the paucity of data in the literature, we attempted to evaluate the safety of carotid endarterectomy and carotid artery stenting in carotid near-occlusion. MATERIALS AND METHODS A retrospective data base review was performed from January 2010 to December 2018 to identify patients who underwent carotid endarterectomy or carotid artery stenting for symptomatic ICA near-occlusion and had 1-month clinical and imaging follow-up with carotid sonography. The medical records and imaging studies of patients with ICA near-occlusion were selected for analysis. RESULTS Forty-five patients met the criteria for ICA near-occlusion, of whom 39 were included in the study, given insufficient 1-month follow-up on 6 patients. Of the 39 patients, 25 underwent carotid endarterectomy and 14 underwent carotid artery stenting. All patients had technically successful immediate revascularization of the ICA. Most (33 of 39) had 1-year follow-up postoperatively. Patients with carotid artery stenting had 20% restenosis and 79% vessel maturation rates, while patients with carotid endarterectomy had 17.4% restenosis and 84% vessel maturation. There was no significant difference in periprocedural complication rates between the 2 procedures. CONCLUSIONS Carotid artery stenting shows similar outcomes in restenosis and vessel maturation rates compared with carotid endarterectomy for ICA near-occlusion. There were no major differences between the 2 treatments in clinical outcomes or periprocedural complications. Carotid artery stenting is a revascularization option for carotid near-occlusion if the patient is considered at high risk for carotid endarterectomy.
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Affiliation(s)
- J Kim
- From the Departments of Neurology, Neurosurgery, and Radiology (J.K., S.M., R.P.T.), University of Minnesota, Minneapolis, Minnesota
| | - S Male
- From the Departments of Neurology, Neurosurgery, and Radiology (J.K., S.M., R.P.T.), University of Minnesota, Minneapolis, Minnesota
| | - D Damania
- Department of Medicine (D.D.), State University of New York, Downstate Medical Center, Brooklyn, New York
| | - B S Jahromi
- Department of Neurological Surgery (B.S.J.), Northwestern University, Chicago, Illinois
| | - R P Tummala
- From the Departments of Neurology, Neurosurgery, and Radiology (J.K., S.M., R.P.T.), University of Minnesota, Minneapolis, Minnesota
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Male S, Mehta T, Tore H, Quinn C, Grande AW, Tummala RP, Jagadeesan BD. Gadolinium to the rescue for mechanical thrombectomy in acute ischemic stroke. Interv Neuroradiol 2018; 25:301-304. [PMID: 30567455 DOI: 10.1177/1591019918815298] [Citation(s) in RCA: 2] [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: 11/17/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy in the setting of acute ischemic stroke (AIS) requires cerebral digital subtraction angiography (DSA), typically performed with iodinated contrast medium. We present a case of emergent cerebral DSA and mechanical thrombectomy using gadolinium-based contrast for cerebral DSA in a patient with a history of anaphylaxis to iodinated contrast agents (ICs). CASE REPORT A 72-year-old man developed left ventricle assist device thrombus while on anticoagulation. During hospitalization he suffered right middle cerebral artery occlusion with a National Institutes of Health stroke scale score of 10. He had a history of anaphylaxis and the advanced directives revealed do not resuscitate/do not intubate status. We performed an emergent DSA as part of thrombectomy procedure using gadolinium-based contrast mixed in 1:1 proportion with normal saline. The images obtained were of adequate quality and the patient underwent successful thrombectomy with modified thrombolysis in cerebral infarction 2B recanalization. CONCLUSION Gadolinium-based contrast agents could be effective alternatives for cerebral DSA in patients undergoing mechanical thrombectomy for AIS who have a history of anaphylactic reaction to ICs.
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Affiliation(s)
- Shailesh Male
- 1 Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tapan Mehta
- 1 Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Huseyin Tore
- 2 Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Coridon Quinn
- 3 Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew W Grande
- 3 Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
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Jagadeesan BD, Grande AW, Tummala RP. Safety and Feasibility of Balloon-Assisted Embolization with Onyx of Brain Arteriovenous Malformations Revisited: Personal Experience with the Scepter XC Balloon Microcatheter. Interv Neurol 2018; 7:439-444. [PMID: 30410522 DOI: 10.1159/000490579] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
Background/Objective Compliant dual-lumen balloon microcatheters have been used to perform balloon-assisted embolization (BAE) of brain arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (Onyx). However, vessel rupture and microcatheter retention have been reported from BAE using these microcatheters. Using an extra-compliant balloon microcatheter (Scepter XC; Microvention, Tustin, CA, USA) could help avoid pial vessel rupture during BAE. We herein report our experience using this balloon microcatheter for BAE. Methods This retrospective study included patients who underwent BAE of brain AVMs at our institution between June 2012 and March 2017. Results The extra-compliant Scepter XC balloon microcatheter was used for BAE of brain AVMs in 23 patients aged 44.3 ± 16.7 years (range 0-65 years). A total of 40 intracranial vessels (39 pial arteries and 1 pial vein) were catheterized and embolized during 30 separate sessions. In all instances, the balloon microcatheter could be successfully advanced to the AVM nidus. A mean volume of 2.4 ± 1.7 mL (range 0.65-4.6 mL) of Onyx was injected per session. There were no instances of vessel rupture, microcatheter retention, or stroke. Conclusion Utilization of the extra-compliant balloon microcatheter results in safe and effective BAE, which adds to the growing experience with BAE for AVM treatment.
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Affiliation(s)
- Bharathi D Jagadeesan
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew W Grande
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ramachandra P Tummala
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
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Kim J, Male S, Jagadeesan BD, Streib C, Tummala RP. Safety of cerebral angiography and neuroendovascular therapy in patients with chronic kidney disease. Neuroradiology 2018; 60:529-533. [DOI: 10.1007/s00234-018-1996-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 02/13/2018] [Indexed: 11/25/2022]
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Jagadeesan BD, Sandhu D, Hong KJ, Roshan Khanipour S, Grande AW, Tummala RP. Salvage of Herniated Flow Diverters Using Stent and Balloon Anchoring Techniques: A Technical Note. Interv Neurol 2017; 6:31-35. [PMID: 28611831 DOI: 10.1159/000452284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The pipeline embolization device (PED; Medtronic, MN, USA) can sometimes herniate into the aneurysmal sac in an unexpected manner during or shortly after its deployment due to device foreshortening. In this report, we describe 2 endovascular techniques, which can be used to reposition a herniated PED construct into a more favorable alignment. SUMMARY In a 67-year-old patient who had an intraprocedural herniation of a PED device into a giant cavernous aneurysm, a stent anchor technique was used to reverse the herniation, reorient the PED construct, and achieve successful flow diversion. In a different patient with a giant superior hypophyseal aneurysm, a balloon anchor technique followed by deployment of an LVIS Jr (Microvention, Tustin, CA, USA) stent was used to reverse the herniation into the aneurysmal sac. KEY MESSAGES Stent anchor and balloon anchor techniques as described here can be used to reposition PED constructs, which have unexpectedly herniated into the aneurysm sac during attempted flow diversion for the treatment of giant aneurysms.
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Affiliation(s)
- Bharathi D Jagadeesan
- Department of Radiology, Minneapolis MN, USA.,Department of Neurosurgery, Minneapolis MN, USA.,Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Divyajot Sandhu
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Kim Jae Hong
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | | | - Andrew W Grande
- Department of Radiology, Minneapolis MN, USA.,Department of Neurosurgery, Minneapolis MN, USA.,Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Ramachandra P Tummala
- Department of Radiology, Minneapolis MN, USA.,Department of Neurosurgery, Minneapolis MN, USA.,Department of Neurology, University of Minnesota, Minneapolis, MN, USA
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Abstract
OBJECTIVE
External ventricular drains (EVDs) have an important role in the management of neurological disease, and their placement is a frequently performed neurosurgical procedure. Hemorrhage is a common complication of EVD placement and occurs more frequently than originally believed. There is also risk of hemorrhage with removal of an EVD, which has not been well described. The authors investigated the risk factors associated with placement and removal of EVDs at their institution.
METHODS
A database was created including patients who required EVD placement from March 2008 to June 2014 at the University of Minnesota. A retrospective chart review was completed, and data were collected for each patient. All cranial imaging studies during the index hospitalization were reviewed to identify hemorrhages associated with either EVD placement or removal. The study was performed using a research protocol approved by the University of Minnesota's institutional review board.
RESULTS
Four hundred eighty-two EVDs were placed during the designated time period. Among the cases in which patients underwent imaging after the placement procedure, hemorrhage was found in 94 (21.6%). The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean [± SD] 1.96 ± 6.48 cm3). Two of these hemorrhages resulted in additional interventions: 1 surgical evacuation and 1 contralateral EVD. In 55 (22.5%) of the 244 cases in which imaging was performed after EVD removal, hemorrhage associated with removal was identified. The mean volume of these hemorrhages was 8.25 ± 20.34 cm3 (range 0.012–82.08 cm3). Two EVDs were replaced, and 1 patient died as a result of a large hemorrhage. Large hemorrhages (> 30 cm3) occurred in 2 patients on placement (0.46%) and in 5 patients on removal (2.0%). In this series, decreased platelet levels on admission and an increasing number of EVD placement attempts correlated with an increased risk of hemorrhage on placement. Only those with an EVD placed at bedside were more likely to have hemorrhage on EVD removal.
CONCLUSIONS
Multiple studies have reported varying EVD hemorrhage rates while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. Hemorrhages occur relatively frequently following EVD placement and removal, though clinical significance of these events seems to be low.
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Jagadeesan BD, Zacharatos H, Nascene DR, Grande AW, Guillaume DJ, Tummala RP. Endovascular management of a vein of Galen aneurysmal malformation in an infant with challenging femoral arterial access. J Neurosurg Pediatr 2016; 18:231-4. [PMID: 27058455 DOI: 10.3171/2016.2.peds15652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 5-month-old infant was to be treated with elective transarterial embolization for a vein of Galen aneurysmal malformation (VGAM). A team of endovascular surgical neuroradiologists, pediatric interventional radiologists, and pediatric cardiologists attempted conventional femoral arterial access, which was unsuccessful given the small caliber of the femoral arteries and superimposed severe vasospasm. Thereafter, eventual arterial access was achieved by navigating from the venous to the arterial system across the patent foramen ovale following a right femoral venous access. Embolization was then successfully performed. At a later date, the child underwent successful transvenous balloon-assisted embolization and eventual arterial embolization with cure of the VGAM.
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Affiliation(s)
- Bharathi D Jagadeesan
- Departments of 1 Radiology.,Neurosurgery, and.,Neurology, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Andrew W Grande
- Departments of 1 Radiology.,Neurosurgery, and.,Neurology, University of Minnesota, Minneapolis, Minnesota
| | | | - Ramachandra P Tummala
- Departments of 1 Radiology.,Neurosurgery, and.,Neurology, University of Minnesota, Minneapolis, Minnesota
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Jagadeesan BD, Grande AW, Guillaume DJ, Nascene DR, Tummala RP. The role of percutaneous embolization techniques in the management of dural sinus malformations with atypical angioarchitecture in neonates: report of 2 cases. J Neurosurg Pediatr 2015; 16:74-9. [PMID: 25910034 DOI: 10.3171/2014.12.peds145] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dural sinus malformations (DSMs) are rare congenital malformations that can be midline or lateral in location. Midline DSMs have been reported to have a worse prognosis than lateral DSMs and have traditionally been more difficult to manage. The authors report 2 unusual manifestations of midline DSMs and their management with percutaneous transfontanelle embolization. The first patient (Case 1) presented at 21 days of life with a large midline DSM and multiple highflow dural and pial arteriovenous shunts. The child developed congestive cardiac failure and venous congestion with intracranial hemorrhage and seizures within a few weeks. The second patient (Case 2) presented with a large midline DSM found on prenatal imaging that was determined to be a purely venous malformation on postnatal evaluation. This large malformation resulted in consumptive coagulopathy and apneic episodes from brainstem compression. The patient in Case 1 was treated initially with endovascular embolization and eventually with curative percutaneous-transfontanelle embolization. The patient in Case 2 was treated with percutaneous transfontanelle embolization in combination with posterior fossa decompression and cranial expansion surgery.
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Affiliation(s)
| | - Andrew W Grande
- Department of Radiology.,Department of Neurosurgery, and.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Ramachandra P Tummala
- Department of Radiology.,Department of Neurosurgery, and.,Department of Neurology, University of Minnesota, Minneapolis, Minnesota
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Miley JT, Rodriguez GJ, Tummala RP. Endovascular retrieval of a prematurely deployed covered stent. World J Radiol 2015; 7:139-142. [PMID: 26120384 PMCID: PMC4473308 DOI: 10.4329/wjr.v7.i6.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 04/20/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
Several techniques have been reported to address different endovascular device failures. We report the case of a premature deployment of a covered balloon mounted stent during endovascular repair of a post-traumatic carotid-cavernous fistula (CCF). A 50-year-old male suffered a fall resulting in loss of consciousness and multiple facial fractures. Five weeks later, he developed decreased left visual acuity, proptosis, chemosis, limited eye movements and cranial/orbit bruit. Cerebral angiography demonstrated a direct left CCF and endovascular repair with a 5.0 mm × 19 mm covered stent was planned. Once in the lacerum segment, increased resistance was encountered and the stent was withdrawn resulting in premature deployment. A 3 mm × 9 mm balloon was advanced over an exchange length microwire and through the stent lumen. Once distal to the stent, the balloon was inflated and slowly pulled back in contact with the stent. All devices were successfully withdrawn as a unit. The use of a balloon to retrieve a prematurely deployed balloon mounted stent is a potential rescue option if leaving the stent in situ carries risks.
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Jagadeesan BD, Grigoryan M, Hassan AE, Grande AW, Tummala RP. Endovascular balloon-assisted embolization of intracranial and cervical arteriovenous malformations using dual-lumen coaxial balloon microcatheters and Onyx: initial experience. Neurosurgery 2014; 73:ons238-43; discussion ons243. [PMID: 24077579 DOI: 10.1227/neu.0000000000000186] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ethylene vinyl alcohol copolymer (Onyx) is widely used for the embolization of arteriovenous malformations (AVMs) of the brain, head, and neck. Balloon-assisted Onyx embolization may provide additional unique advantages in the treatment of AVMs in comparison with traditional catheter-based techniques. OBJECTIVE To report our initial experience in performing balloon-assisted AVM embolization for brain and neck AVMs with the use of the new Scepter-C and Scepter-XC coaxial dual-lumen balloon microcatheters. METHODS Balloon-assisted transarterial embolization was performed in a series of 7 patients with AVMs (4 with brain AVMs, 1 with a dural arteriovenous fistula, and 2 with neck AVMs) by using Onyx delivered through the lumen of Scepter-C or Scepter XC coaxial balloon microcatheters. Following the initial balloon-catheter navigation into a feeding artery and the subsequent inflation of the balloon, the embolization was performed by using Onyx 18, Onyx 34, or both. RESULTS A total of 12 embolization sessions were performed via 17 arterial feeders in these 7 patients. In 1 patient, there was an arterial perforation from the inflation of the balloon; in all others, the embolization goals were successfully achieved with no adverse events. CONCLUSION The balloon microcatheters showed excellent navigability, and there were no problems with retrieval or with the repeated inflation and deflation of the balloons. A proximal Onyx plug, which is crucial in many AVM embolizations, was not necessary with this technique. Additionally, fluoroscopy and procedural times seemed lower with this technique compared with conventional embolization methods.
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Affiliation(s)
- Bharathi D Jagadeesan
- *Department of Radiology; ‡Department of Neurosurgery; §Department of Neurology, University of Minnesota, Minneapolis, Minnesota
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Tekle WG, Grigoryan M, Tummala RP. Marginal sinus fistula supplied exclusively by vertebral artery feeders. J Vasc Interv Neurol 2013; 6:30-33. [PMID: 24358414 PMCID: PMC3868244] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A 54-year-old woman is reported with severe pulsatile tinnitus. Digital subtraction angiography demonstrated dural arteriovenous fistula of the marginal sinus with feeders arising exclusively from bilateral vertebral arteries. Patient underwent successful transarterial Onyx embolization with complete angiographic and clinical cure.
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Affiliation(s)
| | | | - Ramachandra P Tummala
- Department of Neurology, University of Minnesota, Minneapolis, MN ; Department of Neurosurgery, University of Minnesota, Minneapolis, MN
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Jagadeesan BD, Siddiq F, Grande AW, Tummala RP. Modified balloon assisted coil embolization for the treatment of intracranial and cervical arterial aneurysms using coaxial dual lumen balloon microcatheters: initial experience. J Neurointerv Surg 2013; 6:704-7. [DOI: 10.1136/neurintsurg-2013-010936] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hassan AE, Akbar U, Chaudhry SA, Tekle WG, Tummala RP, Rodriguez GJ, Qureshi AI. Rate and prognosis of patients under conscious sedation requiring emergent intubation during neuroendovascular procedures. AJNR Am J Neuroradiol 2013; 34:1375-9. [PMID: 23370474 DOI: 10.3174/ajnr.a3385] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Neuroendovascular procedures are performed with the patient under conscious sedation (local anesthesia) in varying numbers of patients in different institutions, though the risk of unplanned conversion to general anesthesia is poorly characterized. Our aim was to ascertain the rate of failure of conscious sedation in patients undergoing neuroendovascular procedures and compare the in-hospital outcomes of patients who were converted from conscious sedation to general anesthesia with those whose procedures were initiated with general anesthesia. MATERIALS AND METHODS All patients who had an endovascular procedure initiated under general anesthesia or conscious sedation were identified through a prospective data base maintained at 2 comprehensive stroke centers. Patient clinical and procedural characteristics, in-hospital deaths, and favorable outcomes (modified Rankin Scale score, 0-2) at discharge were ascertained. RESULTS Nine hundred seven endovascular procedures were identified, of which 387 were performed with the patient under general anesthesia, while 520 procedures were initiated with conscious sedation. Among procedures initiated with intent to be performed under conscious sedation, 9 (1.7%) procedures required emergent conversion to general anesthesia. Favorable clinical outcome and in-hospital mortality in patients requiring emergent conversion from conscious sedation to general anesthesia and in those with procedures initiated with general anesthesia were not statistically different (42% versus 50%, P = .73 and 17% versus 13%, P = 1.00, respectively). CONCLUSIONS In our study, there was a very low rate of conscious sedation failure and associated adverse outcomes among patients undergoing neuroendovascular procedures. Proper patient selection is important if procedures are to be performed with the patient under conscious sedation. Limitations of the methodology used in our study preclude us from offering specific recommendations regarding when to use a specific anesthetic protocol.
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Affiliation(s)
- A E Hassan
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN 55455,
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Hassan AE, Jadhav V, Zacharatos H, Chaudhry SA, Rodriguez GJ, Mohammad YM, Suri MFK, Tariq N, Vazquez G, Tummala RP, Taylor RA, Qureshi AI. Determinants of Neurologic Deterioration and Stroke-Free Survival After Spontaneous Cervicocranial Dissections: A Multicenter Study. J Stroke Cerebrovasc Dis 2013; 22:389-96. [DOI: 10.1016/j.jstrokecerebrovasdis.2011.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 09/29/2011] [Indexed: 10/15/2022] Open
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Jagadeesan BD, Grigoryan M, Hassan AE, Grande AW, Tummala RP. Endovascular Balloon-Assisted Embolization of Intracranial and Cervical Arteriovenous Malformations Using Dual Lumen Co-axial Balloon Microcatheters and Onyx. Neurosurgery 2013. [DOI: 10.1227/neu.0b013e31828d602b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Jagadeesan BD, Grigoryan M, Hassan AE, Grande AW, Tummala RP. Abstract TMP120: Endovascular Balloon-Assisted Embolization of Intracranial Arteriovenous Malformations Using Dual Lumen Co-Axial Balloon Microcatheters and Onyx: Initial Experience. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atmp120] [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
Background:
Ethylene Vinyl alcohol co-polymer (Onyx) is widely used for embolization of intracranial arteriovenous malformations. Traditional catheter based techniques for Onyx infiltration may be associated with reflux of Onyx resulting in cathteter retention, vessel rupture or reflux into en-passage arteries. Balloon assisted Onyx embolization may eliminate some of these problems encountered with traditional catheter based techniques. Herein, we report our initial experience in performing balloon assisted AVM embolization for brain AVMs and dural AVFs using the new Scepter-C and Scepter-XC co- axial dual lumen balloon microcatheters.
Methods:
Balloon-assisted trans-arterial embolization was carried out in a series of six patients (5 with brain AVMs, one with a dural AVF ) using Onyx delivered through the lumen of Scepter-C or Scepter XC co-axial balloon microcatheters. Following initial balloon-catheter navigation into a feeding artery as close to the nidus of the malformation as possible, and subsequent balloon inflation, embolization was performed using Onyx 18 or Onyx 34 or both. The balloon was delated and removed once adequate embolization had been achieved.
Results:
A total of ten embolization sessions were performed via fifteen arterial feeders in these five patients. In one out of fifteen vessels (7%), there was a quickly controlled arterial perforation from balloon inflation, in all others embolization goals for each session were successfully achieved with no adverse events.
Conclusion:
We found that the balloon microcatheters showed excellent navigability and there were no problems with retrieval or repeated inflation and deflation of the balloons. Using this technique, we were able to avoid the need for formation of a proximal Onyx plug and its associated risks. Additionally, fluoroscopy and procedural times seemed lower with this technique compared to conventional embolization methods.
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Siddiq F, Chaudhry SA, Tummala RP, Suri MFK, Qureshi AI. Factors and outcomes associated with early and delayed aneurysm treatment in subarachnoid hemorrhage patients in the United States. Neurosurgery 2013; 71:670-7; discussion 677-8. [PMID: 22653398 DOI: 10.1227/neu.0b013e318261749b] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recent studies from selected centers have shown that early surgical treatment of aneurysms in subarachnoid hemorrhage (SAH) patients can improve outcomes. These results have not been validated in clinical practice at large. OBJECTIVE To identify factors and outcomes associated with timing of ruptured intracranial aneurysm obliteration treatment in patients with SAH after hospitalization in the United States. METHODS We analyzed the data from the Nationwide Inpatient Sample (2005-2008) for all patients presenting with primary diagnosis of SAH, receiving aneurysm treatment (endovascular coil embolization or surgical clip placement). Early treatment was defined as aneurysm treatment performed within 48 hours and delayed treatment if treatment was performed after 48 hours of admission. RESULTS Of 32 048 patients with SAH who underwent aneurysm treatment, 24 085 (75.2%) underwent early treatment and 7963 (24.8%) underwent delayed treatment. Female sex (P = .002), endovascular embolization (P < .001), and weekday admission (P < .001) were independent predictors of early treatment. In the early treatment group, patients were more likely discharged with none to minimal disability (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.14-1.47) and less likely to be discharged with moderate to severe disability (OR 0.77, 95%CI 0.67-0.87) compared with those in the delayed treatment group. The in-hospital mortality was higher in the early treatment group compared with the delayed treatment group (OR 1.36 95%CI 1.12-1.66). CONCLUSION Patients with SAH who undergo aneurysm treatment within 48 hours of hospital admission are more likely to be discharged with none to minimal disability. Early treatment is more likely to occur in those undergoing endovascular treatment and in patients admitted on weekdays.
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Affiliation(s)
- Farhan Siddiq
- The Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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20
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Hassan AE, Zacharatos H, Rodriguez GJ, Suri MFK, Tariq N, Vazquez G, Tummala RP, Qureshi AI. Long-term Clinical and Angiographic Outcomes in Patients with Spontaneous Cervico-Cranial Arterial Dissections Treated with Stent Placement. J Neuroimaging 2012; 22:384-93. [DOI: 10.1111/j.1552-6569.2012.00724.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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21
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Miley JT, Tariq N, Souslian FG, Qureshi N, Suri MFK, Tummala RP, Vazquez G, Qureshi AI. Comparison between angioplasty using compliant and noncompliant balloons for treatment of cerebral vasospasm associated with subarachnoid hemorrhage. Neurosurgery 2012; 69:ons161-8; discussion ons168. [PMID: 21712743 DOI: 10.1227/neu.0b013e31822a8976] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Considerable controversy exists regarding the choice of balloon used for performing angioplasty as treatment of cerebral vasospasm associated with subarachnoid hemorrhage. OBJECTIVE To determine the impact of compliant and noncompliant balloons on angiographic and clinical outcomes among patients with subarachnoid hemorrhage-related cerebral vasospasm. METHODS Consecutive patients with cerebral vasospasm who underwent balloon angioplasty were included. Patient characteristics, rate of angiographic recurrence, and occurrence of cerebral infarcts in the affected vessel distribution were compared between arteries treated using different balloons. RESULTS A total of 30 patients underwent a first-time angioplasty using compliant (n = 34) or noncompliant (n = 51) balloons. At admission, patients were classified Hunt and Hess grade I to III (n = 20) and Hunt and Hess grade IV to V (n = 10). Fisher grades in patients were I (n = 1), II (n = 3), III (n = 20), and IV (n = 6). No significant differences in the rate of angiographic recurrence (32% vs 53%; P = .14), need for repeat angioplasty (21% vs 20%; P = .97), and occurrence of cerebral infarcts in the affected arterial distribution (21% vs 10% P = .39) were observed with compliant and noncompliant balloons, respectively. Independent of the balloon type, a significant reduction in the need for repeat angioplasty was observed when the initial angioplasty resulted in a normal or supranormal diameter compared with a subnormal diameter (63.5% vs 36.5%; P = .01). CONCLUSION No clear difference was observed between compliant and noncompliant balloons for therapeutic angioplasty in preventing angiographic recurrence or the need for repeat angioplasty in patients with subarachnoid hemorrhage-related cerebral vasospasm. An immediate normal or supranormal vessel diameter after the first-time angioplasty resulted in a significant reduction in the need for repeat angioplasty.
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Affiliation(s)
- Jefferson T Miley
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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22
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Khatri R, Ansar M, Sultan F, Chaudhry SA, Khan AA, Rodriguez GJ, Tummala RP, Qureshi AI. Requirements for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures in contemporary practice. AJNR Am J Neuroradiol 2011; 33:465-8. [PMID: 22116112 DOI: 10.3174/ajnr.a2787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Provisions for an emergent neurosurgical procedure have been a mandatory component of centers that perform neuroendovascular procedures. We sought to determine the need for emergent neurosurgical procedures following neuroendovascular interventions in 2 comprehensive stroke centers in settings with such provisions. MATERIALS AND METHODS Analysis of retrospectively collected data from procedure logs and patient charts was performed to identify patients who required immediate (before the termination of the intervention) or adjunctive (within 24 hours of the intervention) neurosurgical procedures related to a neuroendovascular intervention complication. The types of neurosurgical procedures and in-hospital outcomes of identified patients are reported as an aggregate and per endovascular procedure-type analyses. RESULTS We reviewed a total of 933 neuroendovascular procedures performed during 3.5 years (2006-2010). A total of 759 intracranial procedures were performed. There was a need for emergent neurosurgical procedures in 8 patients (0.85% cumulative incidence and 1.05% for major intracranial procedures) (mean age, 46 years; 7 were women); the procedures were categorized as 3 immediate and 5 adjunctive procedures. There were 5 in-hospital deaths (62.5%) among these 8 patients. Neurosurgical procedures performed were external ventricular drainage placement in 6 (6 of 8, 75%) patients, decompressive craniectomy in 1 (12.5%) patient, and both surgical procedures in 1 (12.5%) patient. CONCLUSIONS The need for emergent neurosurgical procedures is very low among patients undergoing intracranial neuroendovascular procedures. Survival in such patients despite emergent neurosurgical procedures is quite low.
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Affiliation(s)
- R Khatri
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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23
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Tawk RG, Tummala RP, Memon MZ, Siddiqui AH, Hopkins LN, Levy EI. Utility of Pharmacologic Provocative Neurological Testing Before Embolization of Occipital Lobe Arteriovenous Malformations. World Neurosurg 2011; 76:276-81. [DOI: 10.1016/j.wneu.2011.02.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Accepted: 02/17/2011] [Indexed: 11/26/2022]
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24
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Khatri R, Rodriguez GJ, Siddiq F, Tummala RP. Early migration of a self-expanding intracranial stent after the treatment of a basilar trunk aneurysm: report of a second case. Neurosurgery 2011; 69:E513-5; author reply E515-7. [PMID: 21792122 DOI: 10.1227/neu.0b013e3182242bfd] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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25
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Seibert B, Tummala RP, Chow R, Faridar A, Mousavi SA, Divani AA. Intracranial aneurysms: review of current treatment options and outcomes. Front Neurol 2011; 2:45. [PMID: 21779274 PMCID: PMC3134887 DOI: 10.3389/fneur.2011.00045] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [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: 04/08/2011] [Accepted: 06/29/2011] [Indexed: 11/21/2022] Open
Abstract
Intracranial aneurysms are present in roughly 5% of the population, yet most are often asymptomatic and never detected. Development of an aneurysm typically occurs during adulthood, while formation and growth are associated with risk factors such as age, hypertension, pre-existing familial conditions, and smoking. Subarachnoid hemorrhage, the most common presentation due to aneurysm rupture, represents a serious medical condition often leading to severe neurological deficit or death. Recent technological advances in imaging modalities, along with increased understanding of natural history and prevalence of aneurysms, have increased detection of asymptomatic unruptured intracranial aneurysms (UIA). Studies reporting on the risk of rupture and outcomes have provided much insight, but the debate remains of how and when unruptured aneurysms should be managed. Treatment methods include two major intervention options: clipping of the aneurysm and endovascular methods such as coiling, stent-assisted coiling, and flow diversion stents. The studies reviewed here support the generalized notion that endovascular treatment of UIA provides a safe and effective alternative to surgical treatment. The risks associated with endovascular repair are lower and incur shorter hospital stays for appropriately selected patients. The endovascular treatment option should be considered based on factors such as aneurysm size, location, patient medical history, and operator experience.
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Affiliation(s)
- Brad Seibert
- Department of Biomedical Engineering, College of Science and Engineering, University of Minnesota Minneapolis, MN, USA
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26
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Abstract
Background and Purpose—
Both initial hematoma volume and hematoma growth are independent predictors of clinical outcomes and mortality among intracerebral hemorrhage patients. The purpose of this study was to evaluate the accuracy of different computed tomography image acquisition protocols and hematoma volume measurement techniques.
Methods—
We used plastic and cadaveric phantoms to determine the accuracy of different volumetric measurement techniques. We performed both axial and spiral computed tomography scans with 0.75-, 1.5-, 3.0-, and 4.5-mm-thick transverse sections (with no gap). Different measurement techniques (planimetry, ABC/2, and 3D rendering) and different window width/level settings (I, 150/50 versus II, 587/−321) were used to assess generated errors in volumetric calculations.
Results—
Both axial and spiral computed tomography scans yielded similar percent errors for different slice thicknesses and different measurement techniques. Comparison of different measurement techniques revealed a significant difference in measurement error only from the ABC/2 method as compared with 3D-rendering measurements (
P
<0.0001). The overall measurement error according to the ABC/2 method was further increased by ≈8% for irregularly shaped hematomas (
P
=0.0004). A significant percent difference in measurement error was observed between window width/levels I and II for both planimetry (mean difference across all thicknesses, 1.91±3.78,
P
=0.004) and Analyze software (mean difference across all thicknesses, 6.92±7.29,
P
<0.0001) methods.
Conclusions—
A better understanding of the limitations that may affect measurement of hematoma volume is crucial in the assessment of hematoma volume, which is considered an independent marker of clinical outcome.
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Affiliation(s)
- Afshin A. Divani
- From the Departments of Neurology (A.A.D., S.M., F.G.S., A.A., R.P.T.), Neurosurgery (A.A.D., F.G.S., A.A., R.P.T.), and Radiology (A.A.D., J.Z., R.P.T.), and the Division of Biostatistics (X.L.), School of Public Health, University of Minnesota, Minneapolis, MN
| | - Shahram Majidi
- From the Departments of Neurology (A.A.D., S.M., F.G.S., A.A., R.P.T.), Neurosurgery (A.A.D., F.G.S., A.A., R.P.T.), and Radiology (A.A.D., J.Z., R.P.T.), and the Division of Biostatistics (X.L.), School of Public Health, University of Minnesota, Minneapolis, MN
| | - Xianghua Luo
- From the Departments of Neurology (A.A.D., S.M., F.G.S., A.A., R.P.T.), Neurosurgery (A.A.D., F.G.S., A.A., R.P.T.), and Radiology (A.A.D., J.Z., R.P.T.), and the Division of Biostatistics (X.L.), School of Public Health, University of Minnesota, Minneapolis, MN
| | - Fotis G. Souslian
- From the Departments of Neurology (A.A.D., S.M., F.G.S., A.A., R.P.T.), Neurosurgery (A.A.D., F.G.S., A.A., R.P.T.), and Radiology (A.A.D., J.Z., R.P.T.), and the Division of Biostatistics (X.L.), School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jie Zhang
- From the Departments of Neurology (A.A.D., S.M., F.G.S., A.A., R.P.T.), Neurosurgery (A.A.D., F.G.S., A.A., R.P.T.), and Radiology (A.A.D., J.Z., R.P.T.), and the Division of Biostatistics (X.L.), School of Public Health, University of Minnesota, Minneapolis, MN
| | - Aviva Abosch
- From the Departments of Neurology (A.A.D., S.M., F.G.S., A.A., R.P.T.), Neurosurgery (A.A.D., F.G.S., A.A., R.P.T.), and Radiology (A.A.D., J.Z., R.P.T.), and the Division of Biostatistics (X.L.), School of Public Health, University of Minnesota, Minneapolis, MN
| | - Ramachandra P. Tummala
- From the Departments of Neurology (A.A.D., S.M., F.G.S., A.A., R.P.T.), Neurosurgery (A.A.D., F.G.S., A.A., R.P.T.), and Radiology (A.A.D., J.Z., R.P.T.), and the Division of Biostatistics (X.L.), School of Public Health, University of Minnesota, Minneapolis, MN
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27
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Khatri R, Memon MZ, Zacharatos H, Taqui AM, Qureshi MH, Vazquez G, Suri MFK, Rodriguez GJ, Tummala RP, Ezzeddine MA, Qureshi AI. Impact of Percutaneous Transluminal Angioplasty for Treatment of Cerebral Vasospasm on Subarachnoid Hemorrhage Patient Outcomes. Neurocrit Care 2011; 15:28-33. [DOI: 10.1007/s12028-010-9499-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Qureshi AI, Tariq N, Hassan AE, Vazquez G, Hussein HM, Suri MFK, Georgiadis AL, Tummala RP, Taylor RA. Predictors and Timing of Neurological Complications Following Intracranial Angioplasty and/or Stent Placement. Neurosurgery 2011; 68:53-60; discussion 60-1. [DOI: 10.1227/neu.0b013e3181fc5f0a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Transient or permanent neurological complications can occur in the periprocedural period following intracranial angioplasty and/or stent placement. Which patients are at risk and the time period for maximum vulnerability among those who undergo intracranial angioplasty and/or stent placement have not been formally studied.
OBJECTIVE:
To assess the predictors and timing of neurological complications following intracranial angioplasty and/or stent placement in the periprocedural period in a consecutive series of patients.
METHODS:
We reviewed medical records and angiograms of consecutive patients treated with intracranial angioplasty and/or stent placement in 3 academic institutions. We evaluated the effect of demographic, clinical, intraprocedural, and angiographic risk factors on subsequent development of periprocedural neurological complications. Periprocedural neurological complications were defined as new or worsening transient or permanent neurological complications that occurred during or within 1 month of the procedure. We also recorded the timing and nature of neurological complications in the periprocedural period.
RESULTS:
A total of 92 patients were included in the study (mean age ± standard deviation: 59 ± 14 years; 59 were men). The overall rate of in-hospital neurological complications was 9.8% (9 of 92 patients). Eight out of 9 neurological complications occurred either during the procedure or within 6 hours thereafter. Presence of diabetes mellitus (P = .003) and use of balloon-expandable stent (P = .09) were associated with periprocedural neurological complications. The degree of pre- and post-procedure stenosis, morphological appearance, and length of lesion were unrelated to periprocedural complications.
CONCLUSION:
Patients with diabetes mellitus and those treated with balloon expandable stents are at high risk for periprocedural neurological complications. The first 6 hours following intracranial angioplasty and stent placement represent the period of highest risk.
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Affiliation(s)
- Adnan I. Qureshi
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Nauman. Tariq
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Ameer E. Hassan
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Gabriela. Vazquez
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Haitham M. Hussein
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - M Fareed K. Suri
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Alexandros L. Georgiadis
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Ramachandra P. Tummala
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Robert A. Taylor
- Zeenat Qureshi Stroke Research Center, Departments of Neurology and Neurosurgery, University of Minnesota, Minneapolis, Minnesota
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Suri MFK, Tariq N, Siddiq F, Vazquez G, Taylor RA, Tummala RP, Wojak JC, Chaloupka JC, Qureshi AI. Intracranial angioplasty and/or stent placement in octogenarians is associated with a threefold greater risk of periprocedural stroke or death. J Endovasc Ther 2010; 17:314-9. [PMID: 20557168 DOI: 10.1583/09-2993.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients. METHODS Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled. Baseline, 30-day, and follow-up clinical and angiographic information were collected. Rates of clinical and angiographic endpoints were compared between patients >or=80 years old versus those <80 years. RESULTS Patients >or=80 years (n = 15) were more likely to be hypertensive (87% versus 69%) and have underlying coronary artery disease (73% versus 36%, p<0.05) compared to younger patients (n = 229). The rate of periprocedural stroke and/or death was 3-fold higher among patients aged >or=80 years compared with those <80 years (20% versus 7%, p = 0.11). No recurrent stroke or death (excluding periprocedural events) was observed during follow-up in the octogenarian group. In patients who had follow-up angiography, a similar rate of >or=50% restenosis was observed among patients aged >or=80 years and those aged <80 years (25% versus 29%, p>0.1). CONCLUSION The 3-fold higher periprocedural death and/or stroke rate suggests cautious use of intracranial angioplasty and/or stent placement in octogenarians.
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Affiliation(s)
- M Fareed K Suri
- The Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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30
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Hassan AE, Zacharatos H, Vazquez G, Rodriguez GJ, Suri MFK, Tummala RP, Taylor RA, Qureshi AI. Low Risk of Intracranial and Systemic Hemorrhages in Patients on Dual Antiplatelet Treatment Beyond 1 Month Following Neuroendovascular Angioplasty and/or Stent Placement. J Neuroimaging 2010; 22:67-73. [DOI: 10.1111/j.1552-6569.2010.00520.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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31
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Tummala RP, Qureshi AI. Is carotid artery stent placement a viable option for carotid artery stenosis in patients aged 80 years or greater? J Neuroimaging 2010; 20:109-10. [PMID: 19138355 DOI: 10.1111/j.1552-6569.2008.00329.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ramachandra P Tummala
- Zeenat Qureshi Stroke Research Center and Minnesota Stroke Initiative, Departments of Neurosurgery and Neurology, University of Minnesota, Minneapolis, MN, USA
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32
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Hassan AE, Zacharatos H, Rodriguez GJ, Vazquez G, Miley JT, Tummala RP, Suri MFK, Taylor RA, Qureshi AI. A Comparison of Computed Tomography Perfusion-Guided and Time-Guided Endovascular Treatments for Patients With Acute Ischemic Stroke. Stroke 2010; 41:1673-8. [DOI: 10.1161/strokeaha.110.586685] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [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
Background and Purpose—
The role of CT perfusion (CT-P) imaging for the selection of patients with acute ischemic stroke who may benefit from endovascular treatment is not defined. The objective of this study was to determine whether CT-P-guided endovascular treatment improves clinical outcomes compared with standard endovascular treatment based on the time interval between symptom onset and presentation and noncontrast cranial CT imaging.
Methods—
A retrospective study was performed comparing the clinical characteristics, complications, and clinical outcomes of patients with acute ischemic stroke who were treated using endovascular modalities based on either CT-P imaging (CT-P-guided) or time interval between symptom onset and presentation and absence of intracerebral hemorrhage or extensive ischemic changes on noncontrast cranial CT scan (time-guided).
Results—
The rates of partial and complete recanalization were similar between the CT-P- and time-guided treatment groups (n=61 [88%] versus n=103 [81%];
P
=0.52) regardless of whether they received intravenous recombinant tissue plasminogen activator before endovascular treatment. Comparing the CT-P-guided with the time-guided patients, favorable discharge outcome (modified Rankin Scale 0 to 2) was observed in 23 (32%) versus 41 (33%) of the patients, respectively (
P
=0.9). In-hospital mortality was observed in 15 (21%) of CT-P- and 29 (23%) of time-guided patients (
P
=0.74).
Conclusion—
CT-P-guided endovascular treatment did not increase the rate of short-term favorable outcomes among patients with acute ischemic stroke. Prospective studies are required to validate the CT-P criteria and protocols currently in use before incorporating CT-P as a routine modality for patient selection for endovascular treatment.
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Affiliation(s)
- Ameer E. Hassan
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - Haralabos Zacharatos
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - Gustavo J. Rodriguez
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - Gabriela Vazquez
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - Jefferson T. Miley
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - Ramachandra P. Tummala
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - M. Fareed K. Suri
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - Robert A. Taylor
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
| | - Adnan I. Qureshi
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minn
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Memon MZ, Vazquez G, Tummala RP, Qureshi AI. Impact of International Subarachnoid Aneurysm Trial Results on Treatment of Ruptured Intracranial Aneurysms in the United States. Neurosurgery 2009. [DOI: 10.1227/01.neu.0000358689.79045.0d] [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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Shah QA, Memon MZ, Suri MFK, Rodriguez GJ, Kozak OS, Taylor RA, Tummala RP, Vazquez G, Georgiadis AL, Qureshi AI. Super-Selective Intra-arterial Magnesium Sulfate in Combination With Nicardipine for the Treatment of Cerebral Vasospasm in Patients With Subarachnoid Hemorrhage. Neurocrit Care 2009; 11:190-8. [DOI: 10.1007/s12028-009-9209-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 02/27/2009] [Indexed: 11/29/2022]
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Jahromi BS, Tummala RP, Levy EI. Inadvertent subclavian artery catheter placement complicated by stroke: Endovascular management and review. Catheter Cardiovasc Interv 2009; 73:706-11. [DOI: 10.1002/ccd.21884] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tummala RP, Jahromi BS, Yamamoto J, Levy EI, Siddiqui AH, Hopkins LN. Carotid artery stenting under flow arrest for the management of intraluminal thrombus: technical case report. Neurosurgery 2009; 63:ONSE87-8; discussion ONSE88. [PMID: 18728612 DOI: 10.1227/01.neu.0000335017.60746.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The management of intraluminal carotid thrombus is not well defined. Medical and surgical management carry a relatively high risk of thromboembolism. Although endovascular options also carry the risk of thromboembolism from manipulation of the lesion, successful carotid stent placement using various methods of flow restriction has been reported anecdotally. We describe a technique to arrest antegrade flow before placement of carotid stents in the setting of symptomatic intraluminal thrombus. CLINICAL PRESENTATION A 49-year-old woman presented with expressive dysphasia, right-upper extremity weakness, and an episode of left monocular blindness. Angiography confirmed the presence of a large intraluminal thrombus in a chronic dissection of the left internal carotid artery. RESULTS We devised a configuration to arrest antegrade flow in the internal carotid artery before crossing the thrombus with a distal embolic protection device by inflating balloons in the common carotid artery and external carotid artery before crossing the lesion. After inflation of a balloon in the internal carotid artery, we completed overlapping stent placement to completely exclude the thrombus from the lumen. CONCLUSION The patient remained neurologically unchanged during and immediately after the procedure. She had mild neurological deficits at the 1 month follow-up evaluation. Follow-up ultrasonography at 1 and 3 months and computed tomographic angiography at 3 months after the procedure showed patency of the stented carotid artery, with no evidence of restenosis or thrombus. Although the risks of carotid stent placement for intraluminal thrombus remain unclear, the technique of flow arrest seems to provide a safe endovascular treatment option.
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Affiliation(s)
- Ramachandra P Tummala
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, University at Buffalo, State University of New York, Buffalo, New York 14209, USA
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Chang FC, Tummala RP, Jahromi BS, Samuelson RM, Siddiqui AH, Levy EI, Hopkins LN. Use of the 8 French Simmons-2 guide catheter for carotid artery stent placement in patients with difficult aortic arch anatomy. J Neurosurg 2009; 110:437-41. [PMID: 18950261 DOI: 10.3171/2008.7.17627] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Inability to achieve vascular access is a common reason for failure to perform carotid artery angioplasty and stent placement. The authors report their experience with the use of an 8 Fr Simmons-2 catheter to gain carotid artery access in the setting of complex aortic arch anatomy. This guide catheter was used successfully to perform carotid artery angioplasty and stent placement in 10 patients with markedly tortuous aortic arches or supra-aortic branches. As the authors gained experience with this catheter, they used it as a first option in patients with the appropriate aortic arch anatomy.
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Affiliation(s)
- Feng-Chi Chang
- 1Department of Radiology, Taipei Veterans General Hospital
- 2National Yang Ming University School of Medicine, Taipei, Taiwan, Republic of China
| | - Ramachandra P. Tummala
- 3Department of Neurosurgery and
- 4Zeenat Qureshi Stroke Research Center, University of Minnesota Medical School, Minneapolis, Minnesota
- 5Departments of Neurosurgery and
- 6Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; and
- 8Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Babak S. Jahromi
- 5Departments of Neurosurgery and
- 6Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; and
- 8Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Rodney M. Samuelson
- 5Departments of Neurosurgery and
- 6Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; and
- 8Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Adnan H. Siddiqui
- 5Departments of Neurosurgery and
- 6Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; and
- 7Radiology and
- 8Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Elad I. Levy
- 5Departments of Neurosurgery and
- 6Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; and
- 7Radiology and
- 8Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - L. Nelson Hopkins
- 5Departments of Neurosurgery and
- 6Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York; and
- 7Radiology and
- 8Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
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Jahromi BS, Tummala RP, Yamamoto J, Levy EI, Siddiqui AH, Hopkins LN. Early carotid stenting for symptomatic stenosis and intraluminal thrombus presenting with stroke. Neurology 2008; 71:1831-3. [PMID: 19029524 DOI: 10.1212/01.wnl.0000339379.15449.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- B S Jahromi
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, NY, USA.
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Shah QA, Memon MZ, Tummala RP, Qureshi AI. Combined surgical and endovascular approach to treat symptomatic in-stent occlusion of the left common carotid artery origin. J Neurosurg 2008; 110:935-8. [PMID: 19072307 DOI: 10.3171/2008.9.jns08774] [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: 11/06/2022]
Abstract
Symptomatic occlusive lesions at the origins of the supra-aortic vessels pose challenges for treatment. Endovascular angioplasty and stent placement via the transfemoral approach is possible, but obtaining a stable position for the guide catheter via this approach is technically difficult. The authors describe the case of a 56-year-old man presenting with symptomatic occlusion of a previously placed stent at the origin of the left common carotid artery (CCA). An endovascular revascularization of the left CCA was planned. However, the absence of a lumen proximal to the stent prevented stable placement of a guide catheter via the transfemoral route. Consequently, the authors used a combined surgical and endovascular approach to gain access to the lesion. The left CCA was exposed surgically distal to the occlusion and clamped just proximal to its bifurcation to preserve flow from the external to the internal carotid artery (ICA) and to prevent embolism into the ICA. A wire was passed retrograde through the occlusive lesion and then was subsequently advanced proximally into the femoral sheath. This allowed transfemoral advancement of the appropriate endovascular devices to perform an angioplasty and placement of a stent. The patient remained neurologically stable, and postoperative studies showed improvement in cerebral perfusion. This case demonstrates the feasibility of distal-to-proximal stent delivery with a combined endovascular and surgical approach.
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Affiliation(s)
- Qaisar A Shah
- Zeenat Qureshi Stroke Research Center, Minnesota Stroke Initiative, University of Minnesota, Minneapolis, Minnesota, USA.
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Abstract
Subclavian steal is a well-described angiographic finding and clinical syndrome that rarely results in vertebrobasilar ischemic symptoms. In classic subclavian steal, left subclavian artery (SA) stenosis occurs proximal to the left vertebral artery (VA) origin. We report a symptomatic variant of this syndrome that occurred in the setting of left common carotid artery occlusion and anomalous origin of the left VA directly from the aortic arch. The steal and symptoms resolved after stenting of the left SA stenosis.
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Affiliation(s)
- Ramachandra P Tummala
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, NY 14209, USA
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Tummala RP, Jahromi BS, Yamamoto J, Levy EI, Siddiqui AH, Hopkins LN. Carotid Artery Stenting under Flow Arrest for the Management of Intraluminal Thrombus: Technical Case Report. Oper Neurosurg (Hagerstown) 2008. [DOI: 10.1227/01.neu.0000315860.47791.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective
The management of intraluminal carotid thrombus is not well defined. Medical and surgical management carry a relatively high risk of thromboembolism. Although endovascular options also carry the risk of thromboembolism from manipulation of the lesion, successful carotid stent placement using various methods of flow restriction has been reported anecdotally. We describe a technique to arrest antegrade flow before placement of carotid stents in the setting of symptomatic intraluminal thrombus.
Clinical Presentation
A 49-year-old woman presented with expressive dysphasia, right-upper extremity weakness, and an episode of left monocular blindness. Angiography confirmed the presence of a large intraluminal thrombus in a chronic dissection of the left internal carotid artery.
Results
We devised a configuration to arrest antegrade flow in the internal carotid artery before crossing the thrombus with a distal embolic protection device by inflating balloons in the common carotid artery and external carotid artery before crossing the lesion. After inflation of a balloon in the internal carotid artery, we completed overlapping stent placement to completely exclude the thrombus from the lumen.
Conclusion
The patient remained neurologically unchanged during and immediately after the procedure. She had mild neurological deficits at the 1 month follow-up evaluation. Follow-up ultrasonography at 1 and 3 months and computed tomographic angiography at 3 months after the procedure showed patency of the stented carotid artery, with no evidence of restenosis or thrombus. Although the risks of carotid stent placement for intraluminal thrombus remain unclear, the technique of flow arrest seems to provide a safe endovascular treatment option.
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Affiliation(s)
- Ramachandra P. Tummala
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
- Department of Neurosurgery and Zeenat Qureshi Stroke Research Center, University of Minnesota Medical School, Minneapolis, Minnesota
- Toshiba Stroke Research Center, Buffalo, New York
| | - Babak S. Jahromi
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
- Toshiba Stroke Research Center, Buffalo, New York
| | - Junichi Yamamoto
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
- Toshiba Stroke Research Center, Buffalo, New York
| | - Elad I. Levy
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
- Toshiba Stroke Research Center, Buffalo, New York
| | - Adnan H. Siddiqui
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
- Toshiba Stroke Research Center, Buffalo, New York
| | - L. Nelson Hopkins
- Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health
- Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
- Toshiba Stroke Research Center, Buffalo, New York
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Ionita CC, Yamamoto J, Tummala RP, Levy EI. MRI assessment followed by successful mechanical recanalization of a complete tandem (internal carotid/middle cerebral artery) occlusion and reversal of a 10-hour fixed deficit. J Neuroimaging 2008; 18:93-5. [PMID: 18190504 DOI: 10.1111/j.1552-6569.2007.00151.x] [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: 10/20/2022] Open
Abstract
BACKGROUND Mechanical clot extraction up to 8 hours after stroke onset is an alternative strategy for opening large vessels, especially for patients ineligible for intravenous thrombolysis. Safety beyond this therapeutic window is untested. METHODS An 81-year-old woman presented 8 hours after she developed left-sided weakness and dysarthria with a National Institutes of Health Stroke Scale (NIHSS) score fluctuating between 6 and 13. Neuroimaging revealed a large perfusion deficit with no diffusion abnormalities. An emergent cerebral angiogram revealed a complete internal carotid artery terminus occlusion. RESULTS Successful mechanical thrombectomy was performed without complication and resulted in almost complete reversal of the patient's deficit to an NIHSS score of 1, 10 hours after stroke onset. CONCLUSION Patients with large hypoperfused areas and minimal diffusion abnormalities on the MRI may benefit from mechanical thrombectomy beyond an 8-hour window.
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Affiliation(s)
- Catalina C Ionita
- Departments of Neurology and Neurosurgery, Stroke/ Neurocritical Care Division, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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Ecker RD, Tummala RP, Levy EI, Hopkins LN. "Internal cross-clamping" for symptomatic internal carotid artery thrombus. Report of two cases. J Neurosurg 2008; 107:1223-7. [PMID: 18077962 DOI: 10.3171/jns-07/12/1223] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Both carotid endarterectomy and carotid artery stent placement with filter embolic protection present a higher risk for patients with internal carotid artery (ICA) lesions containing intraluminal thrombus. Despite the risk associated with intervention, patients with symptomatic intraluminal thrombus who were enrolled in the North American Symptomatic Endarterectomy Trial did better with surgical than medical treatment. We describe the novel use of an endovascular "internal cross-clamping" technique in two patients with symptomatic intraluminal thrombus in the ICA. A 57-year-old woman presented with a history of multiple episodes of left upper-extremity numbness, mild dysarthria, and agraphia occurring over the previous 24 hours. Cranial magnetic resonance imaging revealed a scattered watershed infarction of the right hemisphere and a critical stenosis of the right ICA. An 81-year-old man awoke with hemiplegia and inability to follow commands after undergoing a complicated carotid endarterectomy. Computed tomographic perfusion imaging demonstrated an increased time to peak in the left middle cerebral territory, and emergent angiography demonstrated both intimal flaps and thrombus in the endarterectomy bed. The lesions in both patients were treated with endovascular stent placement using both proximal and distal flow occlusion--a functional "internal cross-clamping"--for embolic protection. To our knowledge, this is the first report of internal trapping and stent placement for symptomatic carotid stenosis containing intraluminal thrombus. This treatment strategy should be added to the armamentarium of endovascular surgeons in selected patients with symptomatic carotid intraluminal thrombus.
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Affiliation(s)
- Robert D Ecker
- Department of Neurosurgery and Toshiba Stroke Research Center, State University of New York, USA
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Samuelson R, Tummala RP, Jahromi BS, Yamamoto J, Atwal G, Levy EI, Siddiqui AH, Guidot CA, Hopkins LN. Aortic Arch Anatomy and Neurologic Complications with Carotid Artery Stenting among Octogenarians. Neurosurgery 2007. [DOI: 10.1227/01.neu.0000279893.53699.3c] [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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Abstract
PURPOSE OF REVIEW Traumatic brain and spinal cord injuries continue to be a public health problem. These types of injuries often occur in early adulthood and have a major impact for society. This review discusses strategies and therapeutic agents for perioperative neuroprotection in the management of brain and spinal cord trauma. RECENT FINDINGS There are no definitive drugs or strategies that can be utilized to provide perioperative neuroprotection in brain and spinal cord trauma patients. Phase III trials of several pharmacologic agents, including inhibitors of oxidative and excitotoxic injury, have been unable to demonstrate clinical efficacy. Although experimental animal data for hypothermia have been promising over the years, clinical application of therapeutic hypothermia cannot be recommended for routine use in neurotrauma patients. Administration of methylprednisolone, which has become common practice in acute spinal cord injury, has come under close scrutiny. Various experimental animal investigations suggest that potential therapeutic agents include estrogen, progesterone, minocycline, erythropoietin, and magnesium. SUMMARY The main priority in the initial treatment of brain and spinal cord trauma is to maintain oxygenation and perfusion in order to avoid aggravating secondary injury. Future progress will depend on the translation of neuroprotective strategies into well designed clinical trials with promising outcomes.
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Affiliation(s)
- Eugene S Fu
- Department of Anesthesiology, University of Miami School of Medicine, Miami, Florida 33136, USA.
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Tummala RP, Sheth RN, Heros RC. Hemodilution and fluid management in neurosurgery. Clin Neurosurg 2006; 53:238-51. [PMID: 17380758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Ramachandra P Tummala
- Department of Neurological Surgery, University of Miami School of Medicine, Florida, USA
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Wolfe SQ, Başkaya MK, Heros RC, Tummala RP. Cerebral aneurysms: learning from the past and looking toward the future. Clin Neurosurg 2006; 53:157-78. [PMID: 17380748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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Abstract
Skull base tumors involving the carotid artery pose a difficult surgical challenge. The potential for bypass grafting for cerebral revascularization carries inherent risks but may aid in tumor resection and control in those who warrant carotid sacrifice but have inappropriate natural cerebrovascular reserve. We include a review of the literature discussing the indications for carotid resection as part of skull base tumor surgery, indications for cerebral revascularization, balloon test occlusion, graft types and operative technique, complications, and results.
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Abstract
Resection of the petrous temporal bone to various degrees provides different levels of access to lesions of the posterior fossa. Although their nomenclature can be confusing, the numerous variants of the transpetrosal approaches can be classified broadly into anterior and posterior groups. The posterior transpetrosal approaches include the retro-labyrinthine, translabyrinthine, and transcochlear, whereas the ones in the anterior group are extensions of the basic middle fossa approach. Both the anterior and posterior approaches have the potential of exposing the cerebellopontine angle and the petroclival region.
The posterior approaches are based on the standard mastoidectomy and involve resection of the petrous bone to various degrees. This results in progressively increased exposure anteriorly, but comes at the expense of hearing in the translabyrinthine approach and of hearing and facial strength in the transcochlear approach.
In contrast, the middle fossa approaches spare the lateral petrous bone and involve resection of the medial petrous bone to various degrees. All of the middle fossa approaches are designed to preserve hearing. Extensions of the middle fossa approaches involve resection of bone within the Kawase rhomboid and division of the tentorium to provide exposure of the posterior fossa.
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Affiliation(s)
- Ramachandra P Tummala
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida 33136, USA
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