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2.
J Clin Neurosci ; 92: 67-74, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34509265

RESUMO

Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.


Assuntos
Transferência da Responsabilidade pelo Paciente , Comunicação , Humanos , Unidades de Terapia Intensiva , Erros Médicos , Período Pós-Operatório
3.
World Neurosurg ; 153: e259-e264, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34242830

RESUMO

OBJECTIVE: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a pressing public health issue. Although most cases do not result in severe illness requiring hospitalization, there is increasing evidence that SARS-CoV-2-induced inflammation can exacerbate pre-existing diseases. We sought to describe the characteristics of patients with aneurysmal subarachnoid hemorrhage who were actively or very recently infected with SARS-CoV-2. METHODS: We reviewed subarachnoid hemorrhage cases of patients who also were positive for SARS-CoV-2 at 5 high-volume cerebrovascular centers in the United States from March 2020 to January 2021. Cases of aneurysmal subarachnoid hemorrhage were analyzed. RESULTS: A total of 10 patients were identified, consisting of 5 women (50%) and 5 men (50%). Median age was 38.5 years. Four of the 10 patients (40%) were asymptomatic with respect to SARS-CoV-2-related symptoms, 3 patients (30%) had mild-to-moderate symptoms, and 3 patients (30%) had severe coronavirus disease 2019 (COVID-19), with pneumonia and sepsis. Of the 10 cases, 4 had dissecting pseudoaneurysms (40%), 3 in the posterior circulation and 1 in the anterior circulation. Among 6 saccular/blister aneurysms, 4 (67%) were ≤4 mm in largest diameter. CONCLUSIONS: Our experience with aneurysmal subarachnoid hemorrhage in patients positive for COVID-19 reveals a possibly distinct pattern compared with traditional aneurysmal subarachnoid hemorrhage, namely a high frequency of small aneurysms, dissecting pseudoaneurysms, and young patients.


Assuntos
COVID-19/complicações , Aneurisma Intracraniano/complicações , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/epidemiologia , Adulto , Fatores Etários , COVID-19/epidemiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
4.
J Am Heart Assoc ; 10(15): e021845, 2021 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-34325514

RESUMO

Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have emerged over the past decades. Specifically, we discuss microcirculatory dysfunction, glymphatic impairment, inflammation, and neuroelectric disruption as pathological factors in addition to the canonical focus on cerebral vasospasm. This review intends to give clinicians and researchers a summary of the foundations of delayed cerebral ischemia pathophysiology while also underscoring the interactions and interdependencies between pathological factors. Through this overview, we also highlight the advances in translational studies and potential future therapeutic opportunities.


Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea/complicações , Isquemia Encefálica/etiologia , Isquemia Encefálica/imunologia , Isquemia Encefálica/fisiopatologia , Humanos , Inflamação , Microcirculação , Tempo
5.
World Neurosurg ; 154: 13-20, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34245882

RESUMO

The treatment of orbital lymphaticovenous malformations (OLVMs) has evolved from simple surgical resection to a multimodal approach consisting of sclerosing agents, embolization, and resection depending on the specific components that compose the lesion. Here we present a representative case series of 5 nonconsecutive patients who underwent percutaneous embolization of OLVMs with the Onyx Liquid Embolic System (Medtronic, Dublin, Ireland) before surgical resection between 2019 and 2021. OLVMs are rare, benign, congenital lesions that grow with age and can become symptomatic and disabling. Treatment can be conservative or invasive; depending on the clinical presentation and characteristics of the lesions, treatment modalities can vary. Preoperative percutaneous embolization of OLVMs with the Onyx system is a promising technique, as demonstrated in this case series.

6.
Clin Neurol Neurosurg ; 206: 106677, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34020326

RESUMO

Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.


Assuntos
COVID-19/complicações , Trombose das Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Infarto da Artéria Cerebral Média/cirurgia , Acidente Vascular Cerebral/etiologia , Trombectomia , Idoso , Trombose das Artérias Carótidas/diagnóstico , Trombose das Artérias Carótidas/etiologia , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/etiologia
7.
J Clin Neurosci ; 86: 271-275, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33775341

RESUMO

BACKGROUND: Spontaneous intracerebral hemorrhage (sICH) is a disease process with high morbidity and mortality. In particular, hematoma expansion (HE) is a feared complication of sICH. With 15-40% of patients experiencing HE, it has become increasingly important to predict which sICH will remain stable and which will expand. OBJECTIVE: With new treatment options being developed, it is becoming increasingly important to be able to predict which hemorrhages are at high versus low risk for expansion. The authors of this study hope to reexamine variables associated with hematoma expansion in hopes of generating newer data on risk factors for expansion. METHODS: A retrospective analysis identified 334 patients who presented with sICH. The primary outcome was HE on follow up head CT. HE was defined as a greater than 33% increase or an absolute increase in 6 mL or more in overall volume between the two sets of CT images. Analysis was performed using unpaired t-test, Chi-square, and Fisher's exact tests, as appropriate. RESULTS: Of the 334 patients, 247 (74.0%) did not experience an expansion of their ICH while 87 (26.0%) did. Multivariable logistic regression was performed demonstrating ICH score of 3 or greater (4.76 (95% CI 2.60-8.72, p < 0.001) , cortical location of the sICH (1.77 (95% CI 1.03-3.04, p = 0.038), and presence of a fluid level (6.46 (95% CI 2.28-18.3, p < 0.001) as significant predictors of HE. CONCLUSIONS: Our study found that fluid-fluid levels on non-contrast CT, an ICH score 3 or greater, and lobar sICH were all more likely to expand.


Assuntos
Hemorragia Cerebral/complicações , Hemorragia Cerebral/diagnóstico por imagem , Hematoma/diagnóstico por imagem , Hematoma/etiologia , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X/métodos
8.
World Neurosurg ; 146: e607-e617, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33130285

RESUMO

BACKGROUND: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms. METHODS: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes. RESULTS: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling. CONCLUSIONS: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods.


Assuntos
Artéria Carótida Interna/cirurgia , Angiografia Cerebral , Embolização Terapêutica , Aneurisma Intracraniano/terapia , Adulto , Idoso , Angiografia Cerebral/efeitos adversos , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Imageamento Tridimensional/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Artéria Vertebral/cirurgia
9.
World Neurosurg ; 146: e779-e785, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33181379

RESUMO

BACKGROUND: In patients with brain parenchyma extending beyond the craniectomy defect, cerebrospinal fluid diversion may be necessary to facilitate proper bone flap replacement during cranioplasty. In this study, we present our case series of patients who underwent ultrasound-guided ventricular puncture during cranioplasty and report periprocedural metrics and clinical outcomes. METHODS: A retrospective study of patients who presented for cranioplasty that required ultrasound-guided ventricular puncture was performed. We also describe our operative technique for safely and accurately performing ultrasound-guided ventricular puncture. RESULTS: Ten consecutive patients were included in the overall patient cohort, all of whom required intraoperative ventricular puncture to achieve brain relaxation. The mean time between decompressive hemicraniectomy and cranioplasty was 145.4 days (range 19-419). The mean duration of cranioplasty operation was 146 minutes (range 74-193). All patients underwent ultrasound-guided ventricular puncture, and 5 patients had an external ventricular drain left in place for postoperative intracranial pressure monitoring and possible cerebrospinal fluid drainage. There were no instances of pericatheter hemorrhage. One patient presented postoperatively with wound infection, and this same patient was the only one in the cohort who required subsequent ventriculoperitoneal shunt for symptomatic hydrocephalus. CONCLUSIONS: Ultrasound-guided ventricular puncture is safe, feasible, and efficacious for use during cranioplasty to help facilitate bone flap replacement in patients with "full" brains, with an overall low rate of associated periprocedural complications. Although further studies are needed in a larger patient cohort, this technique should be considered to help reduce the morbidity associated with cranioplasty.


Assuntos
Ventrículos Cerebrais/cirurgia , Craniectomia Descompressiva , Procedimentos Cirúrgicos Reconstrutivos/métodos , Crânio/cirurgia , Ventriculostomia/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Punções/métodos , Estudos Retrospectivos , Cirurgia Assistida por Computador/métodos , Ultrassonografia/métodos
10.
Clin Neurol Neurosurg ; 201: 106440, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33383464

RESUMO

BACKGROUND AND IMPORTANCE: Additional time is needed to determine the exact impact of COVID-19 on acute cerebrovascular disease incidence, but recently published data has correlated COVID-19 to large vessel occlusion strokes. CLINICAL PRESENTATION: We report the first case of central retinal artery occlusion (CRAO) as the initial manifestation of COVID-19 infection. Subsequent neuroimaging revealed a large thrombus extending into the internal carotid artery. CONCLUSION: This case illustrates the need to suspect COVID-19 infection in patients presenting with retinal arterial occlusion, including individuals who are asymptomatic or minimally symptomatic for COVID-19 infection.


Assuntos
COVID-19/diagnóstico por imagem , Oclusão da Artéria Retiniana/diagnóstico por imagem , Transtornos da Visão/diagnóstico por imagem , Visão Monocular/fisiologia , COVID-19/complicações , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade , Oclusão da Artéria Retiniana/etiologia , Transtornos da Visão/etiologia
11.
J Neurosurg ; : 1-6, 2020 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-33186909

RESUMO

OBJECTIVE: In this study, the authors aimed to investigate procedural and clinical outcomes between radial and femoral artery access in patients undergoing thrombectomy for acute stroke. METHODS: The authors conducted a single-institution retrospective analysis of 104 patients who underwent mechanical thrombectomy, 52 via transradial access and 52 via traditional transfemoral access. They analyzed various procedural and clinical metrics between the two patient cohorts. RESULTS: There was no difference between patient demographics or presenting symptoms of stroke severity between patients treated via transradial or transfemoral access. The mean procedural time was similar between the two treatment cohorts: 60.35 ± 36.81 minutes for the transradial group versus 65.50 ± 29.92 minutes for the transfemoral group (p = 0.451). The mean total fluoroscopy time for the procedure was similar between the two patient cohorts (20.31 ± 11.68 for radial vs 18.49 ± 11.78 minutes for femoral, p = 0.898). The majority of patients underwent thrombolysis in cerebral infarction score 2b/3 revascularization, regardless of access site (92.3% for radial vs 94.2% for femoral, p = 0.696). There was no significant difference in the incidence of access site or periprocedural complications between the transradial and transfemoral cohorts. CONCLUSIONS: Acute stroke intervention performed via transradial access is feasible and effective, with no significant difference in procedural and clinical outcomes compared with traditional transfemoral access. Larger studies are required to further validate the efficacy and limitations of transradial access for neurointerventional procedures.

12.
J Clin Neurosci ; 81: 302-305, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33222934

RESUMO

Acute ischemic stroke (AIS) is a leading cause of mortality and morbidity in the world. Patients are usually treated with endovascular methods and access is often gained trans-femoral or trans-radial. In patients with difficult anatomy, in rare cases the approach must be done trans-cervical. Our case illustrates a patient who received IVTPA prior to attempted endovascular treatment, leading to a direct carotid cutdown for mechanical thrombectomy. Our patient presented with a left M1 occlusion and had received intravenous thrombolytic at the presentation of his symptoms. Due to unfavorable anatomy and tortuous aortic arch, conventional access could not be obtained. In order to achieve reperfusion while maintaining hemostasis, a decision was made to perform an open carotid cutdown to catherize the left internal carotid artery to successfully retrieve the thrombus. This resulted in a TICI2B revascularization. This is the first reported case of direct carotid access in the setting of acute ischemic stroke with IVTPA. Open technique allowed us to maintain hemostasis while bypassing the tortuous arch and achieving reperfusion and give the patient the best chance for a functional recovery.


Assuntos
Artéria Carótida Interna/cirurgia , Trombectomia/métodos , Idoso , Procedimentos Endovasculares/métodos , Fibrinolíticos , Humanos , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/cirurgia , Masculino , Ativador de Plasminogênio Tecidual/uso terapêutico
15.
J Neurosurg ; 134(3): 902-908, 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32114538

RESUMO

OBJECTIVE: Inflammation plays an integral role in the formation, growth, and progression to rupture of unruptured intracranial aneurysms (UIAs). Animal and human studies have suggested that, due to its antiinflammatory effect, aspirin (ASA) may decrease the risks of growth and rupture of UIAs. High-resolution vessel wall imaging (HR-VWI) has emerged as a noninvasive method to assess vessel wall inflammation and UIA instability. To the authors' knowledge, to date no studies have found a significant correlation between patient use of ASA and contrast enhancement of UIAs on HR-VWI. METHODS: The University of Iowa HR-VWI Project database was analyzed. This database is a compilation of data on patients with UIAs who prospectively underwent HR-VWI on a 3T Siemens MRI scanner. The presence of aneurysmal wall enhancement was objectively defined using the aneurysm-to-pituitary stalk contrast ratio (CRstalk). This ratio was calculated by measuring the maximal signal intensity in the aneurysmal wall and the pituitary stalk on postcontrast T1-weighted images. Data on aneurysm size, morphology, and location and patient demographics and comorbidities were collected. Use of ASA was defined as daily intake of ≥ 81 mg during the previous 6 months or longer. Univariate and multivariate logistic regression analyses were performed to determine factors independently associated with increased contrast enhancement of UIAs on HR-VWI. RESULTS: In total, 74 patients harboring 96 UIAs were included in the study. The mean patient age was 64.7 ± 12.4 years, and 60 patients (81%) were women. Multivariate analysis showed that age (OR 1.12, 95% CI 1.05-1.19), aneurysm size ≥ 7 mm (OR 21.3, 95% CI 4.88-92.8), and location in the anterior communicating, posterior communicating, and basilar arteries (OR 10.7, 95% CI 2.45-46.5) were significantly associated with increased wall enhancement on HR-VWI. On the other hand, use of ASA was significantly associated with decreased aneurysmal wall enhancement on HR-VWI (OR 0.22, 95% CI 0.06-0.83, p = 0.026). CONCLUSIONS: The study results establish a correlation between use of ASA daily for ≥ 6 months and significant decreases in wall enhancement of UIAs on HR-VWI. The findings also demonstrate that detection of wall enhancement using HR-MRI may be a valuable noninvasive method for assessing aneurysmal wall inflammation and UIA instability.


Assuntos
Aspirina/efeitos adversos , Vasos Sanguíneos/diagnóstico por imagem , Aneurisma Intracraniano/diagnóstico por imagem , Idoso , Artéria Cerebral Anterior/diagnóstico por imagem , Artéria Basilar/diagnóstico por imagem , Meios de Contraste , Feminino , Humanos , Inflamação/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Hipófise/diagnóstico por imagem , Artéria Cerebral Posterior/diagnóstico por imagem
16.
J Neurointerv Surg ; 12(11): 1122-1126, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32217626

RESUMO

BACKGROUND: The transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures. METHODS: We reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access. RESULTS: A total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients. CONCLUSION: In this early stage of transforming to the 'radial-first' approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.


Assuntos
Benchmarking/métodos , Procedimentos Endovasculares/tendências , Artéria Femoral/diagnóstico por imagem , Complicações Intraoperatórias/diagnóstico por imagem , Artéria Radial/diagnóstico por imagem , Adulto , Idoso , Procedimentos Endovasculares/efeitos adversos , Feminino , Artéria Femoral/cirurgia , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Artéria Radial/cirurgia , Estudos Retrospectivos , Stents/efeitos adversos , Stents/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia
17.
World Neurosurg ; 137: 338-340, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32035205

RESUMO

BACKGROUND: Cavernous-carotid fistulas (CCFs) can present with a variety of symptoms depending on the anatomy of the fistula and its venous drainage. Patients most commonly present with scleral injection, pulsatile exophthalmos, and/or chemosis. CASE DESCRIPTION: We report a patient who presented with intraparenchymal hemorrhage in the absence of any of the commonly associated ocular symptoms and signs. After multiple imaging studies, the CCF was diagnosed and treated with endovascular embolization that resulted in complete occlusion of the fistula and reflux of embolysate into one of its connecting veins. CONCLUSIONS: The morphology of the venous drainage can lead to atypical hemorrhagic presentation, whereas dilatation of one of the tributary veins with cortical venous reflux should warn the interventionist the path the embolysate may follow. We provide our experience with this unique presentation and its treatment.


Assuntos
Fístula Carotidocavernosa/complicações , Hemorragia Cerebral/etiologia , Adulto , Angiografia Digital , Artérias Carótidas/diagnóstico por imagem , Fístula Carotidocavernosa/diagnóstico por imagem , Fístula Carotidocavernosa/fisiopatologia , Fístula Carotidocavernosa/terapia , Seio Cavernoso/diagnóstico por imagem , Angiografia Cerebral , Hemorragia Cerebral/fisiopatologia , Diplopia , Síndrome de Down/complicações , Embolização Terapêutica , Epilepsia/complicações , Exoftalmia , Olho/irrigação sanguínea , Humanos , Imageamento por Ressonância Magnética , Masculino , Tomografia Computadorizada por Raios X , Transtornos da Visão
18.
Oper Neurosurg (Hagerstown) ; 19(2): E196-E200, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31943088

RESUMO

BACKGROUND AND IMPORTANCE: Carotid-cavernous fistulas (CCF) are pathological connections between carotid artery branches and the cavernous sinus. They can lead to a variety of symptoms, such as chemosis and double vision, or more insidious events, such as vision loss and intracranial hemorrhage. Although these patients are often treated by endovascular means, we describe a case in which the patient's CCF was not able to be accessed by usual methods and required an open surgical approach. CLINICAL PRESENTATION: The patient had progressive chemosis, double vision, and periorbital pain. Angiogram showed an indirect type D CCF with cortical venous drainage with a large sylvian vein that was directly draining the fistula. The patient did not have a dilated superior ophthalmic vein, and the petrosal sinuses could not be catheterized. Therefore, because of the patient's increased risk for intracranial hemorrhage, she was taken to the operating room for an image guided burr hole for direct catheterization of the sylvian vein. From this point, the fistulous point could be catheterized, and the CCF was embolized using onyx. Follow-up angiogram showed complete occlusion. CONCLUSION: This is the first report in literature of an indirect CCF being treated through a transsylvian approach with onyx. This combined open-surgical-and-endovascular approach was necessary to get full resolution of the lesion, and patient had rapid improvement of symptoms.


Assuntos
Fístula Carotidocavernosa , Seio Cavernoso , Embolização Terapêutica , Fístula Carotidocavernosa/diagnóstico por imagem , Fístula Carotidocavernosa/cirurgia , Cateterismo , Seio Cavernoso/diagnóstico por imagem , Seio Cavernoso/cirurgia , Cavidades Cranianas , Feminino , Humanos
19.
World Neurosurg X ; 5: 100067, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31872191

RESUMO

Introduction: We reviewed the literature on interventions for patients with medically refractory chronically occluded internal carotid artery (COICA) to assess the risks and/or benefits after recanalization via an endovascular technique (ET) or hybrid surgery (HS, i.e., ET plus carotid endarterectomy). Methods: A systematic search of the electronic databases was performed. Patients with COICA were classified into 4 different categories according to Hasan et al classification. Results: Eighteen studies satisfied the inclusion criteria. Only 6 studies involved an HS procedure. We identified 389 patients with COICA who underwent ET or HS; 91% were males. The overall perioperative complication rate was 10.1% (95% confidence interval [CI]: 7.4%-13.1%). For types A and B, the successful recanalization rate was 95.4% (95% CI: 86.5%-100%), with a 13.7% (95% CI: 2.3%-27.4%) complication rate. For type C, the success rate for ET was 45.7% (95% CI: 17.8%-70.7%), with a complication rate of 46.0% (95% CI: 20.0%-71.4%) for ET and for the HS technique 87.6% (95% CI: 80.9%-94.4%), with a complication rate of 14.0% (95% CI: 7.0%-21.8%). For type D, the success rate of recanalization was 29.8% (95% CI: 7.8%-52.8%), with a 29.8% (95% CI: 6.1%-56.3%) complication rate. Successful recanalization resulted in a symmetrical perfusion between both cerebral hemispheres, resolution of penumbra, normalization of the mean transit time, and improvement in Montreal Cognitive Assessment (MoCA) score (ΔMoCA = 9.80 points; P = 0.004). Conclusions: Type A and B occlusions benefit from ET, especially in the presence of a large penumbra. Type C occlusions can benefit from HS. Unfortunately, we did not identify an intervention to help patients with type D occlusions. A phase 2b randomized controlled trial is needed to confirm these findings.

20.
World Neurosurg ; 131: 6-9, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31356971

RESUMO

BACKGROUND: Despite the recent increase of transradial access among neurointerventionalists, there is still a paucity of evidence in the neurosurgical literature. There are 3 newly Food and Drug Administration-approved devices-Woven EndoBridge (WEB), Surpass, and PulseRider-that significantly expand the options available for endovascular treatment of cerebral aneurysms. Our work reports the safety and feasibility of radial artery catheterization for the deployment of these new devices. METHODS: We performed a review of the first 10 patients with an unruptured cerebral aneurysm treated via a transradial cerebral angiogram. Seven patients underwent embolization with the WEB device, 1 patient underwent embolization with the PulseRider, and 2 patients underwent embolization with the Surpass device. We describe in detail our workflow and the devices used for transradial access. RESULTS: The aneurysms treated include internal carotid artery bifurcation, middle cerebral artery, anterior communicating artery, basilar tip, and posterior communicating artery. All patients underwent radial artery catheterization, and none of them had to be converted to femoral artery access. Of the 10 patients, 9 required a single attempt for accurate device deployment. One patient had unsuccessful placement of the WEB device and required coiling of the aneurysm because of device herniation into the parent vessel. None of the patients had any postoperative complications and were discharged the following day with the same modified Rankin scale score as preoperatively. CONCLUSIONS: Our experience with 10 patients revealed no limitations during catheterization and deployment of these devices. One patient had to be converted to coil embolization, which was feasible through the same vascular access. None of the patients had vascular complications postoperatively with minimal wrist discomfort.


Assuntos
Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/instrumentação , Aneurisma Intracraniano/terapia , Artéria Radial , Adulto , Angiografia Cerebral , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Equipamentos e Provisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
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