Operative and nonoperative adverse events in the management of traumatic fractures of the thoracolumbar spine: a systematic review.

OBJECT: Thoracolumbar spine injuries are commonly encountered in patients with trauma, accounting for almost 90% of all spinal fractures. Thoracolumbar burst fractures comprise a high percentage of these traumatic fractures (45%), and approximately half of the patients with this injury pattern are neurologically intact. However, a debate over complication rates associated with operative versus nonoperative management of various thoracolumbar fracture morphologies is ongoing, particularly concerning those patients presenting without a neurological deficit. METHODS: A MEDLINE search for pertinent literature published between 1966 and December 2013 was conducted by 2 authors (G.G. and R.D.), who used 2 broad search terms to maximize the initial pool of manuscripts for screening. These terms were "operative lumbar spine adverse events" and "nonoperative lumbar spine adverse events." RESULTS: In an advanced MEDLINE search of the term "operative lumbar spine adverse events" on January 8, 2014, 1459 results were obtained. In a search of "nonoperative lumbar spine adverse events," 150 results were obtained. After a review of all abstracts for relevance to traumatic thoracolumbar spinal injuries, 62 abstracts were reviewed for the "operative" group and 21 abstracts were reviewed for the "nonoperative" group. A total of 14 manuscripts that met inclusion criteria for the operative group and 5 manuscripts that met criteria for the nonoperative group were included. There were a total of 919 and 436 patients in the operative and nonoperative treatment groups, respectively. There were no statistically significant differences between the groups with respect to age, sex, and length of stay. The mean ages were 43.17 years in the operative and 34.68 years in the nonoperative groups. The majority of patients in both groups were Frankel Grade E (342 and 319 in operative and nonoperative groups, respectively). Among the studies that reported the data, the mean length of stay was 14 days in the operative group and 20.75 in the nonoperative group. The incidence of all complications in the operative and nonoperative groups was 300 (32.6%) and 21 (4.8%), respectively (p = 0.1065). There was no significant difference between the 2 groups with respect to the incidence of pulmonary, thromboembolic, cardiac, and gastrointestinal complications. However, the incidence of infections (pneumonia, urinary tract infection, wound infection, and sepsis) was significantly higher in the operative group (p = 0.000875). The incidence of instrumentation failure and need for revision surgery was 4.35% (40 of 919), a significant morbidity, and an event unique to the operative category (p = 0.00396). CONCLUSIONS: Due to the limited number of high-quality studies, conclusions related to complication rates of operative and nonoperative management of thoracolumbar traumatic injuries cannot be definitively made. Further prospective, randomized studies of operative versus nonoperative management of thoracolumbar and lumbar spine trauma, with standardized definitions of complications and matched patient cohorts, will aid in properly defining the risk-benefit ratio of surgery for thoracolumbar spine fractures.

Stent-assisted coiling of intracranial aneurysms: predictors of complications, recanalization, and outcome in 508 cases.

BACKGROUND AND PURPOSE: Self-expanding stents are increasingly used for treatment of complex intracranial aneurysms. We assess the safety and the efficacy of intracranial stenting and determine predictors of treatment outcomes. METHODS: A total of 508 patients with 552 aneurysms were treated with Neuroform and Enterprise stents between 2006 and 2011 at our institution. A multivariate analysis was conducted to identify predictors of complications, recanalization, and outcome. RESULTS: Of 508 patients, 461 (91%) were treated electively and 47 (9%) in the setting of subarachnoid hemorrhage. Complications occurred in 6.8% of patients. In multivariate analysis, subarachnoid hemorrhage, delivery of coils before stent placement, and carotid terminus/middle cerebral artery aneurysm locations were independent predictors of procedural complications. Angiographic follow-up was available for 87% of patients at a mean of 26 months. The rates of recanalization and retreatment were, respectively, 12% and 6.4%. Older age, previously coiled aneurysms, larger aneurysms, incompletely occluded aneurysms, Neuroform stent, and aneurysm location were predictors of recanalization. Favorable outcomes were seen in 99% of elective patients and 51% of subarachnoid hemorrhage patients. Patient age, ruptured aneurysms, and procedural complications were predictors of outcome. CONCLUSIONS: Stent-assisted coiling of intracranial aneurysms is safe, effective, and provides durable aneurysm closure. Higher complication rates and worse outcomes are associated with treatment of ruptured aneurysms. Stent delivery before coil deployment reduces the risk of procedural complications. Staging the procedure may not improve procedural safety. Closed-cell stents are associated with significantly lower recanalization rates.

The superior ophthalmic vein approach for the treatment of carotid-cavernous fistulas: a novel technique using Onyx.

OBJECT: Endovascular therapy is the primary treatment option for carotid-cavernous fistulas (CCFs). Operative cannulation of the superior ophthalmic vein (SOV) provides a reasonable alternative route to the cavernous sinus when all transvenous and transarterial approaches have been unsuccessful. The role of the liquid embolic agent Onyx in the management of CCFs has not been well documented, especially when using an SOV approach. The purpose of this study is to assess the safety and efficacy of Onyx embolization of CCFs through a surgical cannulation of the SOV. METHODS: The authors retrospectively reviewed all patients with CCFs who were treated with Onyx through an SOV approach between April 2009 and April 2011. Traditional endovascular approaches had failed in all patients. RESULTS: A total of 10 patients were identified, 1 with a Type A CCF, 5 with a Type B CCF, and 4 with a Type D CCF. All fistulas were embolized in 1 session. Onyx was the sole embolic agent used in 7 cases and was combined with coils in 3 other cases. Complete obliteration was achieved in 8 patients and a significant reduction in fistulous flow was achieved in 2 patients, which later progressed to near-complete occlusion on angiographic follow-up. All patients experienced a complete clinical recovery with excellent cosmetic results and were free from recurrence at their latest clinical follow-up evaluations. CONCLUSIONS: Onyx embolization is an excellent therapy for CCFs in general, and through an SOV approach in particular. Direct operative cannulation of the SOV followed by Onyx embolization may be the best treatment option in patients with CCFs when all other endovascular approaches have been exhausted.

Contrast stasis on noncontrast computed tomography as a predictor of stroke postthrombolysis.

Multimodal endovascular intervention is becoming more commonplace for the acute intervention of ischemic stroke. Hyperdensity in a portion of the treated territory is a common finding on postthrombolytic noncontrast CT (NCCT), but its significance is poorly understood. The authors conducted a single-institution, retrospective chart review of patients who had intraarterial thrombolysis of the anterior circulation between 2010 and 2011 with evidence of hyperdensity on NCCT following recanalization. Eighteen patients had evidence of postoperative contrast stasis causing hyperdensity on NCCT. One hundred percent of the patients had MR imaging evidence of completed strokes postoperatively in the same distribution as the stasis. Stasis on NCCT after intervention had a sensitivity and specificity of 82% and 0% for predicting stroke, respectively. Furthermore, the positive predictive value was 100%. The presence of contrast stasis on postthrombolytic NCCT correlates well with stroke seen on subsequent MR imaging.

Management of incidental cavernous malformations: a review.

Cavernous malformations (CMs) are angiographically occult vascular malformations that are frequently found incidentally on MR imaging. Despite this benign presentation, these lesions could cause symptomatic intracranial hemorrhage, seizures, and focal neurological deficits. Cavernomas can be managed conservatively with neuroimaging studies, surgically with lesion removal, or with radiosurgery. Considering recent studies examining the CM's natural history, imaging techniques, and possible therapeutic interventions, the authors provide a concise review of the literature and discuss the optimal management of incidental CMs.

Transvenous balloon-protected embolization of a scalp arteriovenous fistula using Onyx liquid embolic.

BACKGROUND: Scalp arteriovenous fistulas (AVFs) are rare and potentially complex lesions that can be treated in a multimodal fashion. We present here the first successful treatment of a Stage Ib scalp AVF using a balloon-protected, retrograde transvenous embolization with the liquid embolic Onyx. METHOD: We describe the case of a 60-year-old man with a scalp AVF that had a fine, diffuse, serpiginous arterial supply, precluding a transarterial approach, and multiple venous drainage paths, including the external jugular vein (EJV). The lesion was successfully embolized exclusively via a femoral transvenous retrograde approach using Onyx with balloon-protection of the EJV to simultaneously prevent pulmonary embolism and enable improved retrograde casting of the fistula-outflow zone. FINDINGS: The combined use of Onyx with proximal balloon-protection in a transvenous retrograde femoral approach is a novel method that can be used to definitively treat scalp AVFs with a defined catheter-accessible venous outflow. CONCLUSION: This technique may be useful when transarterial embolization, direct puncture, or surgical excision are not practical or possible.

Radiosurgery for Spinal Intramedullary Arteriovenous Malformations: A Literature Review.

INTRODUCTION: Intramedullary spinal cord arteriovenous malformations (SCAVMs) comprise only 3 to 4% of spinal cord pathologies and are often not amenable to total resection due to extensive involvement with spinal cord parenchyma and multiple arterial feeding vessels. METHODS: A electronic database search from 1966 to February 28, 2014, was conducted for relevant articles using the keywords and Medical Subject Headings strings spinal arteriovenous malformation, spinal radiosurgery, spinal vascular malformation, and radiosurgery for vascular lesions. Target outcomes measures were nidus obliteration, neurologic improvement, and complication rate. RESULTS: Four retrospective articles containing a total of 30 patients were identified that described patients with SCAVMs presenting with symptomatic intramedullary or subarachnoid hemorrhage. Eighteen patients underwent treatment with CyberKnife with dosages ranging from 21 to 40 Gy (or a maximum biological equivalent dose of 58 Gy for early treatment effect) (Accuray, Inc., Sunnyvale, California, United States), 10 with a linear accelerator and real-time respiratory tracking ranging from 32 to 40 Gy, and 2 patients with external-beam radiotherapy receiving 45 Gy and 50 Gy, respectively. The mean time for clinical follow-up was 43.5 months (range: 27.9-60 months). There were no cases of spinal cord hemorrhage after radiosurgery. Nor were there any cases of neurologic worsening or signs and symptoms of neuropathic pain or myelitis. A total of 29 of the 30 patients obtained follow-up.

Arachnolysis or cerebrospinal fluid diversion for adult-onset syringomyelia? A Systematic review of the literature.

OBJECTIVE: To identify surgical practice patterns in the literature for nonpediatric syringomyelia by systematic review and to determine the following: 1) What is the best clinical practice of cerebrospinal fluid (CSF) diversion to maximize clinical improvement or to achieve the lowest recurrence rate? 2) Does arachnolysis, rather than CSF diversion, lead to prolonged times to clinical recurrence? METHODS: A database search comprising PubMed, Cochrane Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Database of Systematic Reviews was conducted to find pertinent articles on postinfectious, posttraumatic, or idiopathic syringomyelia. RESULTS: An advanced PubMed search in August 2012 yielded 1350 studies, including 12 studies meeting Oxford Centre for Evidence-Based Medicine criteria for level IV evidence as a case series, with a total of 410 patients (mean age, 39 years). Data on 486 surgeries were collected. Mean follow-up data were available for 10 studies, with a mean follow-up time of 62 months. On regression analysis, increased age had a significant correlation with a higher likelihood of having clinically significant recurrence on mean follow-up (P < 0.05). The use of arachnolysis in surgery was associated with a longer duration until clinically symptomatic recurrence (P = 0.02). Data on mortality were unavailable. The mean number of surgeries per patient across all studies was 1.20 (range, 0.95-2.00). CONCLUSIONS: With postinfectious and posttraumatic etiologies, arachnolysis was the only surgical treatment to have a statistically significant effect on decreasing recurrence rates. More prospective, randomized, controlled studies are required to reach a clear consensus.

Saving the ischemic penumbra: endovascular thrombolysis versus medical treatment.

Endovascular thrombolysis may allow rapid arterial recanalization in patients with acute ischemic stroke. We present the first study to our knowledge comparing the ischemic penumbra saved with endovascular versus medical therapy. A retrospective review of 21 patients undergoing endovascular intervention for stroke from 2010 to 2011 was contrasted with 21 consecutive patients treated with antiplatelet agents alone. Immediate computed tomography perfusion (CTP) scan of the head and neck was obtained in all patients. Patients with lacunar and posterior circulation infarcts, and those who were medically unstable for MRI post-operatively were excluded. CTP and MRI underwent volumetric calculation. CTP penumbra was correlated with diffusion restriction volumes on MRI, and an assessment was made on the volume of ischemic burden saved with either endovascular treatment or antiplatelet agents. The median age was 70 years (interquartile range 62-80). Median National Institutes of Health Stroke Scale score was 18 and 14 in the control and endovascular groups, respectively. Intravenous tissue plasminogen activator was administered in 22 of 42 patients (52%). Median penumbra calculated was 32,808 mm(3) in the control group and 46,255 mm(3) in the endovascular group. Median penumbra spared was 9550 mm(3) (4980-18,811) in the control group versus 38,155 mm(3) in the endovascular group (p=0.0001). Endovascular thrombolysis may be more efficient than medical therapy alone in saving ischemic penumbra. Future advances in recanalization techniques will further improve the efficacy of endovascular therapy.

Radiosurgery for dural arterio-venous fistulas: a review.

Dural arteriovenous fistulas (dAVFs) are vascular lesions involving direct connections between intracranial dural arteries and venous sinuses. The goal of treatment of these vascular lesions is to alleviate symptoms and prevent future hemorrhage. While endovascular embolization remains the primary method of treatment and obliteration of dAVF recently, stereotactic radiosurgery (SRS) has been used as a treatment modality in select dAVF either alone or in conjunction with endovascular embolization. Considering recent studies examining dAVFs natural history and possible therapeutic interventions, the authors provide a concise review of the literature and discuss the indications, efficacy, and safety of SRS in the management of dAVFs.

Stent-assisted endovascular recanalization of extracranial internal carotid artery occlusion in acute ischemic stroke.

OBJECTIVE: Carotid artery occlusions traditionally have extremely poor outcomes with intravenous tissue plasminogen activator treatment or emergent thromboendarterectomy. We retrospectively reviewed our institutional experience with acute carotid occlusions using internal carotid artery endovascular thrombolysis and stent placement. METHODS: We studied the radiographic and clinical characteristics of 17 patients with an acute cervical internal carotid artery occlusion treated with stent-assisted endovascular thrombolysis. Clinical outcomes were assessed by using National Institute of Health Stroke Scale (NIHSS) scores, which were obtained on admission and discharge. Inclusion criteria were an NIHSS score of at least 6 and the presence of significant penumbra on computed tomographic perfusion. Morbidity and mortality data were collected and analyzed. RESULTS: Seventeen candidates met our inclusion criteria, 16 (94%) of whom had successful immediate recanalization of the internal carotid artery. On admission, the mean NIHSS score was 16.5 and the mean modified Rankin Scale score was 4.8. The mean NIHSS score improved to 6.9 on discharge, with a mean modified Rankin Scale score of 2.88. Eight (47%) patients recovered ambulatory function on discharge. The overall mortality rate of our series was 17%. CONCLUSIONS: In the setting of acute ischemic stroke, emergent carotid artery thrombolysis and stenting is a promising treatment for acute carotid occlusions with excellent recanalization rates and favorable clinical outcomes.

Preoperative spinal tumor embolization: an institutional experience with Onyx.

BACKGROUND: Preoperative embolization has the potential to decrease intraoperative blood loss and facilitate spinal cord decompression and tumor resection. OBJECTIVE: We report our institutional experience with the embolization of hypervascular extradural spinal tumors with Onyx as well as earlier embolic agents in a series of 28 patients. METHODS: A retrospective case review was conducted on patients undergoing preoperative transarterial embolization of a spinal tumor between 1995 and 2012 at our institution. RESULTS: Twenty-eight patients met the inclusion criteria, with a mean age of 60.6 years. Twenty-eight patients had metastatic tumors. In 14 (50%) patients the metastases were from renal cell carcinomas. Fifty-four vessels were embolized using PVA, NBCA, Onyx, coils, or embospheres. Sixteen patients were treated with Onyx, 6 patients with PVA, 3 patients with embospheres, 2 patients with NBCA, and 3 patients with a combination of embolic agents. The average decrease in tumor blush was 97.8% with Onyx versus 92.7% with the rest of the embolic agents (p=0.08). The estimated blood loss was 1616ml (range 350-5000ml). Blood loss was 750cm(3) on average with Onyx versus 1844 with the rest of the embolic agents (p=0.14). The mean length of stay was 16 days. The mortality rate was zero. Pre- and post-operative modified Rankin Score (mRS) did not differ significantly in the series (3.12 versus 3.10, respectively, p=0.9). CONCLUSION: In our experience, the use of transarterial tumor embolization as an adjunct for spinal surgery is a safe and feasible option.

Safety and efficacy of intraoperative angiography in craniotomies for cerebral aneurysms and arteriovenous malformations: a review of 1093 consecutive cases.

BACKGROUND: In an era of indocyanine angiography, the routine use of intraoperative angiography (IOA) in the surgical treatment of aneurysms and vascular malformations is controversial. OBJECTIVE: To retrospectively assess the safety and efficacy of IOA and to determine predictors of surgical revision. METHODS: Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 101 arteriovenous malformations (AVMs), and 16 arteriovenous fistulas. RESULTS: In 80 of 976 aneurysms (8.2%), IOA prompted clip repositioning. The reason for readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both in 2.4% of cases. In multivariate analysis, increasing aneurysm size (P, .001), ruptured aneurysm (P, .001), and increasing number of vessels injected (P, .001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (P = .06). IOA revealed residual nidus/ fistula requiring further intervention in 9 of 101 AVMs (8.9%) and 3 of 16 arteriovenous fistulas (18.8%). Of 9 AVMs requiring a surgical revision, 2 (22.2%) were Spetzler-Martin grade II, 5 (55.6%) were grade III, and 2 (22.2%) were grade IV. Mean Spetzler-Martin grade was 3.0 in AVMs requiring surgical revision compared with 2.3 in those not requiring revision (P = .05). IOA-related complications were all transient or minor and occurred in 0.99% of patients; none resulted in permanent morbidity. CONCLUSION: IOA remains a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in .8% of cases. Easy access to an angiographer and routine use of IOA are important factors contributing to procedural safety and efficacy.

Treatment of endovascular coil and stent migration using the merci retriever: report of three cases.

Background. Coil and stent migration is a potentially catastrophic complication in endovascular neurosurgery, which may lead to cerebral thromboembolism. Techniques for removing migrated coil and stent are not well established. Methods and Results. We present three cases in which coil or stent migration occurred during endovascular embolization of a cerebral aneurysm. The Merci Retrievers were used successfully in all cases to remove the displaced foreign bodies. Technical details are described. Conclusion. The Merci Retriever device can be utilized successfully for removal of migrated coils and stents in endovascular neurosurgery.

Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65 patients.

BACKGROUND: Stent-assisted coiling in the setting of subarachnoid hemorrhage remains controversial. Currently, there is a paucity of data regarding the utility of this procedure and the risks of hemorrhagic and ischemic complications. OBJECTIVE: To assess the utility of stent-assisted coil embolization and pretreatment with antiplatelet agents in the management of ruptured wide-necked aneurysms. METHODS: A retrospective study of 65 patients with ruptured wide-necked aneurysms treated with stent-assisted coiling. Patients with hydrocephalus or a Hunt and Hess grade ≥ III received a ventriculostomy before endovascular intervention. Patients were treated intraoperatively with 600 mg of clopidogrel and maintained on daily doses of 75 mg of clopidogrel and 81 mg of aspirin. The Glasgow outcome scale (GOS) score was recorded at the time of discharge. We identified major bleeding complications secondary to antiplatelet therapy and cases of in-stent thrombosis that required periprocedural thrombolysis. RESULTS: Of the aneurysms, 66.2% arose within the anterior circulation; 69.2% of patients presented with hydrocephalus or a Hunt and Hess grade ≥ III and required a ventriculostomy. A good outcome (GOS of 4 or 5) was achieved in 63.1% of patients, and the overall mortality rate was 16.9%. There were 10 (15.38%) major complications associated with bleeding secondary to antiplatelet therapy (5 patients, 7.7%) or intraoperative in-stent thrombosis (5 patients, 7.7%). Three (4.6%) patients had a fatal hemorrhage. CONCLUSION: Our findings suggest that stent-assisted coiling and routine treatment with antiplatelet agents is a viable option in the management of ruptured wide-necked aneurysms.