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2.
Neurosurg Focus ; 52(5): E8, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35535823

RESUMO

OBJECTIVE: Neurocutaneous melanocytosis (NCM), also referred to as neurocutaneous melanosis, is a rare neurocutaneous disorder characterized by excess melanocytic proliferation in the skin, leptomeninges, and cranial parenchyma. NCM most often presents in pediatric patients within the first 2 years of life and is associated with high mortality due to proliferation of melanocytes in the brain. Prognosis is poor, as patients typically die within 3 years of symptom onset. Due to the rarity of NCM, there are no specific guidelines for management. The aims of this systematic review were to investigate approaches toward diagnosis and examine modern neurosurgical management of NCM. METHODS: A systematic review was performed using the PubMed database between April and December 2021 to identify relevant articles using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search criteria were created and checked independently among the authors. Inclusion criteria specified unique studies and case reports of NCM patients in which relevant neurosurgical management was considered and/or applied. Exclusion criteria included studies that did not report associated neurological diagnoses and neuroimaging findings, clinical reports without novel observations, and those unavailable in the English language. All articles that met the study inclusion criteria were included and analyzed. RESULTS: A total of 26 extracted articles met inclusion criteria and were used for quantitative analysis, yielding a cumulative of 74 patients with NCM. These included 21 case reports, 1 case series, 2 retrospective cohort studies, 1 prospective cohort study, and 1 review. The mean patient age was 16.66 years (range 0.25-67 years), and most were male (76%). Seizures were the most frequently reported symptom (55%, 41/74 cases). Neurological diagnoses associated with NCM included epilepsy (45%, 33/74 cases), hydrocephalus (24%, 18/74 cases), Dandy-Walker malformation (24%, 18/74 cases), and primary CNS melanocytic tumors (23%, 17/74 cases). The most common surgical technique was CSF shunting (43%, 24/56 operations), with tethered cord release (4%, 2/56 operations) being the least frequently performed. CONCLUSIONS: Current management of NCM includes CSF shunting to reduce intracranial pressure, surgery, chemotherapy, radiotherapy, immunotherapy, and palliative care. Neurosurgical intervention can aid in the diagnosis of NCM through tissue biopsy and resection of lesions with surgical decompression. Further evidence is required to establish the clinical outcomes of this rare entity and to describe the diverse spectrum of intracranial and intraspinal abnormalities present.


Assuntos
Melanose , Síndromes Neurocutâneas , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Imageamento por Ressonância Magnética , Masculino , Melanose/complicações , Melanose/patologia , Melanose/cirurgia , Pessoa de Meia-Idade , Síndromes Neurocutâneas/complicações , Síndromes Neurocutâneas/diagnóstico por imagem , Síndromes Neurocutâneas/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Adulto Jovem
3.
World Neurosurg ; 161: 90, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35114408

RESUMO

Pericallosal artery aneurysms are rare, accounting for 2%-9% of all intracranial aneurysms. They are most commonly saccular and wide necked. Although typically small, they are more prone to rupture compared with other aneurysms in the anterior circulation. They are more common in people with unpaired or azygous arteries. Rupture of pericallosal artery aneurysm results in intracerebral hematoma in approximately 50% of patients, usually in the frontal lobe, anterior interhemispheric fissure, pericallosal cistern, or cingulate gyrus. Compared with other supratentorial aneurysms, surgical clipping of pericallosal aneurysms carries a higher morbidity and mortality. A 47-year-old female presented with sudden-onset worst headache of her life followed by dizziness, syncope, transient weakness, and numbness over the left lower extremity. She was neurologically intact, and imaging revealed a right pericallosal artery aneurysm. The patient consented to the procedure. The 2-dimensional Video 1 demonstrates the interhemispheric approach for clipping of a pericallosal artery aneurysm. These aneurysms are approached in the distal-to-proximal direction along with the distal anterior cerebral artery. Meticulous dissection avoids rupture without proximal control. We highlight the key surgical steps and microsurgical techniques in approaching these aneurysms. The patient tolerated the operation well with an uneventful postoperative course.


Assuntos
Artéria Cerebral Anterior , Aneurisma Intracraniano , Artéria Cerebral Anterior/diagnóstico por imagem , Artéria Cerebral Anterior/cirurgia , Artérias , Tronco Braquiocefálico , Dissecação , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Pessoa de Meia-Idade
4.
World Neurosurg ; 161: e126-e133, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35093577

RESUMO

OBJECTIVE: Although several commercially available sutureless anastomotic techniques are available, they are not routinely used in neurosurgery. We performed an in vivo flow analysis of end-to-end anastomosis using a microvascular coupler device in rats. We report our first clinical use of the microvascular anastomotic coupler. METHODS: Bilateral rat common carotid arteries (CCAs) were exposed, and a microvascular coupler was used to perform 8 anastomoses. A microflow probe provided quantitative measurement of blood-flow volume. Flow augmentation was assessed with end-to-side anastomoses connecting the distal CCA to the jugular vein (JV). A patient with chronic dominant hemisphere atherosclerotic ischemic disease and progressive symptoms refractory to medical management underwent end-to-end cerebral artery bypass using the microvascular coupler. RESULTS: Mean preanastomosis flow in the rat CCA was 3.95 ± 0.45 mL/min; this flow was maintained at 3.99 ± 0.24 mL/min on final measurements 54-96 minutes postanastomosis. Total occlusion time for each rat CCA was 12-19 minutes. After end-to-side anastomosis, with proximal and distal JV patent, CCA flow increased 477% to 22.8 ± 3.70 mL/min (P = 0.04, proximal; P = 0.01, distal). After in vivo testing, we successfully used the coupler clinically in a superficial temporal artery-to-middle cerebral artery bypass for dominant hemisphere flow augmentation. CONCLUSIONS: In vivo quantitative flow analysis demonstrated no flow difference between an unaltered artery and artery with end-to-end anastomosis using a microvascular coupler in rats. A 1-mm coupled anastomosis achieved a 4-fold flow increase with low-resistance venous outflow in rats, simulating increased arterial demand. The coupler was successfully used for extracranial-to-intracranial bypass in a patient.


Assuntos
Artérias Temporais , Procedimentos Cirúrgicos Vasculares , Anastomose Cirúrgica/métodos , Animais , Humanos , Microcirurgia , Artéria Cerebral Média/cirurgia , Ratos , Artérias Temporais/cirurgia
5.
J Neurointerv Surg ; 14(4): 397-402, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34083399

RESUMO

BACKGROUND: Transradial arterial access (TRA) for cerebral diagnostic angiography is associated with fewer access site complications than transfemoral access (TFA). However, concerns about increased procedure time and radiation exposure with TRA may slow its adoption. Our objective was to measure TRA rates of success and fluoroscopy time per vessel after 'radial-first' adoption and to compare these rates to those obtained with TFA. METHODS: We examined 500 consecutive cerebral angiograms on an intent-to-treat basis during the first full year of radial-first adoption, recording patient and procedural characteristics and outcomes. RESULTS: Over a 9-month period at a single center, 457 of 500 angiograms (91.4%) were performed with intent-to-treat via TRA, and 431 cases (86.2%) were ultimately performed via TRA. One patient (0.2%) experienced a temporary neurologic deficit in the TRA group, and none (0%) did in the TFA group (p=0.80). The mean±SD fluoroscopy time per vessel decreased significantly from the first half of the study to the second half for TRA (5.0±3.8 vs 3.4±3.5 min/vessel; p<0.001), while TFA time remained unchanged (3.7±1.8 vs 3.5±1.4 min/vessel; p=0.69). The median fluoroscopy time per vessel for TRA became faster than that for TFA after 150 angiograms. CONCLUSION: Of 500 consecutive angiograms performed during the first full year of radial-first implementation, 86.2% were performed successfully using TRA. TRA efficiency exceeded that of TFA after 150 angiograms. Concerns about the length of procedure or radiation exposure should not be barriers to TRA adoption.


Assuntos
Artéria Femoral , Exposição à Radiação , Angiografia Cerebral/métodos , Artéria Femoral/diagnóstico por imagem , Fluoroscopia/efeitos adversos , Humanos , Artéria Radial/diagnóstico por imagem , Resultado do Tratamento
6.
J Neurointerv Surg ; 14(3): 257-261, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33906940

RESUMO

BACKGROUND: The ideal treatment for unruptured vertebral artery dissecting aneurysms (VADAs) and ruptured dominant VADAs remains controversial. We report our experience in the management and endovascular treatment of patients with VADAs. METHODS: Patients treated endovascularly for intradural VADAs at a single institution from January 1, 1999, to December 31, 2019, were retrospectively reviewed. Primary neurological outcomes were assessed using modified Rankin Scale (mRS) scores, with mRS >2 considered a poor neurological outcome. Additionally, any worsening (increase) in the mRS score from the preoperative neurological examination was considered a poor outcome. RESULTS: Ninety-one patients of mean (SD) age 53 (11.6) years (48 (53%) men) underwent endovascular treatment for VADAs. Fifty-four patients (59%) presented with ruptured VADAs and 44 VADAs (48%) involved the dominant vertebral artery. Forty-seven patients (51%) were treated with vessel sacrifice of the parent artery, 29 (32%) with flow diversion devices (FDDs), and 15 (17%) with stent-assisted coil embolization (stent/coil). Rates of procedural complications and retreatment were significantly higher with stent/coil treatment (complications 4/15; retreatment 6/15) than with vessel sacrifice (complications 1/47; retreatment 2/47) or FDD (complications 2/29; retreatment 4/29) (p=0.008 and p=0.002, respectively). Of 37 patients with unruptured VADAs treated, only two (5%) had mRS scores >2 on follow-up. CONCLUSION: Endovascular FDD treatment of VADAs appears to be associated with lower retreatment and complication rates than stenting/coiling, although further study is required for confirmation. Endovascular treatment of unruptured VADAs was safe and was associated with favorable angiographic and neurological outcomes.


Assuntos
Aneurisma Roto , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Dissecação da Artéria Vertebral , Aneurisma Roto/terapia , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do Tratamento , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/cirurgia , Dissecação da Artéria Vertebral/diagnóstico por imagem , Dissecação da Artéria Vertebral/cirurgia
7.
Clin Neurol Neurosurg ; 210: 107008, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34775364

RESUMO

Terson's Syndrome describes intraocular hemorrhage secondary to an acutely raised intracranial pressure (ICP). Although Terson's Syndrome is common amongst patients with subarachnoid hemorrhage (SAH), it is underdiagnosed and often overlooked. This review discusses the current understanding of the etiopathogenesis, clinical features, and management of Terson's Syndrome and highlights the visual and prognostic implications to stress the importance of timely diagnosis and management. The origin of intraocular hemorrhage in Terson's Syndrome has been debated. A recognized theory suggests that an acutely raised ICP induces effusion of cerebrospinal fluid into the optic nerve sheath which dilates the retrobulbar aspect of the sheath in the orbit. Dilatation mechanically compresses the central retinal vein and retinochoroidal veins resulting in venous hypertension and rupture of thin retinal vessels. A commonly reported clinical feature is decreased visual acuity and blurred vision. These may be accompanied by symptoms of increased ICP including loss of consciousness and headache. Diagnosis is established using evidence from the clinical presentation, ophthalmoscopy, and, when required, imaging including B-mode ultrasound, CT, MRI, and fluorescein angiography. Terson's Syndrome is managed conservatively by observation for mild cases and with vitrectomy for bilateral cases and for patients whose hemorrhage has not spontaneously resolved after an observational period. Terson's Syndrome can be used as a prognostic indicator of morbidity and mortality in underlying pathology like SAH. Fundoscopy of patients with SAH, acutely raised ICP or visual disturbance with unknown etiology can help establish a timely Terson's Syndrome diagnosis. This may avoid the risk of permanent visual impairment.


Assuntos
Gerenciamento Clínico , Pressão Intracraniana/fisiologia , Hemorragia Vítrea/diagnóstico por imagem , Hemorragia Vítrea/terapia , Tratamento Conservador/métodos , Humanos , Procedimentos Neurocirúrgicos/métodos , Oftalmoscopia , Transtornos da Visão/diagnóstico por imagem , Transtornos da Visão/fisiopatologia , Transtornos da Visão/terapia , Acuidade Visual/fisiologia , Hemorragia Vítrea/fisiopatologia
8.
World Neurosurg ; 2021 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-34775085

RESUMO

BACKGROUND: The coronavirus disease 2019 pandemic necessitated the use of telemedicine for most medical specialties, including neurosurgery, although before the pandemic, neurosurgeons infrequently used telemedicine for outpatient visits. We conducted a patient-centric evaluation of telemedicine in our endovascular neurosurgery practice, covering a 4-month period early in the pandemic. METHODS: Survey e-mails after telemedicine visits were sent to all patients who underwent an outpatient telemedicine visit between March 11, 2020, and June 22, 2020, at an endovascular neurosurgery clinic affiliated with a tertiary care center. RESULTS: Of 140 patients, 65 (46%) completed the e-mail survey. Of the 65 respondents, 35 (54%) agreed or strongly agreed with the statement that even before their telemedicine experience, they thought telemedicine would be a convenient way to receive a neurological consultation. After their telemedicine visit, 47 (72%) agreed or strongly agreed with this statement, and 28 (43%) agreed or strongly agreed that they would prefer telemedicine for future visits. Of the 65 respondents, 61 (94%) rated their telemedicine visit as average or better: 34 (52%) rated it excellent, 12 (18%) rated it above average, and 15 (23%) rated it average. When patients compared their telemedicine visit with a prior in-person clinic visit, only 10 of 44 patients (23%) thought the telemedicine visit was more complicated than an in-person visit, and 21 of 44 (48%) said they would prefer telemedicine for future visits. CONCLUSIONS: Our patients expressed satisfaction with their telemedicine visits, and telemedicine will likely play an important role in future outpatient endovascular neurosurgery consultations.

9.
J Neurosurg ; : 1-6, 2021 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-34653974

RESUMO

OBJECTIVE: Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings. METHODS: The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications. RESULTS: A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications. CONCLUSIONS: Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

10.
Pediatr Neurosurg ; 56(6): 584-590, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34614493

RESUMO

INTRODUCTION: Pediatric vein of Galen malformations (VOGMs) are fistulous intracranial malformations arising congenitally within the choroidal fissure that can present with an array of neurological and cardiac sequelae. Associated venous stenosis may result in intracranial venous hypertension and ischemia leading to severe, irreversible cerebral injury. Management of neonatal VOGMs typically involves staged embolization and angioplasty/stenting for relief of venous stenosis. Rarely, jugular foraminal narrowing has been identified as causing jugular bulb stenosis. CASE PRESENTATION: We present the case of a 22-month-old female diagnosed with VOGM prenatally who displayed persistent intracranial venous hypertension despite multiple neuroembolization procedures during the neonatal period. Following initial reduction in arteriovenous shunting, she once again developed venous hypertension secondary to jugular bulb stenosis for which angioplasty was attempted. Failure of angioplasty to relieve the venous hypertension prompted skull base imaging, which revealed jugular foraminal ossification and stenosis. Microsurgical jugular foraminotomy followed by balloon angioplasty and stenting significantly reduced jugular pressure gradients. Restenosis requiring re-stenting developed postoperatively at 9 months, but the patient has remained stable with significant improvement in cortical venous congestion. DISCUSSION/CONCLUSION: This case demonstrates the efficacy of microsurgical decompression of the jugular foramen and endovascular angioplasty/stenting as a novel treatment paradigm for the management of intracranial venous hypertension in the setting of VOGM.


Assuntos
Veias Cerebrais , Embolização Terapêutica , Hipertensão Intracraniana , Malformações da Veia de Galeno , Criança , Constrição Patológica/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , Malformações da Veia de Galeno/diagnóstico por imagem , Malformações da Veia de Galeno/cirurgia
11.
Brain Circ ; 7(2): 65-70, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34189348

RESUMO

BACKGROUND: The transfemoral approach (TFA) has been the traditional approach for neurointerventional cases. While the TFA allows for triaxial support in flow diverting stent cases, it is associated with access site complications. Recently, the transradial approach (TRA) has emerged as a safer alternative to the TFA. To the best of our knowledge, there have only been single-center studies comparing outcomes in flow diverter cases for these approaches. We demonstrate the safety and feasibility of the TRA for placement of flow diverting stents in the treatment of unruptured intracranial aneurysms at two high-volume centers. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected institutional databases at two high-volume neuroendovascular centers. Cases from 2016 to 2018 of unruptured intracranial aneurysms treated by flow diverting stenting accessed through either the TRA or the TFA were compared. Patient demographics, procedural and radiographic metrics including location and size of the aneurysm, size, and length of the flow diverter implant, and fluoroscopic time were recorded. Puncture site complications and length of hospital stay were also included in the data analysis. RESULTS: There were three out of 29 TRA cases which were converted to the TFA. None of the TRA patients experienced site complications, whereas three TFA patients experienced site complications. While TRA and TFA patients did not differ significantly in their exposure to radiation, TRA patients experienced shorter hospital stays. CONCLUSIONS: While long-term studies are still lacking regarding this approach, we demonstrate that the TRA is a safe and feasible approach for flow diverter stent placement.

12.
J Neurosurg ; : 1-6, 2021 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-33636706

RESUMO

OBJECTIVE: Middle meningeal artery (MMA) embolization is a promising treatment strategy for chronic subdural hematomas (cSDHs). However, studies comparing MMA embolization and conventional therapy (surgical intervention and conservative management) are limited. The authors aimed to compare MMA embolization versus conventional therapy for cSDHs using a propensity-adjusted analysis. METHODS: A retrospective study of all patients with cSDH who presented to a large tertiary center over a 2-year period was performed. MMA embolization was compared with surgical intervention and conservative management. Neurological outcome was assessed using the modified Rankin Scale (mRS). A propensity-adjusted analysis compared MMA embolization versus surgery and conservative management for all individual cSDHs. Primary outcomes included change in hematoma diameter, treatment failure, and complete resolution at last follow-up. RESULTS: A total of 231 patients with cSDH met the inclusion criteria. Of these, 35 (15%) were treated using MMA embolization, and 196 (85%) were treated with conventional treatment. On the latest follow-up, there were no statistically significant differences between groups in the percentage of patients with worsening mRS scores. Of the 323 total cSDHs found in 231 patients, 41 (13%) were treated with MMA embolization, 159 (49%) were treated conservatively, and 123 (38%) were treated with surgical evacuation. After propensity adjustment, both surgery (OR 12, 95% CI 1.5-90; p = 0.02) and conservative therapy (OR 13, 95% CI 1.7-99; p = 0.01) were predictors of treatment failure and incomplete resolution on follow-up imaging (OR 6.1, 95% CI 2.8-13; p < 0.001 and OR 5.4, 95% CI 2.5-12; p < 0.001, respectively) when compared with MMA embolization. Additionally, MMA embolization was associated with a significant decrease in cSDH diameter on follow-up relative to conservative management (mean -8.3 mm, 95% CI -10.4 to -6.3 mm, p < 0.001). CONCLUSIONS: This propensity-adjusted analysis suggests that MMA embolization for cSDH is associated with a greater extent of hematoma volume reduction with fewer treatment failures than conventional therapy.

13.
Clin Neurol Neurosurg ; 202: 106539, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33601270

RESUMO

OBJECTIVE: The management of traumatic pseudoaneurysm (PA) with concomitant arteriovenous fistula (AVF) arising from the thyrocervical trunk is challenging and rarely reported. Here, the usefulness of a multi-modal endovascular strategy for management of traumatic PA and AVF arising from the thyrocervical trunk is presented. A literature review describing unique clinical features and management strategies of traumatic vascular lesions of the thyrocervical trunk is included. METHODS: A 58-year-old man presented with two PAs arising from the ascending cervical artery (AsCA) and a robust AVF between the AsCA and the left vertebral venous plexus which arose acutely after a stabbing incident. These lesions were managed with endovascular vessel sacrifice via coiling and controlled Onyx injection. Relevant literature was identified via a targeted search of the PubMed database. RESULTS: Post-management angiography demonstrated complete occlusion of the two traumatic PAs and successful disconnection of the concomitant AVF. Our literature review demonstrates a shift in preferred management approach from invasive surgery to endovascular treatment due to the lower risk and cosmetic preferability. CONCLUSION: Timely treatment of enlarging PA is necessary for reducing associated morbidity and mortality. While surgical resection has been the mainstay therapy, endovascular management has gained popularity in recent years. The choice of endovascular technique is variable and should be individualized based on patient's clinical status, associated risk factors, and lesion morphology. We have shown that parent vessel sacrifice is safe and effective. Reconstruction with a combination of stents, coils, glue, or liquid embolics may be necessary when collateral flow is limited.


Assuntos
Falso Aneurisma/terapia , Fístula Arteriovenosa/terapia , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Lesões do Pescoço/terapia , Lesões do Sistema Vascular/terapia , Ferimentos Perfurantes/terapia , Falso Aneurisma/diagnóstico por imagem , Angiografia Digital , Fístula Arteriovenosa/diagnóstico por imagem , Terapia Combinada , Angiografia por Tomografia Computadorizada , Humanos , Masculino , Pessoa de Meia-Idade , Lesões do Pescoço/diagnóstico por imagem , Artéria Subclávia , Lesões do Sistema Vascular/diagnóstico por imagem
14.
Neurosurgery ; 88(6): E505-E509, 2021 05 13.
Artigo em Inglês | MEDLINE | ID: mdl-33582816

RESUMO

BACKGROUND: Transradial artery (TRA) catheterization for neuroendovascular procedures is associated with a lower risk of complications than transfemoral artery (TFA) procedures. However, the majority of literature on TRA access pertains to diagnostic procedures rather than interventional treatments. OBJECTIVE: To compare TRA and TFA approaches for cerebrovascular interventions. METHODS: All patients with an endovascular intervention performed at a single center from October 1, 2018 to December 31, 2019 were retrospectively analyzed. Patients were grouped into 2 cohorts on the basis of whether TRA or TFA access was used. Outcomes included complications, fluoroscopy times, and total contrast administered. RESULTS: A total 579 interventional treatments were performed during the 15-mo study period. TFA procedures (n = 417) were associated with a significantly higher complication rate than TRA (n = 162) procedures (43 cases [10%] vs 5 cases [3%]; P = .008). After excluding patients who underwent thrombectomy and performing a propensity adjustment (including age, sex, pathology, procedure, sheath size, and catheter size), TRA catheterization was associated with decreased odds of a complication (odds ratio, 0.25; 95% CI 0.085-0.72; P = .01), but no significant difference in the amount of contrast administered (6.7-mL increase; 95% CI, -7.2 to 20.6; P = .34) or duration of fluoroscopy (2.1-min increase; 95% CI, -2.5 to 6.7; P = .37) compared with TFA catheterization. CONCLUSION: Neurointerventional procedures and treatments for a variety of pathologies can be performed successfully using the TRA approach, which is associated with a lower risk of complications and no difference in fluoroscopy duration compared with the TFA approach.


Assuntos
Cateterismo Periférico/métodos , Transtornos Cerebrovasculares/terapia , Procedimentos Endovasculares/métodos , Artéria Femoral/cirurgia , Artéria Radial/cirurgia , Idoso , Estudos de Casos e Controles , Feminino , Fluoroscopia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
16.
Neurosurgery ; 88(5): 996-1002, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33427287

RESUMO

BACKGROUND: Spetzler-Martin (SM) grade III arteriovenous malformations (AVMs) are at the boundary of safe operability, and preoperative embolization may reduce surgical risks. OBJECTIVE: To evaluate the benefits of preoperative AVM embolization by comparing neurological outcomes in patients with grade III AVMs treated with or without preoperative embolization. METHODS: All microsurgically treated grade III AVMs were identified from 2011 to 2018 at 2 medical centers. Neurological outcomes, measured as final modified Rankin Scale scores (mRS) and changes in mRS from preoperative baseline to last follow-up evaluation, were compared in patients with and without preoperative embolization. RESULTS: Of the 102 patients with grade III AVMs who were treated microsurgically, 57 (56%) underwent preoperative embolization. Significant differences were found between the patients with and without embolization in AVM eloquence (74% vs 93%, P = .02), size ≥ 3 cm (47% vs 73%, P = .01), diffuseness (7% vs 22%, P = .04), and mean final mRS (1.1 vs 2.0, P = .005). Poor outcomes were more frequent in patients without embolization (38%) than with embolization (7%) (final mRS > 2; P < .001). Propensity-adjusted analysis revealed AVM resection without embolization was a risk factor for poor outcome (mRS score > 2; odds ratio, 4.2; 95% CI, 1.1-16; P = .03). CONCLUSION: Nonembolization of SM grade III AVMs is associated with an increased risk of poor neurological outcomes after microsurgical resection. Preoperative embolization of intermediate-grade AVMs selected because of large AVM size, surgical inaccessibility of feeding arteries, and high flow should be employed more often than anticipated, even in the context of increasing microsurgical experience with AVMs.


Assuntos
Embolização Terapêutica , Malformações Arteriovenosas Intracranianas/terapia , Microcirurgia , Cuidados Pré-Operatórios , Humanos , Procedimentos Neurocirúrgicos , Complicações Pós-Operatórias , Pontuação de Propensão , Resultado do Tratamento
17.
J Neurointerv Surg ; 13(7): 614-618, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32958518

RESUMO

BACKGROUND: Both stentriever and direct-aspiration thrombectomy effectively treat large-vessel occlusions. However, data are limited comparing clinical outcomes after aspiration-first versus stentriever-assisted aspiration for thrombectomy. METHODS: A retrospective cohort study compared procedure times and radiographic outcomes after two mechanical thrombectomy techniques (aspiration first or stentriever). To minimize bias and variability inherent to multi-operator series, we assessed consecutive patients with cerebrovascular occlusions treated by a single surgeon during a 1 year period at two stroke centers. Expanded Thrombolysis in Cerebral Infarction (eTICI) grades were assessed by an investigator blinded to treatment. RESULTS: Data from 93 patients (median age 70 years) were analyzed: 73 patients (78.5%) were treated with a strentriever-first strategy and 20 (21.5%) were treated with aspiration first, with stentriever rescue therapy required in only three of these cases following unsuccessful aspiration. There were no significant differences in patient demographics, sites of occlusion, or rates of tandem occlusions between aspiration-first and stentriever-assisted groups (p≥0.36). The rate of first-pass eTICI ≥2b was 75.0% (15/20) for aspiration-first and 52.1% (38/73) for strentriever-first groups (p=0.07), while the rate of final eTICI ≥2b was 100% (20/20) and 82.2% (60/72), respectively (p=0.04). The aspiration-first technique was associated with procedural times ≤25 min in a multivariable analysis (adjusted OR 4.77, 95% CI 1.15 to 18.39; p=0.03). CONCLUSIONS: In this single-surgeon series, an aspiration-first technique was associated with a statistically significant improvement in eTICI outcomes and faster procedure times compared with stentriever-assisted aspiration. Further prospective studies are necessary to minimize selection bias inherent in this study design.


Assuntos
Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/cirurgia , Paracentese/métodos , Stents , Trombectomia/métodos , Dispositivos de Acesso Vascular , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
18.
J Neurointerv Surg ; 13(8): 752-754, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33106321

RESUMO

BACKGROUND: Transradial artery (TRA) access for neuroendovascular procedures is associated with fewer complications than transfemoral artery (TFA) access. This study compares hospital costs associated with TRA access to those associated with TFA access for neurointerventions. METHODS: Elective neuroendovascular procedures at a single center were retrospectively analyzed from October 1, 2018 to May 31, 2019. Hospital costs for each procedure were obtained from the hospital financial department. The primary outcome was the difference in the mean hospital costs after propensity adjustment between patients who underwent TRA compared with TFA access. RESULTS: Of the 338 elective procedures included, 63 (19%) were performed through TRA versus 275 (81%) through TFA access. Diagnostic procedures were more common in the TRA cohort (51 of 63, 81%) compared with the TFA cohort (197 of 275, 72%), but the difference was not significant (p=0.48). The TRA cohort had a shorter length of hospital stay (mean (SD) 0.3 (0.5) days) compared with the TFA cohort (mean 0.7 (1.3) days; p=0.02) and lower hospital costs (mean $12 968 ($6518) compared with the TFA cohort (mean $17 150 ($10 946); p=0.004). After propensity adjustment for age, sex, symptoms, angiographic findings, procedure type, sheath size, and catheter size, TRA access was associated with a mean hospital cost of $2514 less than that for TFA access (95% CI -$4931 to -$97; p=0.04). CONCLUSION: Neuroendovascular procedures performed through TRA access are associated with lower hospital costs than TFA procedures. The lower cost is likely due to a decreased length of hospital stay for TRA.


Assuntos
Cateterismo Periférico/economia , Transtornos Cerebrovasculares/cirurgia , Procedimentos Endovasculares/economia , Artéria Femoral/cirurgia , Tempo de Internação/economia , Artéria Radial/cirurgia , Angiografia/métodos , Cateterismo Periférico/métodos , Transtornos Cerebrovasculares/epidemiologia , Custos e Análise de Custo , Procedimentos Endovasculares/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
19.
J Neurointerv Surg ; 13(7): 657-660, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33077579

RESUMO

BACKGROUND: Recently, middle meningeal artery (MMA) embolization has emerged as a potentially safe and effective method of treating chronic subdural hematoma (cSDH). OBJECTIVE: To report a single-center experience with MMA embolization and examines the type of embolic material used, the extent of penetration, and the number of MMA branches embolized. METHODS: A retrospective analysis of all patients with MMA embolization from 2018 through 2019 was performed. A failed outcome was defined as either surgical rescue and/or greater than 10 mm of hematoma residual or reaccumulation following embolization. RESULTS: Of 35 patients, surgery had failed for 9 (26%) and initial conservative treatment had failed for 6 (17%). Of 41 MMA embolizations, including those in six patients with bilateral cSDH who underwent bilateral MMA embolization, 29 (72%) were performed using ethylene vinyl alcohol copolymer (Onyx), 7 (17%) using particles, and 5 (12%) using n-butyl cyanoacrylate. Both the anterior and posterior MMA divisions were embolized in 29 cases (71%); distal penetration of these branches was achieved in 25 embolizations (61%). Twenty-six (63%) cSDHs completely resolved. Complete resolution was seen in 22 of 29 hematomas (76%) in which both anterior and posterior MMA branches were occluded versus 4 of 12 (33%) following single-branch embolization (p=0.014). Embolization of one cSDH (2%) failed. CONCLUSION: MMA embolization of cSDHs appears to be both safe and efficacious. Furthermore, embolization of both the anterior and posterior MMA branches may be associated with increased odds of complete resolution.


Assuntos
Embolização Terapêutica/métodos , Embucrilato/administração & dosagem , Hematoma Subdural Crônico/diagnóstico por imagem , Hematoma Subdural Crônico/terapia , Artérias Meníngeas/diagnóstico por imagem , Polivinil/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Hematoma Subdural Crônico/cirurgia , Humanos , Masculino , Artérias Meníngeas/cirurgia , Pessoa de Meia-Idade , Estudos Retrospectivos
20.
J Neurointerv Surg ; 13(10): 942-945, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33303697

RESUMO

BACKGROUND: Radial artery occlusion (RAO) occurs in 1% to 10% of cases following transradial arterial access (TRA) for neuroendovascular procedures. When repeat access is required in patients discovered to have RAO, a transfemoral approach is often used. This study reports experience with repeat TRA procedures at a single center and techniques for reaccessing an occluded radial artery in select patients. METHODS: The electronic records of all patients who underwent multiple neuroendovascular procedures with an attempted TRA as the index procedure at a single center from July 2019 through February 2020 were reviewed. RESULTS: There were 656 TRA attempts for diagnostic angiography or intervention from July 2019 through February 2020. A total of 106 patients underwent a repeated attempt at TRA. Techniques for reaccessing an occluded radial artery were implemented halfway through the study period. One hundred patients (94.3%) had a successful second radial catheterization. Six patients required conversion to a transfemoral approach: five for RAO and one for radial branch perforation during the index procedure. After we implemented our techniques for reaccess, four additional patients with RAO successfully underwent TRA. There were no short-term complications, including pain, vessel perforation, forearm hematoma, or hand ischemia, following successful repeat catheterization of a previously occluded radial artery. CONCLUSION: RAO is not an absolute limitation for attempting TRA in patients undergoing repeat catheterization. Reaccessing the radial artery after occlusion is feasible for repeat neuroendovascular procedures.


Assuntos
Arteriopatias Oclusivas , Artéria Radial , Angiografia , Humanos , Artéria Radial/diagnóstico por imagem , Artéria Radial/cirurgia
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