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1.
J Stroke Cerebrovasc Dis ; 31(3): 106106, 2022 Jan 09.
Artigo em Inglês | MEDLINE | ID: mdl-35026494

RESUMO

BACKGROUND: Nonagenarians have been underrepresented in stroke trials that established endovascular treatment as the standard for acute ischemic stroke (AIS). Evidence remains inconclusive regarding the efficacy of thrombectomy in this population. OBJECTIVES: To report our experience with thrombectomy in nonagenarians with stroke, and to identify predictors of mortality. We further investigated the effects of first-pass reperfusion and the addition of intravenous thrombolysis (IVT) on achieving better outcomes. MATERIALS AND METHODS: Data was collected for consecutively treated patients at three affiliated comprehensive stroke centers from 2010 to 2021. We included patients ≥90 years-old with AIS secondary to large vessel occlusion. Bivariate analyses were performed using the Mann-Whitney U test for continuous variables, and χ2 and Fisher's exact tests, respectively, for nominal and ordinal variables. RESULTS: Thirty-two nonagenarians underwent thrombectomy, of whom 25 (81%) had prestroke mRS ≤2. Thrombectomies were performed using stents (2, 6.7%), aspiration (8, 26.7%), or a combination of both (20, 66.7%). Successful recanalization was achieved in 97%. Procedural complications occurred in 2 (6.3%) and intracranial hemorrhage in 3 (9.4%). Sixteen patients (50%) were discharged home or to rehabilitation, 9 (28.2%) to nursing home or hospice, and 7 (21.9%) died during hospitalization. Only 2 (6%) patients had mRS ≤2 at discharge. No independent predictors of in-hospital mortality were identified, and neither first-pass reperfusion nor the addition of IVT correlated with improvement in clinical outcome. CONCLUSIONS: Although thrombectomy is safe for nonagenarian stroke and can achieve excellent recanalization, high mortality and poor functional status remain high given the advanced age and frailty of this population.

2.
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
4.
Interv Neuroradiol ; : 15910199211039924, 2021 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-34516323

RESUMO

BACKGROUND: Congenital aortic arch anomalies are commonly encountered during neurointerventional procedures. While some anomalies are identified at an early age, many are incidentally discovered later in adulthood during endovascular evaluations or interventions. Proper understanding of the normal arch anatomy and its variants is pivotal to safely navigate normal aortic arch branches and to negotiate the catheter through anomalies during neurointerventional procedures. This is particularly relevant in the increasingly "transradial first" culture of neurointerventional surgery. Moreover, some of these anomalies have a peculiar predilection for complications including aneurysm formation, dissection, and rupture during the procedure. Therefore, an understanding of these anomalies, their underlying embryological basis and associations, and pattern of circulation will help endovascular neurosurgeons and interventional radiologists navigate with confidence and consider relevant pathologic associations that may inform risk of cerebrovascular disease. METHODS: Here, we present a brief review of the basic embryology of the common anomalies of the aortic arch along with their neurological significances and discuss, through illustrative cases, the association of aortic arch anomalies with cerebral vascular pathology. CONCLUSIONS: Understanding the aortic arch anomalies and its embryological basis is essential to safely navigate the cerebral vascular system during neurointerventional surgeries.

5.
Neurosurg Focus ; 51(3): E5, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34469865

RESUMO

OBJECTIVE: Moyamoya disease (MMD) is an intracranial steno-occlusive pathology characterized by progressive narrowing of proximal large vessels, including the terminal internal carotid arteries (ICAs), middle cerebral arteries, or anterior cerebral arteries. Named for the "puff of smoke" appearance of the anomalous vascularization visualized on cerebral angiography, MMD lacks a well-defined etiology, although significant insights have been made, including the identification of a susceptibility gene, RNF213, in humans with the disease. A limitation to advancing the understanding and treatment of MMD has been the lack of experimental animal models that authentically reflect the clinical pathogenesis. In an effort to analyze characteristics of currently available models and identify strategies for future model generation, the authors performed a scoping review of experimental animal models that have been used to study MMD. METHODS: A systematic search of PubMed, Web of Science, and Scopus was performed to identify articles describing animal models used to study MMD. Additional articles were identified via citation searching. Study selection and data extraction were performed by two independent reviewers based on defined inclusion and exclusion criteria. RESULTS: A total of 44 articles were included for full-text review. The methods used to generate these animal models were broadly classified as surgical (n = 25, 56.8%), immunological (n = 7, 15.9%), genetic (n = 6, 13.6%), or a combination (n = 6, 13.6%). Surgical models typically involved permanent ligation of one or both of the common carotid arteries or ICAs to produce chronic cerebral hypoperfusion. Genetic models utilized known MMD or cerebrovascular disease-related genes, such as RNF213 or ACTA2, to induce heritable cerebral vasculopathy. Finally, immunological models attempted to induce vasculitis-type pathology by recapitulating the inflammatory milieu thought to underlie MMD. CONCLUSIONS: Models generated for MMD have involved three general approaches: surgical, immunological, and genetic. Although each reflects a key aspect of MMD pathogenesis, the failure of any individual model to recapitulate the development, progression, and consequences of the disease underscores the importance of future work in developing a multietiology model.


Assuntos
Doença de Moyamoya , Adenosina Trifosfatases/genética , Animais , Predisposição Genética para Doença , Humanos , Modelos Animais , Doença de Moyamoya/genética , Doença de Moyamoya/cirurgia , Ubiquitina-Proteína Ligases/genética
7.
Pediatr Neurosurg ; 56(3): 274-278, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33789317

RESUMO

BACKGROUND: Knobloch syndrome (KS) is a rare autosomal recessive disorder associated with multiple ocular and cranial abnormalities. Occult occipital skull defect or encephalocele should raise suspicion of this disease. It is never reported in neurosurgical literature, possibly due to a lack of clinician familiarity, leading to underdiagnosis and inadequate management. Our patient also had seizures, which is a sporadic presentation of this syndrome. CASE DESCRIPTION: Here, we report a clinico-radiologic finding of a 7-year-old boy who presented with seizures, cataracts, and an occipital bone defect along with bilateral subependymal heterotopias and polymicrogyria. CONCLUSIONS: This case highlights the importance of consideration of this syndrome in children with a midline occipital bone defect with or without encephalocele and seizures. Early recognition of this presentation is critical for obtaining access to appropriate genetic counseling and subsequent monitoring and prevention of complications by surgical intervention.


Assuntos
Degeneração Retiniana , Descolamento Retiniano , Criança , Encefalocele/complicações , Encefalocele/diagnóstico por imagem , Encefalocele/cirurgia , Humanos , Masculino , Descolamento Retiniano/congênito , Convulsões/etiologia
8.
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.

9.
World Neurosurg ; 141: e213-e222, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32434019

RESUMO

BACKGROUND: The aftermath of the Affordable Care Act (ACA) witnessed the rise of narrow networks, which feature fewer providers in exchange for lower premiums. Debate still continues on whether narrow networks provide adequate access to health care, especially in specialty care services such as neurosurgery. The objective of this article was to analyze the 2019 Marketplace plans' impact on delivering outpatient neurosurgical care in New Jersey. METHODS: The 2019 Marketplace Public Use Files were queried for "silver" plans, identifying a total of 11 plans across 3 insurance companies. Online search engines were used to identify the number of in-network neurosurgeons within 20-25 miles of ZIP codes at the center of each county. The primary outcome was the number of neurosurgeon-deficient plans, defined as those having no in-network neurosurgeons within the assigned mile radius. RESULTS: Of all individuals who purchased an insurance plan, 73% (185,797/255,246) opted for a silver plan. Out of 111 active neurosurgeons in New Jersey, 25% (28/111) did not participate in any of the silver plans. Analysis showed 8 plans as neurosurgeon-deficient in Sussex and Warren. Meanwhile, most of the silver plans provided access to >5 neurosurgeons within 20-25 miles of most (17/21) county centers. CONCLUSIONS: In more densely populated states such as New Jersey, the impact of narrow networks on neurosurgical coverage is less apparent. However, frustrations regarding access to care still exist because nearly 25% of neurosurgeons do not participate in the standard ACA insurance product. Furthermore, guidelines that define network adequacy in neurosurgery remain elusive, which calls for more robust parameters to monitor and ensure adequate access to health care.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Humanos , Seguro Saúde/estatística & dados numéricos , Neurocirurgiões/estatística & dados numéricos , Neurocirurgia/economia , Neurocirurgia/estatística & dados numéricos , Procedimentos Neurocirúrgicos/economia , New Jersey , Estados Unidos
10.
World Neurosurg ; 139: 121-131, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32165344

RESUMO

OBJECTIVES: Management of incidental asymptomatic brain tumors in children is controversial due to lack of clear evidence-based guidelines. We present this systematic review in an attempt to highlight an optimal treatment paradigm. METHODS: This systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Databases were searched up to August 2019 using the keywords "incidental," "brain tumor," and "pediatric." Our main focus was on brain lesions suspected for neoplasm, diagnosed incidentally on neuroimaging in an otherwise asymptomatic patient <18 years old. Cystic, vascular, and inflammatory brain lesions were excluded. RESULTS: Fourteen studies comprising 308 patients were included. All cases were diagnosed using magnetic resonance imaging. The most common indications for imaging were headache (93; 30%) and trauma (72; 23%). Lesion distribution was supratentorial (179; 58%), infratentorial (121; 40%), and intraventricular (8; 3%). Of 308 cases, 243 (79%) were managed with neuroradiological surveillance and 57 (19%) by upfront surgical excision. Of those managed conservatively, 177 (73%) remained stable within a mean follow-up of 30 months, 54 (22%) progressed, and 12 (5%) spontaneously regressed. Meanwhile, upfront excision achieved complete remission in all 57 cases over a mean follow-up of 68.3 months. CONCLUSION: A small body of evidence has emerged, highlighting the marked heterogeneity and contradictory results between the available studies, limiting our ability to draw solid conclusions. At this point, the decision between surgery and "watchful waiting" should be tailored on an individual patient basis depending on suspicion of malignancy, clinical or radiologic progression, and parental preference.


Assuntos
Doenças Assintomáticas , Neoplasias Encefálicas/terapia , Tratamento Conservador , Achados Incidentais , Procedimentos Neurocirúrgicos , Conduta Expectante , Adolescente , Neoplasias Encefálicas/diagnóstico por imagem , Criança , Pré-Escolar , Gerenciamento Clínico , Humanos , Lactente , Recém-Nascido , Neurocirurgia , Pediatria
11.
Neurosurg Focus ; 48(3): E20, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32114557

RESUMO

OBJECTIVE: Engagement in research and scholarship is considered a hallmark of neurosurgical training. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States, with little, if any, data available regarding the research environment in neurosurgical training programs across the globe. Here, the authors set out to identify requirements for research involvement and to quantify publication rates in leading neurosurgical journals throughout various nations across the globe. METHODS: The first aim was to identify the research requirements set by relevant program-accrediting and/or board-certifying agencies via query of the literature and published guidelines. For the second part of the study, the authors attempted to determine each country's neurosurgical research productivity by quantifying publications in the various large international neurosurgical journals-World Neurosurgery, Journal of Neurosurgery, and Neurosurgery-via a structured search of PubMed. RESULTS: Data on neurosurgical training requirements addressing research were available for 54 (28.1%) of 192 countries. Specific research requirements were identified for 39 countries, partial requirements for 8, and no requirements for 7. Surprisingly, the authors observed a trend of increased average research productivity with the absence of designated research requirements, although this finding is not unprecedented in the literature. CONCLUSIONS: A variety of countries of various sizes and neurosurgical workforce densities across the globe have instituted research requirements during training and/or prior to board certification in neurosurgery. These requirements range in intensity from 1 publication or presentation to the completion of a thesis or dissertation and occur at various time points throughout training. While these requirements do not correlate directly to national research productivity, they may provide a foundation for developing countries to establish a culture of excellence in research.


Assuntos
Bolsas de Estudo/estatística & dados numéricos , Internato e Residência/estatística & dados numéricos , Neurocirurgia/educação , Procedimentos Neurocirúrgicos/educação , Humanos , Pesquisa/economia , Sociedades Médicas/estatística & dados numéricos , Estados Unidos
12.
Neurosurg Open ; 1(3): okaa008, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34632389

RESUMO

BACKGROUND: Preliminary data suggest that Coronavirus Disease-2019 (COVID-19) is associated with hypercoagulability and neurovascular events, but data on outcomes is limited. OBJECTIVE: To report the clinical course and outcomes of a case series of COVID-19 patients with a variety of cerebrovascular events. METHODS: We performed a multicentric, retrospective chart review at our three academic tertiary care hospitals, and identified all COVID-19 patients with cerebrovascular events requiring neuro-intensive care and/or neurosurgical consultation. RESULTS: We identified 26 patients between March 1 and May 24, 2020, of whom 12 (46%) died. The most common event was a large-vessel occlusion (LVO) in 15 patients (58%), among whom 8 died (8/15, 53%). A total of 9 LVO patients underwent mechanical thrombectomy, of whom 5 died (5/9, 56%). A total of 7 patients (27%) presented with intracranial hemorrhage. Of the remaining patients, 2 had small-vessel occlusions, 1 had cerebral venous sinus thrombosis, and another had a vertebral artery dissection. Acute Respiratory Distress Syndrome occurred in 8 patients, of whom 7 died. Mortalities had a higher D-dimer on admission (mean 20 963 ng/mL) than survivors (mean 3172 ng/mL). Admission Glasgow Coma Scale (GCS) score was poor among mortalities (median 7), whereas survivors had a favorable GCS at presentation (median 14) and at discharge (median 14). CONCLUSION: COVID-19 may be associated with hemorrhage as well as ischemia, and prognosis appears poorer than expected-particularly among LVO cases, where outcome remained poor despite mechanical thrombectomy. However, a favorable neurological condition on admission and lower D-dimer may indicate a better outcome.

13.
World Neurosurg ; 125: 392-397, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30763753

RESUMO

BACKGROUND: Cutis verticis gyrata (CVG) is a rare condition of the scalp in which thickening of the dermis induces rigid folds and furrows resembling the cerebral cortex. Two forms of primary CVG exist: essential, in which CVG is the only presenting problem, and nonessential, in which the scalp condition occurs along with neuropsychiatric ailments. CVG can also occur secondary to a variety of causes including inflammatory, neoplastic, and metabolic conditions or drug use. A review of the available literature, including description of the epidemiology, pathophysiology, histology, and typical management of CVG, is provided. However, we identified no literature describing the complications of CVG in the setting of a craniotomy. CASE REPORT: The patient presented here is a 54-year-old man with CVG who presented with occlusion of the M2/M2 branches of the middle cerebral artery, resulting in malignant cerebral edema, requiring emergent management via decompressive craniectomy. Because of the thickening of the scalp, skin incision was complicated by bleeding and difficulty in achieving hemostasis using Raney clips. Plastic surgery was consulted intraoperatively for assistance with complex closure of the wound in a multilayered fashion. Despite this, the patient's postoperative course was complicated by cerebrospinal fluid leakage due to difficulty in approximating the incision during closure. Subsequent cranioplasty was performed jointly between neurosurgery and plastic surgery. CONCLUSIONS: Despite its rarity, CVG is an important issue for neurosurgeons to understand as it can present complications in performing craniotomy, most notably during the scalp exposure and closure. CVG may also complicate the postoperative course if adequate approximation of the tissues cannot be achieved, resulting in wound infection and/or cerebrospinal fluid leak. The presented patient benefited from a combined neurosurgical and plastic surgical approach that was implemented intraoperatively and continued through the postoperative stages and the subsequent cranioplasty.


Assuntos
Craniectomia Descompressiva/métodos , Infarto da Artéria Cerebral Média/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Dermatoses do Couro Cabeludo/complicações , Couro Cabeludo/cirurgia , Edema Encefálico/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade
14.
J Neurochem ; 141(3): 347-357, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28144959

RESUMO

The Notch signaling pathway controls cell fate decision, proliferation, and other biological functions in both vertebrates and invertebrates. Precise regulation of the canonical Notch pathway ensures robustness of the signal throughout development and adult tissue homeostasis. Aberrant Notch signaling results in profound developmental defects and is linked to many human diseases. In this study, we identified the Atrophin family protein RERE (also called Atro2) as a positive regulator of Notch target Hes genes in the developing vertebrate spinal cord. Prior studies have shown that during early embryogenesis in mouse and zebrafish, deficit of RERE causes various patterning defects in multiple organs including the neural tube. Here, we detected the expression of RERE in the developing chick spinal cord, and found that normal RERE activity is needed for proper neural progenitor proliferation and neuronal differentiation possibly by affecting Notch-mediated Hes expression. In mammalian cells, RERE co-immunoprecipitates with CBF1 and Notch intracellular domain (NICD), and is recruited to nuclear foci formed by over-expressed NICD1. RERE is also necessary for NICD to activate the expression of Notch target genes. Our findings suggest that RERE stimulates Notch target gene expression by preventing degradation of NICD protein, thereby facilitating the assembly of a transcriptional activating complex containing NICD, CBF1/RBPjκ in vertebrate, Su(H) in Drosophila melanogaster, Lag1 in C. elegans, and other coactivators.


Assuntos
Peptídeos e Proteínas de Sinalização Intracelular/fisiologia , Receptores Notch/fisiologia , Medula Espinal/embriologia , Medula Espinal/metabolismo , Animais , Diferenciação Celular/fisiologia , Linhagem Celular , Embrião de Galinha , Eletroporação , Regulação da Expressão Gênica/genética , Humanos , Peptídeos e Proteínas de Sinalização Intracelular/metabolismo , Células-Tronco Neurais , Neurônios , Ativação Transcricional , Transfecção
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