Bjorn Lobo

Mid-term results of endovascular coiling of wide-necked aneurysms using double stents in a Y configuration

BACKGROUND:Double stenting in a Y configuration may be used to treat a subset of wide-necked aneurysms not amenable to reconstruction with a single stent. OBJECTIVE:We studied the feasibility, safety, and mid-term angiographic outcome of patients treated using this technique. METHODS:A retrospective review was undertaken of all coil embolizations of wide-necked aneurysms using double stents in a Y configuration. RESULTS:Nineteen patients were identified from 2002 to 2010 (14 women, 5 men) with a mean age of 57.4 years. Stents were deployed in a Y configuration achieving complete occlusion (5/19), residual neck (5/19), and residual aneurysm filling (9/19). Angiographic follow-up was available for a mean of 16 months, and clinical follow up was available for a mean of 21.4 months. The incidence of complications at the initial treatment was 6 of 19 (31.6%), and delayed thromboembolic complications occurred in 2 of 19 (10.5%). An angiographic neck recurrence requiring retreatment developed in only 1 of the patients in whom complete occlusion was obtained with the initial treatment. Spontaneous thrombosis and complete occlusion on follow-up imaging were found in 6 patients in whom initial neck or aneurysm filling was observed. Ultimately, 12 of the aneurysms (63.2%) were completely occluded on follow-up angiography. CONCLUSION:Y-stent reconstruction enables the endovascular management of otherwise complex, wide-necked cerebral aneurysms and can be performed safely in experienced hands with satisfactory mid-term results, even in cases requiring retreatment.

The expanding role of the endonasal endoscopic approach in pituitary and skull base surgery: A 2014 perspective.

Background: The past two decades have been the setting for remarkable advancement in endonasal endoscopic neurosurgery. Refinements in camera definition, surgical instrumentation, navigation, and surgical technique, including the dual surgeon team, have facilitated purely endonasal endoscopic approaches to the majority of the midline skull base that were previously difficult to access through the transsphenoidal microscopic approach. Methods: This review article looks at many of the articles from 2011 to 2014 citing endonasal endoscopic surgery with regard to approaches and reconstructive techniques, pathologies treated and outcomes, and new technologies under consideration. Results: Refinements in approach and closure techniques have reduced the risk of cerebrospinal fluid leak and infection. This has allowed surgeons to more aggressively treat a variety of pathologies. Four main pathologies with outcomes after treatment were identified for discussion: pituitary adenomas, craniopharyngiomas, anterior skull base meningiomas, and chordomas. Within all four of these tumor types, articles have demonstrated the efficacy, and in certain cases, the advantages over more traditional microscope-based techniques, of the endonasal endoscopic technique. Conclusions: The endonasal endoscopic approach is a necessary tool in the modern skull base surgeons armamentarium. Its efficacy for treatment of a wide variety of skull base pathologies has been repeatedly demonstrated. In the experienced surgeons hands, this technique may offer the advantage of greater tumor removal with reduced overall complications over traditional craniotomies for select tumor pathologies centered near the midline skull base.

Evaluation of Non-Watertight Dural Reconstruction with Collagen Matrix Onlay Graft in Posterior Fossa Surgery.

Objective Many surgeons advocate for watertight dural reconstruction after posterior fossa surgery given the significant risk of cerebrospinal fluid (CSF) leak. Little evidence exists for posterior fossa dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Our objective was to report the results of using collagen matrix in a non-watertight fashion for posterior fossa dural reconstruction. Methods We conducted a retrospective review of operations performed by the senior author from 2004–2011 identified collagen matrix (DuraGen) use in 84 posterior fossa operations. Wound complications such as CSF leak, infection, pseudomeningocele, and aseptic meningitis were noted. Fishers exact test was performed to assess risk factor association with specific complications. Results Incisional CSF leak rate was 8.3% and non-incisional CSF leak rate was 3.6%. Incidence of aseptic meningitis was 7.1% and all cases resolved with steroids alone. Incidence of palpable and symptomatic pseudomeningocele in follow-up was 10.7% and 3.6% respectively. Postoperative infection rate was 4.8%. Previous surgery was associated with pseudomeningocele development (p<0.05). Conclusion When primary dural closure after posterior fossa surgery is undesirable or not feasible, non-watertight dural reconstruction with collagen matrix resulted in incisional CSF leak in 8.3%. Incidence of pseudomeningocele, aseptic meningitis, and wound infection were within acceptable range. Data from this study may be used to compare alternative methods of dural reconstruction in posterior fossa surgery.

Biomechanics of the Lumbar Degenerative Intervertebral Disk

Degenerative lumbar disc disease is one of the most common causes of low back pain and disability in patients above 45 years of age. Diagnosis and treatment of lumbar herniated discs remain perplexing at times. MRI is the imaging study of choice for the identification of herniated lumbar discs; however, there remains only a moderate correlation between imaging findings and patients’ symptoms. Disc degeneration is a broad term that includes a variety of changes noted in gross specimens and radiographs from patients with clinical dysfunction. These changes may lead to derangement of the normal biomechanics of the lumbar spine, such as pathological and dysfunctional intervertebral motion – with a commensurate clinical response.