Carlos A. David

Giant intracranial aneurysms: development, clinical presentation and treatment

The natural history of giant intracranial aneurysms are grave. More than 50% of patients suffer from rupture of these aneurysms and mortality is >60% in 2 years. Modern technology and advancement of knowledge in neurosurgery and interventional neuroradiology have altered its natural course for the better. As many reports have shown, the majority of these aneurysms can be treated either by surgery or by endovascular approach, even though morbidity is higher than when treating smaller aneurysms. Certain aneurysms are more suitable to direct surgical clipping and others may have better chances of good clinical outcome by endovascular treatment. It is imperative to analyse the location, morphology, hemodynamics and circulation of normal brain of each aneurysm before the mode of treatment is decided. Needless to say, the individual patients age, neurological and medical condition should be considered. For endovascular treatment, application of each technique, endosaccular occlusion or parent artery occlusion depends on the aneurysm location and geometry as well as its pathology. Several reports indicated that clinical outcome is better in patients treated by parent artery occlusion since it eliminates any blood flow to the aneurysm and it provides a more effective reduction of the mass effect. However, not all parent arteries can be sacrificed. In addition, endosaccular treatment is effective in preventing haemorrhage if the aneurysm is not re-canalised. It is also demonstrated that symptoms of mass effect can be reversed by endosaccular coiling. The patients who are treated this way should be closely monitored for re-canalisation.

Incidence and Predictors of Intracranial Hemorrhage After Minor Head Trauma in Patients Taking Anticoagulant and Antiplatelet Medication

BACKGROUND The yield of head computed tomography (CT) for patients who suffered head trauma with a presenting Glasgow Coma Scale (GCS) score of 15 has been reported to be low, even in patients who are anticoagulated or on antiplatelet therapy. We undertook this study to (1) determine the frequency of intracranial hemorrhage in anticoagulated patients and patients on antiplatelet therapy and its impact on clinical management, (2) identify predictors of positive imaging findings, and (3) assess potential differences between anticoagulation and antiplatelet therapy. METHODS We conducted a retrospective review of the trauma registry at our institution, a Level II trauma center. All trauma registry patients with a minor head injury registered between the years 2004 and 2006 who were taking warfarin or clopidogrel, had a presenting GCS score of 15, and underwent head CT were included in this study. Intracranial hemorrhage on head CT was considered a positive result. RESULTS One hundred forty-one patients (male, n=67; female, n=74), mean age 79 years (range, 36-101 years), were included in this study. Forty-one patients (29%) were diagnosed with intracranial hemorrhage. Thirty-nine (95%) of these 41 patients underwent reversal and/or discontinuation of clopidogrel and/or warfarin. Five patients required surgical evacuation of an intracranial hemorrhage. Four patients died. Loss of consciousness (Wald=7.468, β=1.179, p=0.008) predicted a positive CT result. Type of medication (warfarin, aspirin, or clopidogrel) did not reach statistical significance as a predictor of positive result. CONCLUSION Despite a presenting GCS score of 15, patients with minor head injury from the trauma registry at our institution taking anticoagulation or antiplatelet therapy have a high incidence of intracranial hemorrhage especially after reported loss of consciousness.

Dissecting Aneurysms of the Distal Segment of the Posterior Inferior Cerebellar Arteries: Clinical Presentation and Management

BACKGROUND AND PURPOSE: Dissecting aneurysms of the distal segment of the PICA are rare. The purpose of this study was to evaluate the clinical presentations, imaging features, treatment options, and clinical outcomes of dissecting PICA aneurysms. MATERIALS AND METHODS: Six patients with dissecting aneurysms in the distal segments of PICA were found in the database of a single medical center, from November 1996 to December 2008, and retrospectively evaluated. Treatment mode and follow-up clinical outcomes were analyzed. RESULTS: Five patients with dissecting PICA aneurysms presented with acute intracranial hemorrhage and 1 patient presented with a large mass from an intramural hematoma. All 5 patients with intracranial hemorrhage were treated with endovascular occlusion of both the dissecting PICA aneurysm and the distal parent artery. The patient with the intramural hematoma underwent surgical trapping with end-to-end anastomosis. In 1 patient, the dissecting aneurysm recurred twice within a 5 year 3 month period, despite endovascular occlusion of both the aneurysm and the parent artery. The clinical outcome postprocedure was excellent in all patients, without permanent neurologic complication. CONCLUSIONS: For the endovascular treatment of dissecting aneurysms in the distal PICA segments, we recommend occlusion of both the dissecting aneurysm and the parent artery to avoid leaving the point of initial intimal tear untreated. All of our patients had excellent clinical outcomes; however, our experience with recanalization illustrates the need for close follow-up of patients.

Lumbar microdiscectomy and microendoscopic discectomy

Lumbar microdiscectomy, which relies on the operating microscope for visualization, was first described in the late 1970s. This operation is considered the gold standard procedure for patients who require surgery for symptomatic lumbar disc herniation causing radiculopathy that has not improved with conservative measures. A new approach to the management of symptomatic lumbar disc herniation, microendoscopic discectomy, was introduced in 1997. This operation utilizes a tubular retractor system and a microendoscope for visualization rather than the operating microscope. As it is a new procedure, long‐term outcomes have not yet been established for this operation. However, recent literature suggests that microendoscopic discectomy may be as effective as the traditional lumbar microdiscectomy in relieving radiculopathy. This article describes the operative techniques and outcomes reported in the literature for both lumbar microdiscectomy and microendoscopic discectomy.

Obliteration of a metameric spinal arteriovenous malformation (Cobb syndrome) using combined endovascular embolization and surgical excision

Cobb syndrome represents the concurrent findings of a metameric spinal vascular malformation and a cutaneous vascular malformation within several dermatomes of each other. This rare entity engenders many difficult decisions with respect to appropriate therapeutic management. Historically, surgical excision carried a high morbidity, and conservative management without intervention was preferred. More recently, several cases of endovascular embolization have been reported with good success. The authors describe the case of a 17-year-old boy who presented with a right gluteal angioma and was found to have a spinal arteriovenous malformation. Multiple embolizations failed to prevent neurological deterioration, and the patient eventually became wheelchair dependent. Surgical excision of the malformation led to partial recovery of neurological function, and at the latest follow-up, 52 months postoperatively, the patient was able to ambulate independently. This case demonstrates the successful treatment of a patient with Cobb syndrome with surgical excision after multiple refractory embolizations. A multidisciplinary approach, which balances the patients current neurological function against the risks and potential gains from any interventional and surgical procedure, is recommended.

Management of intraprocedural spontaneous stent migration into target aneurysm during stent-assisted coiling procedure

Objective The stent-assisted coiling technique has expanded the applicability of endovascular treatment for wide-neck intracranial aneurysms. However, the stability of the deployed stent has been questioned. We present this case to demonstrate intraprocedural migration of the deployed stent and subsequent management. Clinical presentation A 59-year-old female patient presented with dizziness and fatigue. Imaging, including CT and MR angiography, revealed a 7×6.5 mm wide-neck basilar tip aneurysm. Intervention Stent-assisted coiling was attempted. After deployment of the stent, the distal portion of the stent migrated into the aneurysm sac, and then stabilized. Since attempted coiling without an assistance device was unsuccessful, the balloon-assisted coiling technique was applied. Near-total obliteration of the basilar tip aneurysm was accomplished. Conclusion The stability of a deployed stent should be confirmed to exclude the possibility of intraprocedural stent migration. If stent migration into the target aneurysm occurs, the balloon-assisted coiling technique through the deployed stent is a feasible and valuable tool for successful coil embolization.

Health-related quality of life, cognitive screening, and functional status in a randomized phase III trial (EF-14) of tumor treating fields with temozolomide compared to temozolomide alone in newly diagnosed glioblastoma

We characterized health-related quality of life (HRQoL), cognitive, and functional status in newly diagnosed glioblastoma (GBM) patients receiving Tumor treating fields (TTFields) with temozolomide (TMZ) versus TMZ alone in a planned interim analysis of a randomized phase III trial [NCT00916409], which showed significant improvement in progression-free and overall survival with TTFields/TMZ. After radiotherapy with concomitant TMZ, newly diagnosed GBM patients were randomized (2:1) to TTFields/TMZ (n = 210) or TMZ (n = 105). Interim analysis was performed in 315 patients with ≥18 months of follow-up. HRQoL, a secondary endpoint, was evaluated in per-protocol patient population and expressed as change from baseline (CFB) at 3, 6, and 9 months for each subscale in the EORTC QLQ-C30/BN20. Karnofsky performance scores (KPS) and Mini-Mental State Examination scores (MMSE) were assessed. CFB in HRQoL was balanced in treatment groups at the 12-month time point. Initially, HRQoL improved in patients treated with TTFields/TMZ (CFB3: 24% and CFB6: 13%) versus TMZ (CFB3: −7% and CFB6: −17%), though this difference was no longer evident at the 9-month point. General scales, including physical and social functioning, showed no difference at 9 and 12 months. TTFields/TMZ group reported higher concerns of “itchy skin”. KPS over 12 months was just below 90 in both groups. Cognitive status (MMSE) was stable over time. HRQoL, KPS, and MMSE were balanced in both groups over time. There was no preliminary evidence that HRQoL, cognitive, and functional status is adversely affected by the continuous use of TTFields.

Influence of Treatment With Tumor-Treating Fields on Health-Related Quality of Life of Patients With Newly Diagnosed Glioblastoma: A Secondary Analysis of a Randomized Clinical Trial

Importance Tumor-treating fields (TTFields) therapy improves both progression-free and overall survival in patients with glioblastoma. There is a need to assess the influence of TTFields on patients’ health-related quality of life (HRQoL). Objective To examine the association of TTFields therapy with progression-free survival and HRQoL among patients with glioblastoma. Design, Setting, and Participants This secondary analysis of EF-14, a phase 3 randomized clinical trial, compares TTFields and temozolomide or temozolomide alone in 695 patients with glioblastoma after completion of radiochemotherapy. Patients with glioblastoma were randomized 2:1 to combined treatment with TTFields and temozolomide or temozolomide alone. The study was conducted from July 2009 until November 2014, and patients were followed up through December 2016. Interventions Temozolomide, 150 to 200 mg/m2/d, was given for 5 days during each 28-day cycle. TTFields were delivered continuously via 4 transducer arrays placed on the shaved scalp of patients and were connected to a portable medical device. Main Outcomes and Measures Primary study end point was progression-free survival; HRQoL was a predefined secondary end point, measured with questionnaires at baseline and every 3 months thereafter. Mean changes from baseline scores were evaluated, as well as scores over time. Deterioration-free survival and time to deterioration were assessed for each of 9 preselected scales and items. Results Of the 695 patients in the study, 639 (91.9%) completed the baseline HRQoL questionnaire. Of these patients, 437 (68.4%) were men; mean (SD) age, 54.8 (11.5) years. Health-related quality of life did not differ significantly between treatment arms except for itchy skin. Deterioration-free survival was significantly longer with TTFields for global health (4.8 vs 3.3 months; P < .01); physical (5.1 vs 3.7 months; P < .01) and emotional functioning (5.3 vs 3.9 months; P < .01); pain (5.6 vs 3.6 months; P < .01); and leg weakness (5.6 vs 3.9 months; P < .01), likely related to improved progression-free survival. Time to deterioration, reflecting the influence of treatment, did not differ significantly except for itchy skin (TTFields worse; 8.2 vs 14.4 months; P < .001) and pain (TTFields improved; 13.4 vs 12.1 months; P < .01). Role, social, and physical functioning were not affected by TTFields. Conclusions and Relevance The addition of TTFields to standard treatment with temozolomide for patients with glioblastoma results in improved survival without a negative influence on HRQoL except for more itchy skin, an expected consequence from the transducer arrays. Trial Registration clinicaltrials.gov Identifier: NCT00916409

Superficial temporal artery dissection: a technical note.

BACKGROUND: Dissection of the superficial temporal artery (STA) is often required in preparation for a bypass procedure. Traditionally, dissection of the STA involves a direct cutdown on the artery after marking the course of the artery on the skin with the help of a Doppler ultrasound probe. OBJECTIVE: We describe a method that takes advantage of the position of the STA superficial to the temporal fascia. METHODS: The technique was used in a total of 38 procedures in 32 patients to create synangiosis or extracranial-intracranial STA bypasses. The STA was dissected using a blunt malleable brain retractor that was inserted into the subgaleal plane directly over the STA, allowing creation of a linear incision and concurrent protection of the STA in its bed. Either computed tomography– or catheter-based angiography was used to evaluate the patency postoperatively. RESULTS: All STA vessels were dissected without complications or injury to the graft vessel. The sole complication was a superficial wound breakdown in a synangiosis case. Postoperative angiography demonstrated patency in all but 1 of the 24 bypass cases (95.8%). CONCLUSION: We describe a method that takes advantage of the position of the STA superficial to the temporal fascia to allow rapid, safe, and efficacious dissection. The incision is linear and easier to manage and close. In our series, there were no technical complications related to the dissection of the STA. ABBREVIATIONS: EC-IC, extracranial-intracranial STA, superficial temporal artery

The Neuroimaging Spectrum of Septum Posticum Derangement and Associated Thoracic Myelopathy

Arachnoid cysts and meningeal membranes are among the differential diagnostic considerations of extra‐medullary causes of thoracic myelopathy. In this case series of 7 patients, we present compressive meningeal membranes mimicking dorsal arachnoid cyst. The propensity of the meningeal membranes for the dorsal aspect of upper thoracic spine may reflect derangements of the septum posticum.