Hakeem J. Shakir

Management of acute ischemic stroke due to tandem occlusion: should endovascular recanalization of the extracranial or intracranial occlusive lesion be done first?

OBJECTIVE Acute tandem occlusions of the cervical internal carotid artery and an intracranial large vessel present treatment challenges. Controversy exists regarding which lesion should be addressed first. The authors sought to evaluate the endovascular approach for revascularization of these lesions at Gates Vascular Institute. METHODS The authors performed a retrospective review of a prospectively maintained, single-institution database. They analyzed demographic, procedural, radiological, and clinical outcome data for patients who underwent endovascular treatment for tandem occlusions. A modified Rankin Scale (mRS) score ≤ 2 was defined as a favorable clinical outcome. RESULTS Forty-five patients were identified for inclusion in the study. The average age of these patients was 64 years; the mean National Institutes of Health Stroke Scale score at presentation was 14.4. Fifteen patients received intravenous thrombolysis before undergoing endovascular treatment. Thirty-seven (82%) of the 45 proximal cervical internal carotid artery occlusions were atherothrombotic in nature. Thirty-eight patients underwent a proximal-to-distal approach with carotid artery stenting first, followed by intracranial thrombectomy, whereas 7 patients underwent a distal-to-proximal approach (that is, intracranial thrombectomy was performed first). Thirty-seven (82%) procedures were completed with local anesthesia. For intracranial thrombectomy procedures, aspiration alone was used in 15 cases, stent retrieval alone was used in 5, and a combination of aspiration and stent-retriever thrombectomy was used in the remaining 25. The average time to revascularization was 81 minutes. Successful recanalization (thrombolysis in cerebral infarction Grade 2b/3) was achieved in 39 (87%) patients. Mean National Institutes of Health Stroke Scale scores were 9.3 immediately postprocedure (p < 0.05) (n = 31), 5.1 at discharge (p < 0.05) (n = 31), and 3.6 at 3 months (p < 0.05) (n = 30). There were 5 in-hospital deaths (11%); and 2 patients (4.4%) had symptomatic intracranial hemorrhage within 24 hours postprocedure. Favorable outcomes (mRS score ≤ 2) were achieved at 3 months in 22 (73.3%) of 30 patients available for follow-up, with an mRS score of 3 for 7 of 30 (23%) patients. CONCLUSIONS Tandem occlusions present treatment challenges, but high recanalization rates were possible in the present series using acute carotid artery stenting and mechanical thrombectomy concurrently. Proximal-to-distal and aspiration approaches were most commonly used because they were safe, efficacious, and feasible. Further study in the setting of a randomized controlled trial is needed to determine the best sequence for the treatment approach and the best technology for tandem occlusion.

Combined use of covered stent and flow diversion to seal iatrogenic carotid injury with vessel preservation during transsphenoidal endoscopic resection of clival tumor.

Background: Transsphenoidal tumor resection can lead to internal carotid artery (ICA) injury. Vascular disruption is often treated with emergent vessel deconstruction, incurring complications in a subset of patients with poor collateral circulation and resulting in minor and major ischemic strokes. Methods: We attempted a novel approach combining a covered stent graft (Jostent) and two flow diverter stents [Pipeline embolization devices (PEDs)] to treat active extravasation from a disrupted right ICA that was the result of a transsphenoidal surgery complication. This disruption occurred during clival tumor surgery and required immediate sphenoidal sinus packing. Emergent angiography revealed continued petrous carotid artery extravasation, warranting emergent vessel repair or deconstruction for treatment. To preserve the vessel, we utilized a covered Jostent. Due to tortuosity and lack of optimal wall apposition, there was reduced, yet persistent extravasation from an endoleak after Jostent deployment that failed to resolve despite multiple angioplasties. Therefore, we used PEDs to divert the flow. Results: Flow diversion relieved the extravasation. The patient remained neurologically intact post-procedure. Conclusions: This case demonstrates successful combined use of a covered stent and flow diverters to treat acute vascular injury resulting from transsphenoidal surgery. However, concerns remain, including the requirement of dual antiplatelet agents increasing postoperative bleeding risks, stent-related thromboembolic events, and delayed in-stent restenosis rates.

Mandatory Change From Surgical Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce Surgical Site Infections in Class I Surgical Cases: A Single-Center Experience With More Than 15 000 Patients

BACKGROUND Surgical site infections (SSIs) are noteworthy and costly complications. New recommendations from a national organization have urged the elimination of traditional surgeons caps (surgical skull caps) and mandated the use of bouffant caps to prevent SSIs. OBJECTIVE To report SSI rates for >15 000 class I (clean) surgical procedures 13 mo before and 13 mo after surgical skull caps were banned at a single site with 25 operating rooms. METHODS SSI data were acquired from hospital infection control monthly summary reports from January 2014 to March 2016. Based on a change in hospital policy mandating obligatory use of bouffant caps since February 2015, data were categorized into nonbouffant and bouffant groups. Monthly and cumulative infection rates for 13 mo before (7513 patients) and 13 mo after (8446 patients) the policy implementation were collected and analyzed for the groups, respectively. RESULTS An overall increase of 0.07% (0.77%-0.84%) in the cumulative rate of SSI in all class I operating room cases and of 0.03% (0.79%-0.82%) in the cumulative rate of SSI in all spinal procedures was noted. However, neither increase reached statistical significance (P > .05). The cumulative rate of SSI in neurosurgery craniotomy/craniectomy cases decreased from 0.95% to 0.75%; this was also not statistically significant (P = 1.00). CONCLUSION National efforts at improving healthcare performance are laudable but need to be evidence based. Guidelines, especially when applied in a mandatory fashion, should be assessed for effectiveness. In this large, single-center series of patients undergoing class I surgical procedures, elimination of the traditional surgeons cap did not reduce infection rates.

Spinal dural attachments to the vertebral column: An anatomic report and review of the literature.

Background: The spinal dura is anchored within the vertebral canal by connective tissue in the epidural space as well as the spinal roots. Inadvertent disruption of these dural attachments may lead to durotomy and cerebrospinal fluid (CSF) leaks. We observed well-developed connective tissue ligaments connecting the lumbar dura to the spinal column and examined these tissues microscopically. Methods: Intraoperative images were obtained during lumbar laminectomy procedures. They demonstrated connective tissue attachments, linking the lumbar dura to the spinal column in the dorsal midline and dorsolaterally. Tissue samples were obtained and examined microscopically. We then conducted a search of the literature to find references to dural attachments to the spinal column. Results: Histological examination of the samples showed minimal cellular fibrous tissue. To date no references to these attachments have been made in neurosurgical literature. Previous studies, including live, cadaveric, and radiographic examinations, have demonstrated a dorsomedian fold of dura attached to the junction of the ligamentum flavum, and dorsolateral ligaments that divide the dorsal epidural space into an anterior and posterior compartment. Conclusions: Epidural fibrous connections or ligaments between the dura and the lumbar spinal column may be of clinical importance to the neurosurgeon. Care should be taken during lumbar procedures not to disrupt or tear these ligaments as this may cause dural tears and CSF leaks. Identifying these ligaments and cutting them sharply may prevent inadvertent durotomies.

The relationship between the zygomatic arch and the floor of the middle cranial fossa: a radiographic study.

OBJECTIVE Access to the floor of the middle cranial fossa (MCF) is often required for approaches to cranial base lesions. This study measures the craniocaudal distance between the zygomatic arch (ZA) and the floor of the MCF from a random sample of high-resolution computed tomography scans of the cranial base. Methods Forty computed tomography scans were imported into an OsiriX station and reconstructed in multiple planes. The most caudal point of the MCF was determined in each computed tomography scan. The distances between that point and the root of the zygoma and the middle point of the ZA were calculated. The thickness of the temporalis muscle and the vertical height of the zygoma were also calculated. A 2-tailed, paired Student t test was used to compare right and left measurements with a 95% confidence interval and P value <.05 as statistically significant. RESULTS The foramen ovale was consistently the lowest point of the MCF. The average root-to-floor measurement was 5.05 ± 0.42 mm above the floor of the MCF and distance of the mid-zygoma to the floor was 1.94 ± 0.61 mm above the floor of MCF. The average temporalis muscle thickness and vertical height of the ZA were 22.22 ± 0.36 mm and 8.10 ± 0.13 mm, respectively. The muscle-to-floor measurement (muscle thickness + mid-zygoma-to-floor measurement) was 24.16 ± 0.74 mm. Conclusion The routine use of a zygomatic osteotomy in approaches to the MCF does not provide very much increased exposure. However, in patients with exceptionally thick temporalis muscles or a high ZA, a zygomatic osteotomy may be helpful in providing exposure of the floor of the MCF.

Safety and Efficacy of the Sofia (6F) PLUS Distal Access Reperfusion Catheter in the Endovascular Treatment of Acute Ischemic Stroke

BACKGROUND Neuroendovascular intervention has become a key treatment option for acute ischemic stroke. The Sofia (6F) PLUS catheter was designed for neurovascular access for diagnostic or therapeutic interventions. OBJECTIVE To report the first series describing use of the Sofia PLUS intermediate/distal access reperfusion catheter in the treatment of acute ischemic stroke. METHODS In this retrospective study, 41 stroke cases were identified in which the catheter was utilized for thrombolysis/thrombectomy. Mean preprocedure National Institutes of Health Stroke Scale score was 16.5 ± 5.2 (range 4-29). Occluded vessels included the M1 segment, M2 segment, internal carotid artery terminus, cervical internal carotid artery, and basilar artery. RESULTS Successful positioning of the Sofia PLUS catheter near the occlusion site was achieved in 38 (92.7%) of 41 cases in which thrombectomy or thrombolysis was attempted using intraarterial tissue plasminogen activator, a direct aspiration first-pass technique, and/or stent retrieval. A postprocedure thrombolysis in cerebral infarction (TICI) score of 2b/3 was achieved in 37 of 41 cases. Of 15 cases where the Sofia PLUS was used for a direct aspiration first-pass technique, TICI 2b/3 was achieved in 11 (73.3%). In one case where intra-arterial tissue plasminogen activator was used as the only treatment modality, TICI 2a was achieved. No device-related or catheter-related complications were observed. The mean 7-d-postprocedure National Institutes of Health Stroke Scale score among the 39 survivors was 8.5 ± 7.3 (range 0-23). CONCLUSION Initial results with use of the Sofia (6F) PLUS for endovascular treatment of acute ischemic stroke have been encouraging. Experience with a larger series is warranted to further evaluate the safety and efficacy of this device and compare it with other reperfusion catheters.

Carotid and Vertebral Dissection Imaging

Carotid or vertebral artery dissection is the result of a tear in the vessel lining wherein the intima separates the media. This creates a false or pseudo lumen, often accompanied by hemorrhage into the arterial wall. Dissection of these craniocervical vessels often manifests with pain alone but, if untreated, may result in severe neurologic compromise. The causes of dissection are multifactorial, including spontaneous, iatrogenic, and traumatic insults. Regardless of etiology, treatment consists primarily of anticoagulation, whereas endovascular therapy is reserved for cases with persistent thrombus or flow limitation. Given the high risk of neurological compromise or death and the propensity of these injuries to occur in younger individuals, early diagnosis of carotid and vertebral artery dissections is critical. Although angiography remains the criterion standard for diagnosis, advances in noninvasive imaging have placed magnetic resonance and computed tomography at the forefront of diagnosis. This article examines the current imaging modalities used to diagnose this under-recognized entity.

Carotid body tumor imitator: An interesting case of Castleman′s disease

Background: There are very few reports in the literature of Castlemans disease affecting the carotid artery and a single previous report of a case of Castlemans disease of the neck originally mistaken as a carotid body tumor. Case Description: We describe a rare case of Castlemans disease, manifesting with classic radiographic hallmarks of a carotid body tumor. The postoperative pathologic examination identified the resected mass as Castlemans lymphadenopathy. The management of this particular case is discussed, and the findings are highlighted. Conclusions: We present a unique case of a tumor initially and incorrectly diagnosed as a carotid body tumor. However, after comprehensive treatment with endovascular and surgical modalities and subsequent pathologic examination, the diagnosis of this rare entity was made.

The blunt truth behind coiling vs clipping: consumers as decision-drivers.

1. Breivik CN, Nilsen RM, Myrseth E, et al. Conservative management or gamma knife radiosurgery for vestibular schwannoma: tumor growth, symptoms, and quality of life. Neurosurgery. 2013;73(1):48-57. 2. Régis J, Carron R, Park MC, et al. Wait-and-see strategy compared with proactive GAMMA Knife surgery in patients with intracanalicular vestibular schwannomas. J Neurosurg. 2010;113(suppl):105-111. 3. Myrseth E, Møller P, Pedersen PH, Lund-Johansen M. Vestibular schwannoma: surgery or gamma knife radiosurgery? A prospective, nonrandomized study. Neurosurgery. 2009;64(4):654-661. 4. Myrseth E,Møller P, Pedersen PH, Vassbotn FS,Wentzel-Larsen T, Lund-JohansenM. Vestibular schwannomas: clinical results and quality of life after microsurgery or gamma knife radiosurgery. Neurosurgery. 2005;56(5):927-935. 5. Pollock BE, Driscoll CL, Foote RL, et al. Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery. Neurosurgery. 2006;59(1):77-85. 6. Pollock BE. Vestibular schwannoma management: an evidence-based comparison of stereotactic radiosurgery and microsurgical resection. Prog Neurol Surg. 2008;21: 222-227.

Flow Diversion for the Treatment of Basilar Apex Aneurysms

BACKGROUND Flow diversion for basilar apex aneurysms has rarely been reported. OBJECTIVE To assess flow diversion for basilar apex aneurysms in a multicenter cohort. METHODS Retrospective review of prospectively maintained databases at 8 academic institutions was performed from 2009 to 2016 to identify patients with basilar apex aneurysms treated with flow diversion. Clinical and radiographic data were analyzed. RESULTS Sixteen consecutive patients (median age 54.5 yr) underwent 18 procedures to treat 16 basilar apex aneurysms with either the Pipeline Embolization Device (Medtronic Inc, Dublin, Ireland) or Flow Redirection Endoluminal Device (Microvention, Tustin, California). Five aneurysms (31.3%) were treated in the setting of subarachnoid hemorrhage. Seven aneurysms (43.8%) were treated with flow diversion alone, while 9 (56.2%) underwent flow diversion and adjunctive coiling. At a median follow-up of 6 mo, complete (100%) and near-complete (90%-99%) occlusion was noted in 11 (68.8%) aneurysms. Incomplete occlusion occurred more commonly in patients treated with flow diversion alone compared to those with adjunctive coiling. Patients with partial occlusion were significantly younger. Retreatment with an additional flow diverter and adjunctive coiling occurred in 2 aneurysms with wide necks. There was 1 mortality in a patient (6.3%) who experienced posterior cerebral artery and cerebellar strokes as well as subarachnoid hemorrhage after the placement of a flow diverter. Minor complications occurred in 2 patients (12.5%). CONCLUSION Flow diversion for the treatment of basilar apex aneurysms results in acceptable occlusion rates in highly selected cases. Both primary flow diversion and rescue after failed clipping or coiling resulted in a modified Rankin Scale score that was either equal or better than at presentation and the technology represents a viable alternative or adjunctive option.