Jordi X. Kellogg

Efficacy of intraarterial thrombolysis of basilar artery stroke

BACKGROUND Stroke from basilar artery (BA) occlusion is a devastating neurological event with reported mortality rates of up to 90%. This series reports our experience in 15 cases using intraarterial (IA) thrombolysis to treat basilar artery stroke at the Oregon Stroke Center. METHODS Over a 4-year period, consecutive cases of basilar artery stroke were treated with IA urokinase (UK) if they met the following criteria: had a baseline National Institutes of Health Stroke Scale (NIHSS) score greater than 6; symptoms began within 48 hours; had no or minimal early infarct signs on computed tomography (CT) scan; and angiogram confirmed basilar occlusion. Patients were treated with UK infused via a microcatheter directly into the clot. Angiographic efficacy was assessed by a repeat angiogram at the end of infusion and clinical efficacy was determined by NIHSS evaluation at 48 hours and 3 months. RESULTS Fifteen patients, mean age 59 (16 to 78) and baseline NIHSS of 30 (7 to 40), were treated at a mean of 12 hours (4 to 48). An average dose of 500,000 (150,000 to 1,250,000) units of UK was given over 1 to 2 hours. Excellent vessel recanalization occurred in 12 of 15 (80%) patients. All three cases without recanalization died within 48 hours (100%). Of the 12 patients with recanalization, 2 died (16.7%), whereas the 9 of 10 remaining had mild or moderate neurological deficits (mean NIHSS of 5) at 3 months. CONCLUSION IA thrombolysis has the potential to decrease mortality and improve outcome in cases with severe basilar artery stroke even when administered after 6 hours.

Posterior cervical arthrodesis and stabilization: an early report using a novel lateral mass screw and rod technique

OBJECTIVE: Posterior cervical arthrodesis and stabilization with lateral mass plates is a biomechanically sound construct in multiple planes of motion. It is reproducible and especially useful when the posterior elements are missing or fractured. Unfortunately, it is difficult to use in patients with severe degenerative spondylosis because the plate is malleable only in the sagittal plane and the screw positions are dictated by the plates entry holes. METHODS: A novel system of lateral mass screws that can be positioned before placement of a lateral construct was used in nine patients. Their outcomes as well as the technical applications of this system were reviewed. RESULTS: A total of 52 screws were placed in nine patients who underwent posterior cervical arthrodesis with the Cervifix system (Synthes USA, Paoli, PA). Diagnoses included trauma in four patients, degenerative spondylosis in three, and tumor in two. Rods were molded individually according to the patients anatomy. Compression, distraction, and lateral rotation, if indicated, were performed. Follow-up averaged 36 weeks. Lateral and anteroposterior radiographs, obtained at progressive intervals, revealed excellent fixation and screw purchase without pull-out. There were no cases of spinal cord, nerve root, or vertebral artery injury. CONCLUSION: The Cervifix system accommodates variation in anatomic size and spacing of the lateral masses, potentiating precise screw placement. The rods can be molded in multiple planes, and selective application of compressive, distractive, or lateral rotatory forces is allowed. The system is very straightforward and simple to use, and we have had good success without pseudarthrosis or complications from screw placement in our series.

The Role of Angioplasty in the Treatment of Cerebrovascular Disease

Percutaneous transluminal angioplasty (PTA), an established treatment of arterial stenosis in coronary, renal, and other peripheral sites, is being applied to the cerebrovascular territory with greater frequency. Early results suggest that PTA may be safe and efficacious in the treatment of extracranial arterial stenosis secondary to atherosclerosis and fibromuscular dysplasia. PTA is also being used with promising results in treating symptomatic intracranial arterial stenosis from atherosclerosis. This review examines PTA in the treatment of cerebrovascular disease, current indications, and results.

A Hazard of Combining the Infratentorial Supracerebellar and the Cerebellomedullary Fissure Approaches: Cerebellar Venous Insufficiency

The infratentorial supracerebellar approach is a popular technique for exposure of lesions of the superior vermis and pineal region. The cerebellomedullary fissure approach is enjoying increasing application as a technique for exposure of the fourth ventricle. Occasionally, a tumor that arises in the quadrigeminal plate or the superior vermis grows to fill the fourth ventricle, and for such a case a combination of the infratentorial supracerebellar approach and the cerebellomedullary fissure approach might be considered. We report a grave hazard of this combination. Two patients with tumors involving the superior vermis and filling the fourth ventricle were managed with a combined infratentorial supracerebellar/cerebellomedullary fissure approach. The first patient, who underwent a bilateral exposure, died on the sixth postoperative day due to massive hemorrhagic venous infarction of the cerebellum. The second patient, who was explored on one side only, suffered a protracted postoperative course characterized by suboccipital pain, torticollis, feeding difficulties and persisting hydrocephalus. Postoperative imaging showed swelling of the inferior vermis and ipsilateral hemisphere of the cerebellum with unilateral tonsillar herniation. Simultaneous compromise of the galenic and tentorial bridging veins and interruption of collateral pathways between these systems and the petrosal bridging veins, as in the combined infratentorial supracerebellar/cerebellomedullary fissure approach, may cause cerebellar venous insufficiency with venous congestion and possible venous infarction.

Endoscopic treatment of spinal epidural hematoma

We report the use of a spinal endoscope via a limited cervical laminotomy to evacuate a spinal epidural hematoma. The patient was a 75-year-old male with a 32-year history of ankylosing spondylitis. Following a low speed motor vehicle accident he developed a cervicothoracic epidural hematoma without an associated fracture. Despite a rapidly improving neurological state, his rapidly deteriorating cardiorespiratory state required systemic anticoagulation necessitating decompression of the hematoma. The hematoma was successfully removed via a limited C6 and C7 laminotomy using the endoscope and a malleable disposable aspirator. We conclude that epidural hematomas can be readily evacuated via endoscopic techniques without extensive laminectomy. This technique may be used for approaching intraspinal pathology in high risk patients where extensive exposure may be contraindicated.