Joseph G. Adel

The effect of vascular reconstruction device-assisted coiling on packing density, effective neck coverage, and angiographic outcome: an in vitro study.

OBJECTIVEThe objective of this study was to assess the variations in packing density, effective neck coverage, and angiographic outcome between aneurysm coiling alone and with the support of the Enterprise Vascular Reconstruction Device (VRD; Cordis Neurovascular, Inc., Miami Lakes, FL). Although the use of VRD-assisted coiling is growing due to the availability of better devices, little is known about the impact of the VRDs on the aforesaid variables. METHODSTen groups of two silicone aneurysm models each were embolized with detachable coils, one with VRD support and one without. Coil embolization ceased once the microcatheter backed out of the aneurysm or there was a risk that further packing would lead to coil herniation. Angiograms were assessed using the Raymond classification scale. Gross macroscopic images of the aneurysm neck were taken to quantify the coil neck coverage, defined as the surface area fraction of coils at the neck divided by the total neck area. Packing density was calculated. RESULTSPacking density significantly increased with VRD assistance (absolute increase, 10.5%; relative increase, 31%; P < 0.0001, paired t test). Effective neck coverage significantly increased by 9% with VRD deployment (P < 0.05, t test). Angiographically, aneurysms coiled without VRD support were more likely to have a dome remnant (P < 0.05, Fishers exact test) and coil prolapse into the parent vessel. CONCLUSIONVRD deployment improves coil neck coverage and increases packing density. These results support the hypothesis that VRD deployment to reinforce coil embolization of cerebral aneurysms may lead to more durable aneurysm obliteration.

Adenosine for temporary flow arrest during intracranial aneurysm surgery: a single-center retrospective review.

BACKGROUND:Clip application for temporary occlusion is not always practical or feasible. Adenosine is an alternative that provides brief periods of flow arrest that can be used to advantage in aneurysm surgery, but little has been published on its utility for this indication. OBJECTIVE:To report our 2-year consecutive experience with 40 aneurysms in 40 patients for whom we used adenosine to achieve temporary arterial occlusion during aneurysm surgery. METHODS:We retrospectively reviewed our clinical database between May 2007 and December 2009. All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole were included. Aneurysm characteristics, reasons for adenosine use, postoperative angiographic and clinical outcome, cardiac complications, and long-term neurological follow-up with the modified Rankin Scale were noted. RESULTS:Adenosine was used for 40 aneurysms (10 ruptured, 30 unruptured). The most common indications for adenosine were aneurysm softening in 17 cases and paraclinoid location in 14 cases, followed by broad neck in 12 cases and intraoperative rupture in 6 cases. Troponins were elevated postoperatively in 2 patients. Echocardiography did not show acute changes in either. Clinically insignificant cardiac arrhythmias were noted in 5 patients. Thirty-six patients were available for follow-up. Mean follow-up was 12.8 months. The modified Rankin Scale score was 0 for 29 patients at the time of the last follow-up. Four patients had an modified Rankin Scale score of 1, and scores of 2 and 3 were found in 2 and 1 patients, respectively. CONCLUSION:Adenosine appears to allow safe flow arrest during intracranial aneurysm surgery. This can enhance the feasibility and safety of clipping in select circumstances.

Development of venous thromboembolism (VTE) in patients undergoing surgery for brain tumors: Results from a single center over a 10 year period

Patients who undergo craniotomy for brain neoplasms have a high risk of developing venous thromboembolism (VTE), including deep vein thromboses (DVT) and pulmonary emboli (PE). The reasons for this correlation are not fully understood. This retrospective, single-center review aimed to determine the risk factors for VTE in patients who underwent neurosurgical resection of brain tumors at Northwestern University from 1999 to 2010. Our cohort included 1148 patients, 158 (13.7%) of whom were diagnosed with DVT and 38 (3.3%) of whom were diagnosed with PE. A variety of clinical factors were studied to determine predictors of VTE, including sex, ethnicity, medical co-morbidities, surgical positioning, length of hospital stay, tumor location, and tumor histology. Use of post-operative anticoagulants and hemorrhagic complications were also investigated. A prior history of VTE was found to be highly predictive of post-operative DVT (odds ratio [OR]=7.6, p=0.01), as was the patients sex (OR=14.2, p<0.001), ethnicity (OR=0.5, p=0.04), post-operative intensive care unit days (OR=0.2, p=0.003), and tumor histology (OR=-0.16, p=0.01). Contrary to reports in the literature, the data collected did not indicate that the administration of post-operative medical prophylaxis for VTE was significant in preventing their formation (OR=-0.14, p=0.76). Hemorrhagic complications were low (2.2%) and resultant neurologic deficit was lower still (0.7%). The study indicates that patients with high-grade primary brain tumors and metastatic lesions should receive aggressive preventative measures in the post-operative period.

Association of intracranial aneurysm and Loeys-Dietz syndrome: Case illustration, management, and literature review

BACKGROUND AND IMPORTANCE:Loeys-Dietz syndrome (LDS) is a newly described connective tissue disease associated with aortic aneurysms. A strong association between LDS and intracranial aneurysms has not yet been documented in the literature. We present the first detailed report of an intracranial aneurysm finding in an LDS patient. CLINICAL PRESENTATION:The patient is a 20-year-old female recently diagnosed with LDS and found to harbor 2 incidental intracranial aneurysms on a screening magnetic resonance angiography: a 3-mm right carotid ophthalmic aneurysm and an 8-mm partially fusiform paraclinoid carotid artery aneurysm. A standard left pterional craniotomy was performed. Intraoperative adenosine was used instead of temporary clipping because her vessels were extremely friable. After reconstruction, an intraoperative indocyanine green angiogram was obtained, confirming complete aneurysmal obliteration and internal carotid artery patency. CONCLUSION:This is the first detailed report of a clear association between intracranial aneurysms and LDS. An association between LDS and intracranial aneurysms, if substantiated in a larger study, has implications for aneurysm screening in this population. Such an association may shed light on mechanisms of aneurysm formation, growth, and rupture.

Use of heparin-coated stents in neurovascular interventional procedures: Preliminary experience with 10 patients

OBJECTIVE:Currently, there is minimal published data on the use of heparin-coated stents in the neurovasculature; however, these stents have a proven clinical record in the treatment of coronary disease. This article details our experience with the safety and technical aspects of stent deployment in the first 10 patients who had heparin-coated stents placed in the intracranial and cervical vasculature and the preliminary follow-up in most cases. METHODS:We retrospectively reviewed the clinical history, intra- and periprocedural data, and imaging for the patients who received heparin-coated stents in the cervical and intracranial vasculature for cerebrovascular disease between October 2002 and October 2003. RESULTS:Thirteen heparin-coated stents were placed in 10 patients. Seven out of the 10 patients had heparin-coated stents placed in the posterior circulation; the remaining three patients had stents placed in the anterior circulation. Four patients had stents placed intracranially. There was no acute or subacute in-stent thrombosis and no procedure-related complications. Follow-up was performed on most patients, with no clinical symptoms attributable to restenosis in any patient. CONCLUSION:This small series suggests that heparin-coated stents are safe for use in the treatment of cervical and intracranial atherosclerotic disease. Longer-term follow-up is needed to study the heparin coating effect on in-stent restenosis rates and to assess the long-term durability and clinical efficacy of this stent. The use of drug-coated stents in the cerebrovascular circulation is an area that warrants further investigation.

Modern endovascular and aesthetic surgery techniques to treat arteriovenous malformations of the scalp: case illustration

BACKGROUND Arteriovenous malformations of the scalp consist of abnormally connecting arterial feeding vessels and draining veins, devoid of a normal capillary bed within the subcutaneous fatty layer of the scalp. We present a case of a left temporal scalp AVM treated for aesthetic and pain-related concerns. A multidisciplinary approach combining endovascular AVM embolization and AVM excision with local flap reconstruction was chosen. CASE DESCRIPTION The patient presented with a progressive painful pulsatile mass in the left temporal region. On examination, there was no evidence of any facial nerve compromise or any other neurologic deficits. Computed tomographic angiography revealed a 6-mm lesion located totally within the scalp and not associated with bone or periosteum. A recommendation was made to proceed with preoperative embolization to facilitate surgical resection. The AVM was occluded endovascularly using multiple detachable platinum coils, and the patient was neurologically intact. The following day, the patient was taken to the operating room. By that time, the mass was minimally pulsatile. The AVM was resected en bloc, and a 3-layered intermediate closure of the 5.5-cm defect was then performed. The procedure was well tolerated, and the patient had an uneventful postoperative course. CONCLUSIONS Scalp AVMs are interesting lesions with heterogeneous anatomical features. Treatment can be optimized in a multidisciplinary environment, using a prescribed treatment algorithm to minimize the size of soft/hard tissue defect and enhance cosmesis. Careful selection of therapeutic modalities based on AVM anatomy and aesthetic concerns can lead to safe and durable results with high patient satisfaction rates.

External carotid artery angioplasty and stenting to augment cerebral perfusion in the setting of subacute symptomatic ipsilateral internal carotid artery occlusion : Case report

The authors performed external carotid artery (ECA) angioplasty and stenting in a 45-year-old man who had presented with right hemispheric crescendo ischemic symptoms stemming from acute right internal carotid artery occlusion (ICAO). This unique application of ECA angioplasty and stenting augmented cerebral perfusion and improved clinical symptoms. In certain situations, ECA stenting can increase cerebral perfusion in the setting of ICAO and ECA stenosis. The authors are the first to describe this approach in this context.

Reconstruction of pterional defects after frontotemporal and orbitozygomatic craniotomy using Medpor Titan implant: Cosmetic results in 98 patients

OBJECTIVE Reconstruction of pterional and temporal defects after frontotemporal (FT) and orbitozygomatic (OZ) craniotomy is important for avoidance of temporal hollowing, maintaining functional restoration, and achieving optimal cosmesis. The objective of this study is to describe our experience and cosmetic results with pterional reconstruction after FT and OZ craniotomy with the Medpor Titan implant. METHODS Ninety-eight consecutive patients underwent reconstruction of pterional and temporal defects after FT and OZ craniotomy using the Medpor Titan implant. The implant was shaped to recreate the pterion to provide coverage for the cranial defect and to bolster the temporalis muscle to prevent temporal hollowing. The implant was then secured to the bone flap with titanium screws. Cosmetic evaluation was performed from both surgeons and patients perspective. RESULTS Of 90 patients who underwent cosmetic assessment at the 3 month follow-up, temporalis asymmetry was noticed subjectively by three patients and noted in 7 patients by the surgeon. Orbital asymmetry was not noticed in any cases by either surgeon or patient. Overall patient satisfaction was found in 89 of 90 patients (98.9%). There were no cases of temporal hollowing. One patient had a delayed wound infection, and one had an inflammatory reaction that required removal of the implant. CONCLUSIONS Our technique using the Medpor Titan implant is a fast and effective method for pterional reconstruction after FT and OZ craniotomy with excellent cosmetic results and patient satisfaction. The implant combines the advantages of both porous polyethylene and titanium mesh, including easy custom-shaping without sharp edges, structural support and relatively lower cost.

Comparison of intraoperative portable CT scanners in skull base and endoscopic sinus surgery: Single center case series

Precise and safe management of complex skull base lesions can be enhanced by intraoperative computed tomography (CT) scanning. Surgery in these areas requires real-time feedback of anatomic landmarks. Several portable CT scanners are currently available. We present a comparison of our clinical experience with three portable scanners in skull base and craniofacial surgery. We present clinical case series and the participants were from the Northwestern Memorial Hospital. Three scanners are studied: one conventional multidetector CT (MDCT), two digital flat panel cone-beam CT (CBCT) devices. Technical considerations, ease of use, image characteristics, and integration with image guidance are presented for each device. All three scanners provide good quality images. Intraoperative scanning can be used to update the image guidance system in real time. The conventional MDCT is unique in its ability to resolve soft tissue. The flat panel CBCT scanners generally emit lower levels of radiation and have less metal artifact effect. In this series, intraoperative CT scanning was technically feasible and deemed useful in surgical decision-making in 75% of patients. Intraoperative portable CT scanning has significant utility in complex skull base surgery. This technology informs the surgeon of the precise extent of dissection and updates intraoperative stereotactic navigation.

Surgical Treatment of Elevated Intracranial Pressure: Decompressive Craniectomy and Intracranial Pressure Monitoring

Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.