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Davison MA, Lilly DT, Patel AA, Kashkoush A, Chen X, Wei W, Benzel EC, Prayson RA, Chao S, Angelov L. Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas. J Neurooncol 2024:10.1007/s11060-024-04623-4. [PMID: 38438766 DOI: 10.1007/s11060-024-04623-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE Primary treatment of spinal ependymomas involves surgical resection, however recurrence ranges between 50 and 70%. While the association of survival outcomes with lesion extent of resection (EOR) has been studied, existing analyses are limited by small samples and archaic data resulting in an inhomogeneous population. We investigated the relationship between EOR and survival outcomes, chiefly overall survival (OS) and progression-free survival (PFS), in a large contemporary cohort of spinal ependymoma patients. METHODS Adult patients diagnosed with a spinal ependymoma from 2006 to 2021 were identified from an institutional registry. Patients undergoing primary surgical resection at our institution, ≥ 1 routine follow-up MRI, and pathologic diagnosis of ependymoma were included. Records were reviewed for demographic information, EOR, lesion characteristics, and pre-/post-operative neurologic symptoms. EOR was divided into 2 classifications: gross total resection (GTR) and subtotal resection (STR). Log-rank test was used to compare OS and PFS between patient groups. RESULTS Sixty-nine patients satisfied inclusion criteria, with 79.7% benefitting from GTR. The population was 56.2% male with average age of 45.7 years, and median follow-up duration of 58 months. Cox multivariate model demonstrated significant improvement in PFS when a GTR was attained (p <.001). Independently ambulatory patients prior to surgery had superior PFS (p <.001) and OS (p =.05). In univariate analyses, patients with a syrinx had improved PFS (p =.03) and were more likely to benefit from GTR (p =.01). Alternatively, OS was not affected by EOR (p =.78). CONCLUSIONS In this large, contemporary series of adult spinal ependymoma patients, we demonstrated improvements in PFS when GTR was achieved.
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Affiliation(s)
- Mark A Davison
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel T Lilly
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Arpan A Patel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Kashkoush
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaoying Chen
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Wei
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward C Benzel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Richard A Prayson
- Department of Anatomic Pathology, The Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel Chao
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
- Neurologic Oncology and Radiosurgery Fellowships, Neurological Surgery, CCLCM at CWRU, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, 9500 Euclid Ave., CA-51, 44195, Cleveland, OH, USA.
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Achey RL, El-Abtah ME, Davison MA, Glauser G, Thiyagarajah N, Kashkoush A, Patterson TE, Kshettry VR, Rasmussen P, Bain M, Moore NZ. The obesity paradox and ventriculoperitoneal shunting in aneurysmal subarachnoid hemorrhage patients undergoing microsurgical clipping. J Clin Neurosci 2024; 120:42-47. [PMID: 38183771 DOI: 10.1016/j.jocn.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/19/2023] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) can be devastating. Identifying predisposing factors is paramount in reducing aSAH-related mortality. Obesity's negative impact on health is well-established. However, the controversial "obesity paradox" in neurosurgery suggests that obesity may confer a survival advantage in SAH. We hypothesized that obesity would have a negative impact on outcomes following surgical clipping in aSAH. METHODS A single-institution retrospective review was performed of aSAH patients undergoing surgical clipping from 2017 to 2021. Demographics and clinically relevant variables were collected. Obesity was defined as body mass index >30. Primary outcome was death or severe disability (mRS 4-6) at last follow-up. Secondary outcome was VPS placement. Multivariable Cox proportional-hazards model identified predictors of poor outcome. Kaplan-Meier curves identified survivorship differences between obese and non-obese patients. RESULTS Poor outcome occurred in 11 of 52 total patients (21.2 %). There were no differences in demographics or distribution of Hunt Hess (HH), modified Fisher Grade (mFG), or external ventricular drain (EVD) placement between obese and non-obese patients. On univariate analysis, hypertension, older age, and non-obesity were predictive of poor outcome. On multivariable analysis, only obesity remained significant, suggesting a protective effect from poor outcome (HR 0.45 [0.21-0.95], p = 0.037). VPS placement occurred in 6 (11.5 %) patients for which obesity was not a significant predictor. CONCLUSIONS Obesity may have a protective effect against poor outcome following surgical clipping in aSAH. Additionally, obesity does not appear to increase rate of EVD conversion to VPS. Thus, our study suggests that obesity should not preclude patients from open surgical intervention when clinically appropriate.
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Affiliation(s)
- Rebecca L Achey
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Mark A Davison
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Gregory Glauser
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States
| | | | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States
| | | | - Varun R Kshettry
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States; Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, United States; Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, United States
| | - Peter Rasmussen
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States; Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, United States
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States; Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, United States
| | - Nina Z Moore
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, United States; Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, United States.
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Kashkoush A, El-Abtah ME, Davison MA, Toth G, Moore N, Bain M. Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01027. [PMID: 38251895 DOI: 10.1227/ons.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/01/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms. METHODS We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale. RESULTS Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant. CONCLUSION Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mark A Davison
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Moore
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Kashkoush A, El-Abtah ME, Petitt JC, Glauser G, Winkelman R, Achey RL, Davison M, Abdulrazzak MA, Hussain SM, Toth G, Bain M, Moore N. Flow diversion for the treatment of intracranial bifurcation aneurysms: a systematic review and meta-analysis. J Neurointerv Surg 2023:jnis-2023-020582. [PMID: 37541838 DOI: 10.1136/jnis-2023-020582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Flow diversion (FD: flow diversion, flow diverter) is an endovascular treatment for many intracranial aneurysm types; however, limited reports have explored the use of FDs in bifurcation aneurysm management. We analyzed the safety and efficacy of FD for the management of intracranial bifurcation aneurysms. METHODS A systematic review identified original research articles that used FD for treating intracranial bifurcation aneurysms. Articles with >4 patients that reported outcomes on the use of FDs for the management of bifurcation aneurysms along the anterior communicating artery (AComA), internal carotid artery terminus (ICAt), basilar apex (BA), or middle cerebral artery bifurcation (MCAb) were included. Meta-analysis was performed using a random effects model. RESULTS 19 studies were included with 522 patients harboring 534 bifurcation aneurysms (mean size 9 mm, 78% unruptured). Complete aneurysmal occlusion rate was 68% (95% CI 58.7% to 76.1%, I2=67%) at mean angiographic follow-up of 16 months. Subgroup analysis of FD as a standalone treatment estimated a complete occlusion rate of 69% (95% CI 50% to 83%, I2=38%). The total complication rate was 22% (95% CI 16.7% to 28.6%, I2=51%), largely due to an ischemic complication rate of 16% (95% CI 10.8% to 21.9%, I2=55%). The etiologies of ischemic complications were largely due to jailed artery hypoperfusion (47%) and in-stent thrombosis (38%). 7% of patients suffered permanent symptomatic complications (95% CI 4.5% to 9.8%, I2=6%). CONCLUSION FD treatment of bifurcation aneurysms has a modest efficacy and relatively unfavorable safety profile. Proceduralists may consider reserving FD as a treatment option if no other surgical or endovascular therapy is deemed feasible.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jordan C Petitt
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gregory Glauser
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Winkelman
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca L Achey
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Davison
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad A Abdulrazzak
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Shazam M Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nina Moore
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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El-Abtah ME, Kashkoush A, Petitt JC, McMillan A, Hu S, Finocchiaro R, Hunter K, Kelly ML. Diffuse Axonal Injury Pattern Predicts Timing of In-Hospital Neurological Recovery: A Retrospective Case Series. World Neurosurg 2023:S1878-8750(23)00845-8. [PMID: 37356490 DOI: 10.1016/j.wneu.2023.06.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/16/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Diffuse axonal injury (DAI) is a devastating traumatic neurological injury with variable prognosis. Although outcomes such as mortality have been described, the time course of neurological progression is poorly understood. We investigated the association between DAI neuroanatomical injury pattern and neurological recovery timing. METHODS A retrospective review of our institution's trauma registry identified patients diagnosed with DAI from 2017-2021. Neuroradiologist review of head CT was used to score DAI severity. In-hospital neurological exams were reviewed, and GCS was calculated for all patients throughout the hospital stay. Categorical variables were analyzed using Fisher's exact test and continuous variables were analyzed using Kruskal-Wallis test. RESULTS Nineteen DAI patients (Grade 1=8; Grade 2=1; Grade 3=10) were included (mean age 31 years, 79% male). Mean Rotterdam CT score, Injury Severity Scale, and admission GCS were comparable across DAI grades. Mean time in days to follow commands was shorter for those with Grade 1 DAI (9.3) compared to Grade 2 (17 days) or Grade 3 (19 days) DAI (p=0.02). Throughout hospitalization, patients with Grade 1 DAI had higher motor (p=0.006), eye (p=0.001), and total GCS (p=0.011) score compared to those with Grade 2 or 3 DAI. At the time of discharge, total GCS and the frequency of command following was similar across DAI grades. CONCLUSIONS Patients with Grade 1 DAI demonstrated the fastest short-term neurological recovery, although final discharge neurological examination was comparable across DAI grades. DAI classification can provide useful short-term prognostic information regarding in-hospital neurological improvement.
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Affiliation(s)
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, USA, 9500 Euclid Ave, Cleveland, OH, USA 44195
| | - Jordan C Petitt
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Aubrey McMillan
- Department of Radiology, Case Western Reserve University School of Medicine MetroHealth Medical Center, Cleveland, OH, USA, 2500 MetroHealth Drive Cleveland, Ohio, USA 44109
| | - Song Hu
- Department of Radiology, Case Western Reserve University School of Medicine MetroHealth Medical Center, Cleveland, OH, USA, 2500 MetroHealth Drive Cleveland, Ohio, USA 44109
| | - Roman Finocchiaro
- Department of Radiology, Case Western Reserve University School of Medicine MetroHealth Medical Center, Cleveland, OH, USA, 2500 MetroHealth Drive Cleveland, Ohio, USA 44109
| | - Kyle Hunter
- Department of Radiology, Case Western Reserve University School of Medicine MetroHealth Medical Center, Cleveland, OH, USA, 2500 MetroHealth Drive Cleveland, Ohio, USA 44109
| | - Michael L Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine MetroHealth Medical Center, Cleveland, OH, USA, 2500 MetroHealth Drive Cleveland, Ohio 44109.
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Petitt JC, Stanley S, Kashkoush A, Ahorukomeye P, Potter TO, Ho VP, Kelly ML. Percutaneous vertebral augmentation for acute traumatic vertebral Fractures: A TQIP database study. J Clin Neurosci 2023; 110:19-26. [PMID: 36780782 DOI: 10.1016/j.jocn.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/18/2023] [Accepted: 02/02/2023] [Indexed: 02/13/2023]
Abstract
Patients with vertebral fractures may be treated with percutaneous vertebroplasty (VP) and kyphoplasty (KP) for pain relief. Few studies examine the use of VP and KP in the setting of an acute trauma. In this study, we describe the current use of VP/KP in patients with acute traumatic vertebral fractures. All patients in the ACS Trauma Quality Improvement Program (TQIP) 2016 National Trauma Databank with severe spine injury (spine AIS ≥ 3) met inclusion criteria, including patients who underwent PVA. Logistic regression was used to assess patient and hospital factors associated with PVA; odds ratios and 95 % confidence intervals are reported. 20,769 patients met inclusion criteria and 406 patients received PVA. Patients aged 50 or older were up to 6.73 (2.45 - 27.88) times more likely to receive PVA compared to younger age groups and women compared to men (1.55 [1.23-1.95]). Hospitals with a Level II trauma center and with 401-600 beds were more likely to perform PVA (2.07 [1.51-2.83]) and (1.82 [1.04-3.34]) respectively. African American patients (0.41 [0.19-0.77]), isolated trauma (0.64 [0.42-0.96]), neurosurgeon group size > 6 (0.47 [0.30-0.74]), orthopedic group size > 10, and hospitals in the Northeastern and Western regions of the U.S. (0.33 [0.21-0.51] and 0.46 [0.32-0.64]) were less likely to be associated with PVA. Vertebroplasty and kyphoplasty use for acute traumatic vertebral fractures significantly varied across major trauma centers in the United States by multiple patient, hospital, and surgeon demographics. Regional and institutional practice patterns play an important role in the use of these procedures.
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Affiliation(s)
- Jordan C Petitt
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Samuel Stanley
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States of America.
| | - Peter Ahorukomeye
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Tamia O Potter
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
| | - Vanessa P Ho
- Department of Trauma Surgery, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, United States of America.
| | - Michael L Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America.
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7
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Achey R, Kashkoush A, Potter T, Davison M, Moore NZ, Kshettry VR, Bain M. Surgical Resection of Deep-Seated Arteriovenous Malformations Through Stereotactically Guided Tubular Retractor Systems: A Case Series. Oper Neurosurg (Hagerstown) 2023; 24:499-506. [PMID: 36716066 DOI: 10.1227/ons.0000000000000599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/24/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) in the subcortical and/or periventricular regions can cause significant intraventricular and intracranial hemorrhage. These AVMs can pose a unique surgical challenge because traditional, open approaches to the periventricular region require significant cortical/white matter retraction to establish sufficient operative corridors, which may result in risk of neurological injury. Minimally invasive tubular retractor systems represent a novel, feasible surgical option for treating deep-seated AVMs. OBJECTIVE To explore 5 cases of NICO BrainPath-assisted resection of subcortical/periventricular AVMs. METHODS Five patients from a single institution were operated on for deep-seated AVMs using tubular retractor systems. Collected data included demographics, AVM specifications, preoperative neurological status, postoperative neurological status, and postoperative/intraoperative angiogram results. RESULTS Five patients, ranging from age 10 to 45 years, underwent mini-craniotomy for stereotactically guided tubular retractor-assisted AVM resection using neuronavigation for selecting a safe operative corridor. No preoperative embolization was necessary. Mean maximum AVM nidal diameter was 8.2 mm. All deep-seated AVMs were completely resected without complications. All AVMs demonstrated complete obliteration on intraoperative angiogram and on 6-month follow-up angiogram. CONCLUSION Minimally invasive tubular retractors are safe and present a promising surgical option for well-selected deep-seated AVMs. Furthermore, study may elucidate whether tubular retractors improve outcomes after microsurgical AVM resection secondary to mitigation of iatrogenic retraction injury risk.
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Affiliation(s)
- Rebecca Achey
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tamia Potter
- Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - Mark Davison
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nina Z Moore
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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8
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El-Abtah ME, Kashkoush A, Achey R, Patterson T, Moore NZ, Bain MD. Diagnostic yield of cerebral angiography for intracranial hemorrhage in young patients: A single-center retrospective analysis. Interv Neuroradiol 2023:15910199231152505. [PMID: 36691317 DOI: 10.1177/15910199231152505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) secondary to hypertension (HTN) classically occurs in the basal ganglia, cerebellum, or pons. Vascular lesions such as aneurysms or arteriovenous malformations (AVMs) are more common in younger patients. We investigated the utility of diagnostic subtraction angiography (DSA) in young hypertensive patients with non-lobar ICH. METHODS A retrospective review (2013-2022) identified young (18-60 years) patients who underwent DSA for ICH. HTN history, ICH location, presence/absence of subarachnoid hemorrhage (SAH), and computed tomography angiography (CTA) findings were collected. The main outcome was DSA-positivity, defined as presence of an AVM, aneurysm, Moyamoya disease, reversible cerebral vasoconstriction syndrome, or dural arteriovenous fistula on DSA. RESULTS Two hundred sixty patients were included, and the DSA-positivity rate was 19%.DSA-positivity was lower in hypertensive patients with ICHs in the cerebellum, pons, or basal ganglia compared to the rest of the patient sample (9% vs 26%, p = 0.0002, Fisher's exact test). We developed the ICH-Angio score (0-5 points) based on CTA findings, ICH location, HTN history, and presence of SAH to predict risk of underlying vascular lesions. DSA-positivity was lower in those with a score of 0 (0/62; 0%) compared to a score of 1 (5/52; 10%), 2 (17/48; 35%), 3 (10/20; 50%), 4 (5/6; 83%), or 5 (3/3; 100%). CONCLUSION The ICH-Angio score was able to non-invasively rule out an underlying vascular etiology for ICH in up to one-third of patients. HTN, ICH location, CTA findings, and associated SAH can identify patients at low risk for harboring underlying vascular lesions.
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Affiliation(s)
- Mohamed E El-Abtah
- 12304Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ahmed Kashkoush
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Achey
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Patterson
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nina Z Moore
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark D Bain
- Department of Neurological Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, OH, USA
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9
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Kashkoush A, El-Abtah ME, Achey R, Hussain MS, Toth G, Moore NZ, Bain M. Flow Diversion as Destination Treatment of Intracranial Mycotic Aneurysms: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2023; 24:492-498. [PMID: 36715979 DOI: 10.1227/ons.0000000000000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/21/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Mycotic aneurysms represent a rare type of intracranial aneurysm. Treatment options usually consist of coiling, clipping, or liquid embolization. Data regarding outcomes after flow diversion of mycotic aneurysms are sparse. OBJECTIVE To present a single-center case series regarding our experience with FD as definitive treatment for ruptured mycotic aneurysms initially treated with coil embolization. METHODS We retrospectively reviewed a prospectively maintained database of all cerebrovascular procedures performed at a single institution between 2017 and 2021 for cases that used FD for the management of intracranial mycotic aneurysms. Prospectively collected data included patient demographics, medical history, rupture status, aneurysm morphology, aneurysm location, and periprocedural complications. The main outcomes included neurological examination and radiographic occlusion rate on cerebral digital subtraction angiography. RESULTS Three patients with 4 ruptured mycotic aneurysms that were initially treated with coil embolization were identified that required retreatment. The aneurysms were located along the middle cerebral artery bifurcation (n = 2), posterior cerebral artery P1/2 junction (n = 1), and basilar artery apex (n = 1), which all demonstrated recurrence after initial coil embolization. Successful retreatment using flow diverting stents was performed in all 3 patients. At the last angiographic follow-up, all aneurysms demonstrated complete occlusion. No patients suffered new periprocedural complications or neurological deficits after FD. CONCLUSION Flow-diverting stents may be an effective treatment option for intracranial mycotic aneurysms that are refractory to previous endovascular coiling. Future studies are warranted to establish the associated long-term safety and clinical efficacy.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Z Moore
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Kashkoush A, El-Abtah ME, Srivatsa S, Desai A, Davison M, Achey R, Mahapatra A, Patterson T, Moore N, Bain M. Comparative effectiveness of stent-assisted coiling and Woven EndoBridge embolization for the treatment of unruptured wide-neck bifurcation intracranial aneurysms. J Neurosurg 2022:1-7. [PMID: 36334292 DOI: 10.3171/2022.10.jns221138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs. METHODS Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices. RESULTS Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202-834] days vs 228 [177-494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8-3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630. CONCLUSIONS Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.
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Affiliation(s)
- Ahmed Kashkoush
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
| | | | - Shaarada Srivatsa
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
| | - Ansh Desai
- 2Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mark Davison
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
| | - Rebecca Achey
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
| | - Ashutosh Mahapatra
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
| | - Thomas Patterson
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
| | - Nina Moore
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
| | - Mark Bain
- 1Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland; and
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11
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Petitt JC, Desai A, Kashkoush A, Ahorukomeye P, Potter TO, Stout A, Kelly ML. In Reply to the Letter to the Editor Regarding Failure of Conservatively Managed Traumatic Vertebral Compression Fractures: A Systematic Review. World Neurosurg 2022; 167:248. [PMID: 36793174 DOI: 10.1016/j.wneu.2022.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Jordan C Petitt
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, and MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Ansh Desai
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, and MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Peter Ahorukomeye
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, and MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Tamia O Potter
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, and MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Amber Stout
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Michael L Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, and MetroHealth Medical Center, Cleveland, Ohio, USA.
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12
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Achey RL, Soni P, Kashkoush A, Davison M, Kondylis E, Moore N, Bain M. Novel Use of the Aurora Surgiscope System for Minimally Invasive Resection of Intraparenchymal Lesions: A Case Series. Oper Neurosurg (Hagerstown) 2022; 23:182-187. [PMID: 35972079 DOI: 10.1227/ons.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 03/24/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS) for intracranial pathology minimizes surgical morbidity but can come at the cost of operator ergonomics and technical surgical success. Here, the authors present a case series to report the first use of a novel 15-mm tubular retraction system with integrated lighting and visualization capabilities for MIS access to intracranial lesions. OBJECTIVE To demonstrate feasibility and effectiveness of the 15-mm Aurora Surgiscope (Integra Lifesciences) for intracranial MIS approaches. METHODS The 15-mm Aurora Surgiscope facilitated MIS approach to gain access to intraparenchymal pathologies. The device consists of a tubular access system with integrated light source and a reusable control unit that modifies video parameters. The port was inserted along a preplanned trajectory through a mini-craniotomy. Bimanual access allowed the surgeon to comfortably dissect/resect lesional tissue using high-quality video. RESULTS Four patients are presented. In cases 1 and 2, the authors evacuated acute intracerebral hemorrhages. Both had <15 cc hemorrhage with improved or stable neurological examination. In case 3, the authors performed gross total resection of a cerebellar pilocytic astrocytoma. In case 4, the authors resected a mesial posterior temporal cavernoma. No perioperative/technical complications were noted. CONCLUSION The Aurora Surgiscope system is a novel integrated tubular retraction, lighting, and visualization system that allows access to a wide variety of pathologies using a MIS approach. The Surgiscope allows the surgeon to use bimanual dexterity through a small access port while limiting the need for additional equipment such as microscope, exoscope, or endoscope.
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Affiliation(s)
- Rebecca L Achey
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Pranay Soni
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ahmed Kashkoush
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark Davison
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Efstathios Kondylis
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nina Moore
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Department of Neurosurgery, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Department of Neurosurgery, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Petitt JC, Desai A, Kashkoush A, Ahorukomeye P, Potter TO, Stout A, Kelly ML. Failure of Conservatively Managed Traumatic Vertebral Compression Fractures: A Systematic Review. World Neurosurg 2022; 165:81-88. [PMID: 35724881 DOI: 10.1016/j.wneu.2022.06.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Most vertebral compression fractures (VCFs) are successfully managed conservatively, however, some patients fail conservative management and require further surgical treatment. Here, we identify significant variables that contribute to progressive vertebral collapse in non-operative treatment of traumatic VCFs. METHODS A systematic review using PRISMA guidelines identified original research articles of conservatively managed VCF secondary to trauma from inception to September 2021. Articles with patients treated with initial non-operative therapy, AO-Type A0/A1/A2 fractures, risk factor analysis, >10 patients, and vertebral fracture secondary to trauma were included. Articles including pediatric patients, burst fractures or AO-Type A3/A4 fractures, vertebral fractures secondary to neoplasm or infectious disease, and operative versus non-operative treatment comparative studies were excluded. Failure of non-operative treatment was defined as salvage surgery/vertebral augmentation, progressive kyphosis, chronic pain, or functional disability. RESULTS 3,877 articles were identified, and six articles were included. 582 patients had conservatively managed thoracolumbar VCFs. 102 patients had reported treatment failure (17.5%). Of the 102 treatment failures, 37 (36.3%) were due to subsequent VCF, 33 (32.4%) to back pain or functional disability at follow-up, and 32 (31.4%) were to increased compression rate or kyphotic deformity at follow-up. Two of the six studies (33.3%) demonstrated prior VCF as a significant variable. Age, lumbar bone mineral density, segmental Cobb angle, and vertebral height loss were each described as a significant factor in one of the six studies (16.7%). CONCLUSION Identifying patients who are at risk for treatment failure may help select individuals that would benefit from close clinical follow-up or early surgical/procedural intervention.
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Affiliation(s)
- Jordan C Petitt
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Ansh Desai
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States of America. (9500 Euclid Ave, Cleveland, OH 44195)
| | - Peter Ahorukomeye
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Tamia O Potter
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Amber Stout
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America. (11100 Euclid Ave. Cleveland, OH 44106)
| | - Michael L Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH, United States of America. (2500 MetroHealth Drive Cleveland, Ohio 44109).
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14
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El-Abtah ME, Petitt JC, Kashkoush A, Achey R, Bain MD, Moore NZ. Endovascular Management of AVM-Associated Intracranial Aneurysms: A Systematic Literature Review. World Neurosurg 2022; 164:257-269. [PMID: 35597540 DOI: 10.1016/j.wneu.2022.05.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Intracranial aneurysms are present in up to 18% of arteriovenous malformations (AVMs) and increase the risk of intracranial hemorrhage. No consensus exists on the optimal treatment strategy for AVM-associated aneurysms. The goal of this study was to systematically review current endovascular treatment methods of AVM-associated intracranial aneurysms, radiographic outcomes, and periprocedural complications. METHODS A systematic review was performed in accordance with PRISMA guidelines to identify studies that investigated the use of endovascular treatments for management of patients with AVM-associated aneurysms. Collected variables included aneurysm and AVM location, aneurysm size and characteristics, AVM and aneurysm treatment modality, periprocedural complications, and long-term clinical and radiographic outcomes. RESULTS A total of eight studies with 237 patients and 314 AVM-associated intracranial aneurysms were included. Two-hundred twenty four aneurysms were flow-related (71.3%; 224/314), 80 were intranidal (25.5%; 80/314), and 10 were unrelated (3.2%; 10/314). Complete occlusion was 56.3% (18/32) for aneurysmal coil embolization and 99% (104/105) for parent vessel sacrifice. Of the 13 aneurysms treated with ethanol sclerotherapy, eight were successfully obliterated (8/13; 61%) using ethanol sclerotherapy alone and the rest required adjunct endovascular embolization for obliteration of the artery and associated aneurysm. The periprocedural complication rate was approximately 12% and consisted of ischemic symptoms, intracranial hemorrhage, and coiling complications. CONCLUSION Endovascular management options of AVM-associated intracranial aneurysms are limited and mostly comprised of primary aneurysmal coil embolization or parent vessel sacrifice using coils or liquid embolics. Embolization strategy depends on factors such as AVM angioarchitecture, rupture status, and adjunct AVM treatments.
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Affiliation(s)
- Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jordan C Petitt
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark D Bain
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nina Z Moore
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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15
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Kashkoush A, Petitt J, Ladhani H, Ho V, Kelly ML. 474 Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians With Subdural Hematomas. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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16
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Kashkoush A, Petitt JC, Ladhani H, Ho VP, Kelly ML. Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians with Subdural Hematomas. World Neurosurg 2022; 157:e179-e187. [PMID: 34626845 PMCID: PMC8692425 DOI: 10.1016/j.wneu.2021.09.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures. CONCLUSIONS Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, United States of America. (9500 Euclid Ave, Cleveland, OH 44195)
| | - Jordan C. Petitt
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Husayn Ladhani
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Vanessa P. Ho
- Division of Trauma and Acute Care Surgery, Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
| | - Michael L. Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA. (2500 MetroHealth Drive Cleveland, Ohio 44109)
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Sinex DCE, Bowen ST, Kashkoush A, Rosemond A, Carter D, Menon PG, Moalli PA, Abramowitch SD. The establishment of a 3D anatomical coordinate system for defining vaginal axis and spatial position. Comput Methods Programs Biomed 2021; 208:106175. [PMID: 34082373 PMCID: PMC9277768 DOI: 10.1016/j.cmpb.2021.106175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/05/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Pelvic organ prolapse (POP), the herniation of the pelvic organs toward the vaginal opening, is a common pelvic floor disorder (PFD) whose etiology is poorly understood. Traditional methods for evaluating POP are often constrained to external vaginal examination, limited to 2D, or have poor reproducibility. We propose a reliable 3D anatomic coordinate system for standardized 3D assessment of pelvic anatomy using magnetic resonance imaging (MRI). METHODS The novel 3D anatomic reference system is based on six bony landmarks of the pelvis manually identified in MRI: the ischial spines and the superior and inferior pubic points of the left and right pubic symphysis. The origin of this system is defined as the midpoint of the ischial spines. The reproducibility and applicability of the pelvic coordinate system were evaluated by (1) implementing it in a new method to quantify vaginal position and axis (angulation) in 3D space from MRI segmentations of the vagina and (2) computing the intraclass correlation (ICC) on coordinate system and vaginal measures. The MRI analysis was performed by four non-medically trained observers on five pelvic MRI datasets on approximately five separate occasions. RESULTS Overall, all bony landmarks had excellent intra-observer reliability and inter-observer reliability (ICC>0.90); intra-observer reliability was moderate-to-good among the vaginal position parameters (0.5<ICC≤0.90) and moderate for the vaginal axis angles (0.50<ICC≤0.75); inter-observer reliability was moderate in the vaginal position coordinates and vaginal axis measures. On average, within-observer differences in the vaginal position and angle measures relative to the overall mean were <1 mm and <1°, respectively. CONCLUSIONS The proposed anatomic coordinate system and vaginal analysis approach allow quantitative assessment of pelvic anatomy that is robust to the experience level of the observer. The application of these methods in radiographic studies will give new insight into the underlying anatomic changes involved in the pathogenesis of POP and other PFDs and help better understand their etiology.
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Affiliation(s)
- Deanna C E Sinex
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | | | | | | | - Prahlad G Menon
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Pamela A Moalli
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Magee Women's Research Institute, Pittsburgh, PA, United States
| | - Steven D Abramowitch
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States.
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Donohue J, Kashkoush A, Alan N, Agarwal N. Bibliometric profiles of contemporary leaders in neurosurgery. Interdisciplinary Neurosurgery 2021. [DOI: 10.1016/j.inat.2020.101087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Kashkoush A, Chakravarthy V, Bain M, Kalfas I, Steinmetz M. Two cases of supratentorial lobar intracranial hemorrhage following lumbar decompression and stabilization. Surg Neurol Int 2021; 12:221. [PMID: 34084648 PMCID: PMC8168694 DOI: 10.25259/sni_271_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/07/2021] [Indexed: 11/04/2022] Open
Abstract
Background Lumbar spine surgery with or without intraoperative dural tear (DT) may contribute to postoperative subdural hematomas and/or cerebellar intracranial hemorrhages (ICHs). Here, we present two patients, one with and one without an intraoperative DT occurring during lumbar surgery, both of whom developed acute postoperative supratentorial ICHs. Case Description Two patients developed supratentorial lobar ICH following lumbar decompressions and fusion. The first patient, without an intraoperative DT, developed multiple ICHs involving the left cerebellum and left temporal lobe. The second patient, following an L4-5 decompression/instrumented fusion involving a DT, postoperatively developed a large right frontal ICH. Conclusion Here, two patients undergoing lumbar spine surgery with/without DT subsequently developed significant ICH.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Vikram Chakravarthy
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Mark Bain
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Iain Kalfas
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Michael Steinmetz
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, United States
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Kashkoush A, Mehta A, Agarwal N, Nwachuku EL, Fields DP, Alan N, Kanter AS, Okonkwo DO, Hamilton DK, Thirumala PD. Perioperative Neurological Complications Following Anterior Cervical Discectomy and Fusion: Clinical Impact on 317,789 Patients from the National Inpatient Sample. World Neurosurg 2019; 128:e107-e115. [DOI: 10.1016/j.wneu.2019.04.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/26/2022]
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Shah R, Kashkoush J, Kashkoush A, Patel T. Analysis of the top 100 most influential papers in benign prostatic hyperplasia. Can Urol Assoc J 2019; 14:cuaj.5831. [PMID: 31658011 DOI: 10.5489/cuaj.5831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The fund of knowledge on benign prostatic hypertrophy (BPH) has been growing since the 1970s. Citation analysis is a tool by which we can quantify influence of specific articles and assess the growth of a certain topic. This paper seeks to identify trends, as well as draw attention to the most influential papers, authors, and journals. Many analogous studies have been done, but none have been done in the field of BPH. METHODS We used Thomson Reuters Web of Science to collect articles pertaining to BPH in a two-step fashion. We identified 117 keywords relevant to BPH and using these 117 words, we were able to identify 7302 total articles. These articles were organized by number of citations. Of the top 200 articles, 100 articles were excluded based on title and abstract analysis. One hundred articles were included for final analysis, as this is the standard of citation analysis. RESULTS Overall, total citations were slightly correlated with journal impact factor. Author analysis revealed no significant difference between authorship and average citations. Topic analysis showed the most cited topic was surgical management with 657.35 citations per year. Study design analysis showed the predominant study design was the randomized control trial. CONCLUSIONS By using the two-step methodology, we were able to create a list of the top 100 most influential articles in the field of BPH. In doing so, we illustrated the growth of the field over time and paid tribute to the myriad of papers, authors, and journals that have shaped the field to this day.
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Affiliation(s)
- Rohan Shah
- Department of Urology, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Jasmine Kashkoush
- Department of Urology, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Ahmed Kashkoush
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Trushar Patel
- Department of Urology, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
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Kashkoush A, Agarwal N, Ayres A, Novak V, Chang YF, Friedlander RM. Scrubbing technique and surgical site infections: an analysis of 14,200 neurosurgical cases. J Neurosurg 2019; 133:1-8. [PMID: 31200383 DOI: 10.3171/2019.3.jns1930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/15/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The preoperative scrub has been shown to lower the incidence of surgical site infections (SSIs). Various scrubbing and gloving techniques exist; however, it is unknown how specific scrubbing technique influences SSI rates in neurosurgery. The authors aimed to assess whether the range of scrubbing practice in neurosurgery is associated with the incidence of SSIs. METHODS The authors conducted a retrospective review of a prospectively maintained database to identify all 90-day SSIs for neurosurgical procedures between 2012 and 2017 at one of their teaching hospitals. SSIs were classified by procedure type (craniotomy, shunt, fusion, or laminectomy). Surveys were administered to attending and resident physicians to understand the variation in scrubbing methods (wet vs dry, iodine vs chlorhexidine, single vs double glove). The chi-square followed by multivariate logistic regression analyses were utilized to identify independent predictors of SSI. RESULTS Forty-two operating physicians were included in the study (18 attending physicians, 24 resident physicians), who performed 14,200 total cases. Overall, SSI rates were 2.1% (296 SSIs of 14,200 total cases) and 2.0% (192 of 9,669 cases) for attending physicians and residents, respectively. Shunts were independently associated with an increased risk of SSI (OR 1.7 [95% CI 1.3-2.1]), whereas laminectomies were associated with a decreased SSI risk (OR 0.4 [95% CI 0.2-0.8]). Wet versus dry scrub (OR 0.9 [95% CI 0.6-1.4]), iodine versus chlorhexidine (OR 0.6 [95% CI 0.4-1.1]), and single- versus double-gloving (OR 1.1 [95% CI 0.8-1.4]) preferences were not associated with SSIs. CONCLUSIONS There is no evidence to suggest that perioperative infection is associated with personal scrubbing or gloving preference in neurosurgical procedures.
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Agarwal N, Kashkoush A, Baucom ET, Ratliff JK, Stroink AR. Quality Reporting in Neurological Surgery: Practice Adherence to Quality Payment Program Guidelines. Neurosurgery 2019; 84:537-543. [PMID: 29566181 DOI: 10.1093/neuros/nyy063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/08/2018] [Indexed: 11/13/2022] Open
Abstract
Recent legislation has changed quality reporting in neurological surgery. The present study summarizes the reporting of objectives and measures outlined by the Quality Payment Program (QPP) and assesses how practices are preparing to comply. In February 2017, 220 neurosurgical practices were surveyed regarding their adherence to quality reporting objectives and measures. Survey responders were asked to report infrastructure-level data including practice type and number of providers. Furthermore, we evaluated the reporting of quality and advancing care measures outlined by the QPP. Assessment of quality measures was focused on those related to neurosurgical patient management. A total of 27 responses were obtained. Practices consisted of 8 academic (30%), 16 physician-owned (59%), and 3 hospital-owned (11%) neurosurgical practices. Of the 27 total responders, 18 indicated their adherence to a host of quality and advancing care measures. Practice type was strongly associated with the number of quality measures performed (P = .020, Wilcoxon rank-sum test). Physician-owned practices reported performing a median of 5 quality measures (interquartile range, 4.5-9.5), while practices in academic and hospital-owned groups reported performing 12 quality measures (interquartile range, 9.5-13.5). Forty-five percent of physician-owned practices reported performing at least 6 quality measures, whereas 100% of academic and hospital-owned practices reported the same benchmark (P = .038, Fisher's exact test). Performance of advancing care measures was not associated with practice type. Compared to other practice types, the rate of quality reporting among physician-owned neurosurgical practices appears to be modest thus far, which may influence future reimbursement adjustments.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ahmed Kashkoush
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Elizabeth T Baucom
- Department of Neurological Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - John K Ratliff
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California
| | - Ann R Stroink
- Department of Neurological Surgery, Advocate BroMenn, Advocate Health Care, Bloomington, Illinois
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Niranjan A, Kashkoush A, Kano H, Monaco EA, Flickinger JC, Lunsford LD. Seizure control after radiosurgery for cerebral arteriovenous malformations: a 25-year experience. J Neurosurg 2018; 131:1763-1772. [PMID: 30554186 DOI: 10.3171/2018.7.jns18304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Seizures are the second-most common presenting symptom in patients with lobar arteriovenous malformations (AVMs). However, few studies have assessed the long-term effect of stereotactic radiosurgery (SRS) on seizure control. The authors of this study assess the outcome of SRS for these patients to identify prognostic factors associated with seizure control. METHODS Patients with AVM who presented with a history of seizure and underwent SRS at the authors' institution between 1987 and 2012 were retrospectively assessed. The total cohort included 155 patients with a mean follow-up of 86 months (range 6-295 months). Primary outcomes assessed were seizure frequency, antiepileptic drug regimen, and seizure freedom for 6 months prior to last follow-up. RESULTS Seizure-free status was achieved in 108 patients (70%), with an additional 23 patients (15%) reporting improved seizure frequency as compared to their pre-SRS status. The median time to seizure-free status was estimated to be 12 months (95% CI 0-27 months) as evaluated via Kaplan-Meier survival analysis. The mean seizure frequency prior to SRS was 14.2 (95% CI 5.4-23.1) episodes per year. Although not all patients tried, the proportion of patients successfully weaned off all antiepileptic drugs was 18% (28/155 patients). On multivariate logistic regression, focal impaired awareness seizure type (also known as complex partial seizures) and superficial venous drainage were significantly associated with a decreased odds ratio for seizure-free status at last follow-up (OR 0.37 [95% CI 0.15-0.92] for focal impaired awareness seizures; OR 0.36 [95% CI 0.16-0.81] for superficial venous drainage). The effects of superficial venous drainage on seizure outcome were nonsignificant when excluding patients with < 2 years of follow-up. AVM obliteration did not correlate with long-term seizure freedom (p = 0.202, chi-square test). CONCLUSIONS This study suggests that SRS improves long-term seizure control and increases the likelihood of being medication free, independently of AVM obliteration. Patients with focal impaired awareness seizures were less likely to obtain long-term seizure relief.
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Agarwal N, Kashkoush A, McDowell MM, Lariviere WR, Ismail N, Friedlander RM. Comparative durability and costs analysis of ventricular shunts. J Neurosurg 2018:1-8. [PMID: 29749912 DOI: 10.3171/2017.11.jns172212] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEVentricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type-fixed versus programmable-on shunt durability and cost for placement of shunts in adult patients.METHODSThe authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.RESULTSA total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6-1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938-$3876) and $1504 (interquartile range $753-$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2-3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2-2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.CONCLUSIONSLong-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.
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Prabhu AV, Gupta R, Kim C, Kashkoush A, Hansberry DR, Agarwal N, Koch E. Patient Education Materials in Dermatology: Addressing the Health Literacy Needs of Patients. JAMA Dermatol 2018; 152:946-7. [PMID: 27191054 DOI: 10.1001/jamadermatol.2016.1135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Arpan V Prabhu
- Medical student at University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Ahmed Kashkoush
- Medical student at University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David R Hansberry
- Department of Radiology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Nitin Agarwal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ellen Koch
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Kashkoush A, Feroze R, Myal S, Prabhu AV, Sansosti A, Tonetti D, Agarwal N. Fostering Student Interest in Neurologic Surgery: The University of Pittsburgh Experience. World Neurosurg 2017; 108:101-106. [DOI: 10.1016/j.wneu.2017.08.125] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 10/18/2022]
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Kashkoush A, Weisgerber A, Dharaneeswaran K, Agarwal N, Shutter L. Medical Training and the Brain Death Exam: A Single Institution's Experience. World Neurosurg 2017; 108:374-378. [PMID: 28890007 DOI: 10.1016/j.wneu.2017.08.185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/28/2017] [Accepted: 08/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinicians may have limited opportunities to perform neurological determination of death (NDD, or brain death) certification during their training. This study aimed to evaluate the level of resident exposure to the brain death exam at a large-volume donor hospital. METHODS In March 2014, we adapted a dual-physician model for NDD certification at our institution to improve resident education regarding NDD. To evaluate the incidence of resident exposure, we collected examiner information from all brain death exams conducted between January 2014 and July 2015. Organ procurement, family authorization, and brain death intervals were also collected to evaluate the impact of NDD timeliness on organ donation. RESULTS A total of 68 patients who met NDD criteria were included in this study. For these patients, 127 brain death exams were performed, 108 (85%) by a critical care attending physician or fellow, 9 (7%) by a neurology resident, and 7 (6%) by a neurosurgery resident. Exposure rates for neurology and neurosurgery residents were approximately 0.22 and 0.20 exams/resident/year, respectively. The median brain death interval between exams was 1.0 hours (interquartile range, 0.0-2.5) hours. Resident involvement, time between exams, and dual exams were all found to be nonsignificant correlates of organ authorization and family refusal. CONCLUSIONS Neurology and neurosurgery residents may be limited in their exposure to the brain death exam during training. High-volume donor hospitals may be able to complete 2 exams for NDD certification in a timely manner without detrimentally influencing organ authorization or family refusal rates.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amy Weisgerber
- Center for Organ Recovery & Education, Pittsburgh, Pennsylvania, USA
| | | | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lori Shutter
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Kashkoush A, Jankowitz BT, Gardner PA, Friedlander RM, Chang YF, Crammond D, Balzer J, Thirumala PD. 377 Somatosensory Evoked Potentials During Temporary Arterial Occlusion for Intracranial Aneurysm Surgery. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kashkoush A, Prabhu AV, Tonetti D, Agarwal N. The Neurosurgery Match: A Bibliometric Analysis of 206 First-Year Residents. World Neurosurg 2017; 105:341-347. [DOI: 10.1016/j.wneu.2017.05.129] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
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Affiliation(s)
| | | | - Ahmed Kashkoush
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Arpan V. Prabhu
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas G. Benedek
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Prabhu AV, Kashkoush A. Fears from a medical student part II: Prepping the patient. Med Humanit 2017; 43:e9. [PMID: 27920069 DOI: 10.1136/medhum-2016-011120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Arpan V Prabhu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Ahmed Kashkoush
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Affiliation(s)
| | - Ahmed Kashkoush
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Arpan V Prabhu
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas G Benedek
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Kashkoush A, Patel D, Prabhu AV, Benedek TG. Henri Rendu and His Contributions to Dermatology and Neurology. JAMA Dermatol 2017; 153:183. [DOI: 10.1001/jamadermatol.2016.0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ahmed Kashkoush
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Devan Patel
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Arpan V. Prabhu
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas G. Benedek
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Kashkoush A, Agarwal N, Paschel E, Goldschmidt E, Gerszten PC. Evaluation of a Hybrid Dynamic Stabilization and Fusion System in the Lumbar Spine: A 10 Year Experience. Cureus 2016; 8:e637. [PMID: 27433416 PMCID: PMC4938630 DOI: 10.7759/cureus.637] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The development of adjacent-segment disease is a recognized consequence of lumbar fusion surgery. Posterior dynamic stabilization, or motion preservation, techniques have been developed which theoretically decrease stress on adjacent segments following fusion. This study presents the experience of using a hybrid dynamic stabilization and fusion construct for degenerative lumbar spine pathology in place of rigid arthrodesis. METHODS A clinical cohort investigation was conducted of 66 consecutive patients (31 female, 35 male; mean age: 53 years, range: 25 - 76 years) who underwent posterior lumbar instrumentation with the Dynesys Transition Optima (DTO) implant (Zimmer-Biomet Spine, Warsaw, IN) hybrid dynamic stabilization and fusion system over a 10-year period. The median length of follow-up was five years. DTO consists of pedicle screw fixation coupled to a rigid rod as well as a flexible longitudinal connecting system. All patients had symptoms of back pain and neurogenic claudication refractory to non-surgical treatment. Patients underwent lumbar arthrodesis surgery in which the hybrid system was used for stabilization instead of arthrodesis of the stenotic adjacent level. RESULTS Indications for DTO instrumentation were primary degenerative disc disease (n = 52) and failed back surgery syndrome (n = 14). The most common dynamically stabilized and fused segments were L3-L4 (n = 37) and L5-S1 (n = 33), respectively. Thirty-eight patients (56%) underwent decompression at the dynamically stabilized level, and 57 patients (86%) had an interbody device placed at the level of arthrodesis. Complications during the follow-up period included a single case of screw breakage and a single case of pseudoarthrosis. Ten patients (15%) subsequently underwent conversion of the dynamic stabilization portion of their DTO instrumentation to rigid spinal arthrodesis. CONCLUSION The DTO system represents a novel hybrid dynamic stabilization and fusion construct. This 10-year experience found the device to be highly effective as well as safe. The technique may serve as an alternative to multilevel arthrodesis. Implantation of a motion-preserving dynamic stabilization device immediately adjacent to a fused level instead of extending a rigid construct may reduce the subsequent development of adjacent-segment disease in this patient population.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center
| | - Erin Paschel
- Department of Neurological Surgery, University of Pittsburgh Medical Center
| | | | - Peter C Gerszten
- Department of Neurological Surgery, University of Pittsburgh Medical Center
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Prabhu AV, Kashkoush A. Fears from a medical student. Med Humanit 2016; 42:127. [PMID: 26984906 DOI: 10.1136/medhum-2016-010895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Arpan V Prabhu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Ahmed Kashkoush
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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