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Scharf EL, Chakraborty T, Rabinstein A, Miranpuri AS. Endovascular management of cerebral septic embolism: three recent cases and review of the literature. J Neurointerv Surg 2016; 9:463-465. [PMID: 27899517 DOI: 10.1136/neurintsurg-2016-012792] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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: 10/11/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 11/03/2022]
Abstract
Endovascular management of acute ischemic stroke secondary to septic emboli from bacterial endocarditis is case-specific and outside established guidelines. We report three new cases of an acute ischemic stroke secondary to septic embolus from two different centers. All cases reported here were large vessel occlusions of the middle cerebral artery in anticoagulated patients. In one case the embolus was noted to be firm and aspiration thrombectomy was attempted in lieu of stent retrieval. Thrombolysis in Cerebral Ischemia (TICI) 3 recanalization was achieved and the patient experienced a good outcome with resolution of deficits. In this case, pathologic analysis of the embolus was available. These additional three cases from two centers add to the small but growing literature for interventional management of acute ischemic stroke in bacterial endocarditis.
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Affiliation(s)
- Eugene L Scharf
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tia Chakraborty
- Department of Neurology, The Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amrendra S Miranpuri
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Pittman CA, Miranpuri AS. Neurosurgery clinical registry data collection utilizing Informatics for Integrating Biology and the Bedside and electronic health records at the University of Rochester. Neurosurg Focus 2015; 39:E16. [DOI: 10.3171/2015.9.focus15382] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In a population health-driven health care system, data collection through the use of clinical registries is becoming imperative to continue to drive effective and efficient patient care. Clinical registries rely on a department’s ability to collect high-quality and accurate data. Currently, however, data are collected manually with a high risk for error. The University of Rochester’s Department of Neurosurgery in conjunction with the university’s Clinical and Translational Science Institute has implemented the integrated use of the Informatics for Integrating Biology and the Bedside (i2b2) informatics framework with the Research Electronic Data Capture (REDCap) databases.
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Damania D, Kung NTM, Jain M, Jain AR, Liew JA, Mangla R, Koch GE, Sahin B, Miranpuri AS, Holmquist TM, Replogle RE, Benesch CG, Kelly AG, Jahromi BS. Factors associated with recurrent stroke and recanalization in patients presenting with isolated symptomatic carotid occlusion. Eur J Neurol 2015; 23:127-32. [PMID: 26332023 PMCID: PMC5049615 DOI: 10.1111/ene.12819] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/29/2015] [Indexed: 11/28/2022]
Abstract
Background and purpose Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown. Methods Consecutive patients presenting at a single center with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) were retrospectively reviewed. Those treated with intravenous thrombolysis or intra‐arterial thrombolysis/thrombectomy were excluded. Patients were divided into two groups based on whether they experienced recurrent in‐hospital stroke. Results The selected study population (n = 33) represented a small (20.4%) proportion of all newly symptomatic carotid occlusions, who nevertheless had an elevated risk of recurrent stroke during admission (24.2%). Of the variables examined (age, gender, admission National Institutes of Health Stroke Scale score, vascular risk factors, atrial fibrillation, prior stroke/transient ischaemic attack and anticoagulation within 48 h of presentation), only anticoagulation was significantly associated with a lower risk of in‐hospital recurrent stroke. Anticoagulated patients showed a decreased incidence of stroke recurrence within the first week (6.7% vs. 38.9%, P = 0.032) and fewer strokes or deaths at 1 month (13.3% vs. 47.1%, P = 0.040). Hemorrhagic transformation was not observed in any patient. On follow‐up imaging, ICA recanalization was significantly more frequent in anticoagulated patients (46.2% vs. 9.1%, P = 0.047). Conclusion Patients with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) represent a small but high risk subgroup of patients with carotid occlusion. Early anticoagulation was associated with fewer recurrent strokes and increased ICA recanalization. Larger scale prospective studies may be justified.
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Affiliation(s)
- D Damania
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - N T-M Kung
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - M Jain
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - A R Jain
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - J A Liew
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - R Mangla
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - G E Koch
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - B Sahin
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - A S Miranpuri
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - T M Holmquist
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - R E Replogle
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - C G Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - A G Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - B S Jahromi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
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Miranpuri AS, Nickele CM, Akture E, Royalty K, Niemann DB. Neuroangiography simulation using a silicone model in the angiography suite improves trainee skills. J Neurointerv Surg 2013; 6:561-4. [PMID: 24062256 DOI: 10.1136/neurintsurg-2013-010826] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [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: 11/04/2022]
Abstract
PURPOSE Simulation techniques in neurosurgical training are becoming more important. The purpose of this study was to determine whether silicone vascular models used in the angiography suite can render improvement in trainee performance and safety in neuroendovascular procedures. METHODS 10 residents from neurosurgery and radiology training programs were asked to perform a diagnostic angiogram on a silicone based vascular model (United Biologics, Tustin, USA). This was done in the angiography suite with the full biplane fluoroscopy machine (Siemens, Munich, Germany). On their first attempt, they were coached by a faculty member trained in endovascular neurosurgery; on their second attempt, they received coaching only if the procedure had stalled. Technique was scored on multiple criteria by the faculty, and total time and fluoroscopy time were recorded on both attempts. RESULTS In this group of 10 residents, overall procedure time significantly decreased from 51 to 42 min (p=0.01), and total fluoro time significantly decreased from 12 to 9 min (p=0.002) between the first attempt and the second attempt. Technical skill increased significantly in navigation, vessel selection, projection setup, and road map usage. CONCLUSIONS Silicone vascular models used in the angiography suite, with the clinical working tools and biplane fluoroscopy, provide a valuable experience for training residents in diagnostic angiography, and improved performance and safety.
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Affiliation(s)
- Amrendra S Miranpuri
- Department of Neurologic Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Erinc Akture
- Department of Surgery, Division of Neurosurgery, University of Vermont, Burlington, Vermont, USA
| | - Kevin Royalty
- Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA Siemens Medical Solutions, Hoffman Estates, Illinois, USA
| | - David B Niemann
- Department of Neurologic Surgery, University of Wisconsin, Madison, Wisconsin, USA
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Spiotta AM, Miranpuri AS, Vargas J, Magarick J, Turner RD, Turk AS, Chaudry MI. Balloon augmented Onyx embolization utilizing a dual lumen balloon catheter: utility in the treatment of a variety of head and neck lesions. J Neurointerv Surg 2013; 6:547-55. [DOI: 10.1136/neurintsurg-2013-010833] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Miranpuri AS, Aktüre E, Baggott CD, Miranpuri A, Uluç K, Güneş VE, Lin Y, Niemann DB, Başkaya MK. Demographic, circadian, and climatic factors in non-aneurysmal versus aneursymal subarachnoid hemorrhage. Clin Neurol Neurosurg 2013; 115:298-303. [DOI: 10.1016/j.clineuro.2012.05.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 04/17/2012] [Accepted: 05/25/2012] [Indexed: 12/01/2022]
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Miranpuri AS, Rajpal S, Salamat MS, Kuo JS. Upper cervical intramedullary spinal metastasis of ovarian carcinoma: a case report and review of the literature. J Med Case Rep 2011; 5:311. [PMID: 21756304 PMCID: PMC3154862 DOI: 10.1186/1752-1947-5-311] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 07/14/2011] [Indexed: 11/21/2022] Open
Abstract
Introduction Currently there is no generalized approach to treating patients with intra-medullary spinal metastasis. High cervical spinal cord lesions can be particularly challenging cases, and may even be considered inoperable by some. Case report We present what is, to the best of our knowledge, the first reported case of ovarian carcinoma (managed primarily with surgery) in a 65-year-old Caucasian woman metastasizing to the upper cervical spinal cord; we also review the relevant literature and discuss management strategies. Conclusions Due to improving systemic cancer therapies, patients with cancer now often survive longer and are more likely to develop central nervous system metastases. Therefore, neurosurgical oncologists are often challenged with difficult decisions about how to surgically manage these patients. We recommend individualized multidisciplinary management based on patient functional status, the need for definitive diagnosis for possible additional adjuvant therapies, and consideration of extent of systemic disease impacting on desirable quality and length of survival.
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Affiliation(s)
- Amrendra S Miranpuri
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
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Miranpuri AS, Tomé WA, Paliwal BR, Kesslering C, Mehta MP. Assessment of patient-independent intrinsic error for a noninvasive frame for fractionated stereotactic radiotherapy. Int J Cancer 2001; 96:320-5. [PMID: 11582585 DOI: 10.1002/ijc.1029] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The purpose of our study was to examine the extent of patient-independent intrinsic error associated with multiple, repeat remounting of the Laitinen Stereoadapter. The Laitinen frame was repeatedly mounted on a solid water phantom and imaged using computed tomography (CT). The phantom contained five targets located in the center, anterior, right, left, and posterior orientations. The images were processed, fused, and analyzed on the Pinnacle 3-D treatment planning system. The coordinate values (in the x, y, and z directions) for each target were determined for each mounting, and an absolute mean deviation was calculated for 11 repetitions. The mean deviation in the x, y, and z direction for the central and right target, and in the x and y direction for the posterior and anterior target was less than 2.0 mm. However, the mean error in the z direction of the anterior and posterior targets was 1.79 +/- 1.02 mm and 2.20 +/- 1.32 mm, respectively. Rotational misalignment during repeat frame fixation contributed to the observed deviations and in particular affected the antero-posterior plane. With the exception of two occasions where an obvious mounting error occurred, a significant portion of error from remounting the Laitinen Stereoadapter is associated with the operator and the imaging process. The observation of an angular displacement around the axis through the earplugs suggests that a certain degree of rotational misalignment in daily remounting is possible. Targets in the antero-posterior plane are most susceptible to localization error as a consequence of rotational misalignment. In summary, the overall error is within the limits of current imaging technology but not within submillimeter accuracy. Clinical application should take these errors into consideration when designing field margins.
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Affiliation(s)
- A S Miranpuri
- Department of Human Oncology, University of Wisconsin Medical School, 600 Highland Avenue, Madison, WI 53792, USA
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