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Abbas R, Lan M, Naamani KE, Atallah E, Salem M, Burkhardt JK, Kühn AL, Puri A, Monteiro A, Levy EI, Herial NA, Gooch MR, Jabbour J, Rosenwasser R, Tjoumakaris SI. First United States multicenter experience with the new-generation FRED X surface-modified flow diversion stent: feasibility, safety, and short-term efficacy. J Neurosurg 2024; 140:1054-1063. [PMID: 37856406 DOI: 10.3171/2023.7.jns23966] [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: 04/28/2023] [Accepted: 07/27/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Flow diversion created a paradigm shift in the treatment of intracranial aneurysms. The new flow redirection endoluminal device with X technology (FRED X) is the latest update of the recent Food and Drug Administration-approved FRED. The FRED X is engineered to reduce material thrombogenicity and enhance vessel healing. In this study, the authors aimed to evaluate the feasibility and early safety and efficacy of the new FRED X. METHODS The authors retrospectively collected and analyzed data from patients who had undergone flow diversion with the new FRED X at four tertiary cerebrovascular centers in the United States from February 2022 through July 2022. RESULTS Forty-four patients with 45 aneurysms treated using 46 devices comprised the overall study cohort and were divided into two groups: 39 patients with unruptured aneurysms and 5 patients with ruptured aneurysms. The mean patient age was 57.7 ± 9.1 years, and most patients were female (84%). Ninety-one percent of the aneurysms were saccular, with the majority (93%) located in the anterior circulation, specifically the posterior communicating (27%) and carotid ophthalmic (27%) territories. The mean maximum aneurysm diameter was 5.6 ± 4.6 mm, and 20% of the lesions had been previously treated. The mean procedure time was 61.6 minutes, with a mean cumulative fluoroscopy time of 24.6 minutes. Additionally, 7% of the lesions received adjunct treatment. Stent placement was successful in 100% of cases, achieving good wall apposition and complete neck coverage. Further, immediate aneurysm contrast stasis > 90% was observed in 61% of cases. Symptomatic postoperative complications occurred in 3 patients in the unruptured cohort and 1 patient in the ruptured cohort. All patients in the study were discharged on dual antiplatelet regimens with a modified Rankin Scale score of 0. At 6 months after treatment, 89% of cases had adequate occlusion, with < 6% of cases having asymptomatic in-stent stenosis. All patients had excellent functional outcomes. CONCLUSIONS FRED X for the treatment of an intracranial aneurysm is technically feasible alone or in conjunction with intrasaccular embolization. In addition, the study results showed very promising early safety and efficacy. Follow-up studies should establish the long-term safety and efficacy profiles of this new stent.
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Affiliation(s)
- Rawad Abbas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia
| | - Matthews Lan
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia
| | - Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia
| | - Elias Atallah
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia
| | - Mohamed Salem
- 2Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania
| | - Jan-Karl Burkhardt
- 2Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania
| | - Anna Luisa Kühn
- 3Department of Neurosurgery, University of Massachusetts, Boston, Massachusetts
| | - Ajit Puri
- 3Department of Neurosurgery, University of Massachusetts, Boston, Massachusetts
| | - Andre Monteiro
- 4Department of Neurosurgery, University of Buffalo, Buffalo, New York; and
| | - Elad I Levy
- 4Department of Neurosurgery, University of Buffalo, Buffalo, New York; and
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia
| | | | - Robert Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia
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El Naamani K, Mouchtouris N, Majmundar S, Sah E, Kaul A, Sizdahkhani S, Momin AA, Ghanem M, Al Saiegh F, Gooch MR, Herial NA, Rosenwasser RH, Tjoumakaris SI, Bilyk JR, Jabbour P. Comparison of the transarterial, transvenous, and superior ophthalmic vein approaches in the treatment of indirect carotid-cavernous fistulas. Neurosurg Focus 2024; 56:E7. [PMID: 38427999 DOI: 10.3171/2023.12.focus23776] [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: 10/30/2023] [Accepted: 12/27/2023] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Indirect carotid-cavernous fistulas (CCFs) are abnormal arteriovenous shunting lesions with a highly variable clinical presentation that depends on the drainage pattern. Based on venous drainage, treatment can be either transarterial (TA) or transvenous (TV). The aim of this study was to compare the outcomes of indirect CCF embolization via the TA, TV, and direct superior ophthalmic vein (SOV) approaches. METHODS The authors conducted a retrospective analysis of 74 patients admitted to their institution from 2010 to 2023 with the diagnosis of 77 indirect CCFs as confirmed on digital subtraction angiography. RESULTS A total of 74 patients with 77 indirect CCFs were included in this study. Embolization was performed via the TA approach in 4 cases, the TV approach in 50 cases, and the SOV in 23 cases. At the end of the procedure, complete occlusion was achieved in 76 (98.7%) cases. The rate of complete occlusion at the end of the procedure and at last radiological follow-up was significantly higher in the SOV and TV cohorts than in the TA cohort. The rate of recurrence was highest in the TA cohort (25% for TA vs 5.3% for TV vs 0% for SOV, p = 0.68). CONCLUSIONS The rate of immediate complete occlusion was higher in the TV and SOV cohorts than in the TA cohort while the rate of complete occlusion at final follow-up was highest in the SOV cohort. The SOV approach was significantly associated with higher rates of postoperative complications. Indirect CCFs require careful examination of the fistulous point and the venous drainage to provide the most effective patient-tailored approach.
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Affiliation(s)
- Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nikolaos Mouchtouris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Shyam Majmundar
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Eric Sah
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Anand Kaul
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Saman Sizdahkhani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Arbaz A Momin
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Marc Ghanem
- 2School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Fadi Al Saiegh
- 3Department of Neurosurgery, UT Health San Antonio, Texas; and
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stavropoula I Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jurij R Bilyk
- 4Department of Oculoplastic and Orbital Surgery, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Naamani KE, Kaul A, Mouchtouris N, Hunt A, Ahmed MT, Sizdahkhani S, Majmundar S, Ghanem M, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Comparison between endovascular and surgical treatment of spinal dural arteriovenous fistulas: a single-center cohort and systematic review. Neurosurg Focus 2024; 56:E4. [PMID: 38427989 DOI: 10.3171/2023.12.focus23747] [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: 10/23/2023] [Accepted: 12/27/2023] [Indexed: 03/03/2024]
Abstract
OBJECTIVE With recent advancements in minimally invasive techniques, endovascular embolization has gained popularity as a first-line treatment option for spinal dural arteriovenous fistulas (sDAVFs). The authors present their institution's case series of sDAVFs treated endovascularly and surgically, and they performed a systemic review to assess the outcomes of both modalities of treatment. METHODS The authors conducted a retrospective observational study of 24 consecutive patients with sDAVFs treated between 2013 and 2023. The primary outcome was the rate of occlusion, which was compared between the surgically and endovascularly treated sDAVFs. They also conducted a systemic review of all the literature comparing outcomes of endovascular and surgical treatment of sDAVFs. RESULTS A total of 24 patients with 24 sDAVFs were studied. The mean patient age was 63.8 ± 15.5 years, and the majority of patients were male (n = 19, 79.2%). Of the 24 patients, 8 (33.3%) received endovascular treatment, 15 (62.5%) received surgical treatment, and 1 (4.2%) patient received both. Complete occlusion at first follow-up was higher in the surgical cohort but did not achieve statistical significance (66.7% vs 25%, p = 0.52). Recurrence was higher in the endovascular cohort (37.5% vs 13.3%, p = 0.3), while the rate of postprocedural complications was higher in the surgical cohort (13.3% vs 0%, p = 0.52); however, neither of these differences was statistically significant. CONCLUSIONS Endovascular embolization in the management of sDAVFs is an alternative treatment to surgery, whose long-term efficacy is still under investigation. These findings suggest overall comparable outcomes between endovascular and open surgical treatment of sDAVFs. Future studies are needed to determine the role of endovascular embolization in the overall management of sDAVFs.
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Affiliation(s)
- Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Anand Kaul
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Nikolaos Mouchtouris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Adam Hunt
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Meah T Ahmed
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Saman Sizdahkhani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Shyam Majmundar
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Marc Ghanem
- 2Lebanese American University, Beirut, Lebanon
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Stavropoula I Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
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El-Hajj VG, Ghaith AK, Gharios M, El Naamani K, Atallah E, Glener S, Habashy KJ, Hoang H, Sizdahkhani S, Mouchtouris N, Kaul A, Elmi-Terander A, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. General Versus Nongeneral Anesthesia for Carotid Endarterectomy: A Prospective Multicenter Registry-Based Study on 25 000 Patients. Neurosurgery 2024:00006123-990000000-01067. [PMID: 38391204 DOI: 10.1227/neu.0000000000002887] [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: 11/03/2023] [Accepted: 01/05/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Carotid endarterectomy (CEA) is a well-established treatment option for carotid stenosis. The choice between general anesthesia (GA) and nongeneral anesthesia (non-GA) during CEA remains a subject of debate, with concerns regarding perioperative complications, particularly myocardial infarctions. This study aimed to evaluate the outcomes associated with GA vs non-GA CEA using a large, nationwide database. METHODS The National Surgical Quality Improvement Project database was queried for patients undergoing CEA between 2013 and 2020. Primary outcome measures including surgical outcomes and 30-day postoperative complications were compared between the 2 anesthesia methods, after 2:1 propensity score matching. RESULTS After propensity score matching, a total of 25 356 patients (16 904 in the GA and 8452 in the non-GA group) were included. Non-GA compared with GA CEA was associated with significantly shorter operative times (101.9, 95% CI: 100.5-103.3 vs 115.8 95% CI: 114.4-117.2 minutes, P < .001), reduced length of hospital stays (2.3, 95% CI: 2.15-2.4 vs 2.5, 95% CI: 2.4-2.6 days, P < .001), and lower rates of 30-day postoperative complications, including myocardial infarctions (0.8% vs 1.2%, P = .003), unplanned intubations (0.8% vs 1.1%, P = .016), pneumonia (0.5% vs 1%, P < .001), and urinary tract infections (0.4% vs 0.7%, P = .003). These outcomes were notably more pronounced in the younger (≤70 years) and high morbidity (American Society of Anesthesiologists 3-5) cohorts. CONCLUSION In this nationwide registry-based study, non-GA CEA was associated with better short-term outcomes in terms of perioperative complications, compared with GA CEA. The findings suggest that non-GA CEA may be a safer alternative, especially in younger patients and those with more comorbidities.
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Affiliation(s)
| | - Abdul Karim Ghaith
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Gharios
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Glener
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karl John Habashy
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Harry Hoang
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand Kaul
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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El Naamani K, Mastorakos P, Yudkoff CJ, Abbas R, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Jabbour PM. Comparison of PED/PED Flex and PED Shield in the treatment of unruptured intracerebral aneurysms. J Neurosurg 2024; 140:436-440. [PMID: 37877979 DOI: 10.3171/2023.7.jns23981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/11/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity. METHODS This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors' institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates. RESULTS The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts. CONCLUSIONS This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.
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El Naamani K, Momin AA, Hunt A, Jain P, Oghli YS, Ghanem M, Musmar B, El Fadel O, Alhussein A, Alhussein R, Pedapati V, Muharremi E, El-Hajj J, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Causes and Predictors of 30-Day Readmission in Patients With Stroke Undergoing Mechanical Thrombectomy: A Large Single-Center Experience. Neurosurgery 2024:00006123-990000000-01021. [PMID: 38224235 DOI: 10.1227/neu.0000000000002826] [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: 10/12/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The 30-day readmission rate has emerged as a metric of quality care and is associated with increased health care expenditure. We aim to identify the rate and causes of 30-day readmission after mechanical thrombectomy and provide the risk factors of readmission to highlight high-risk patients who may require closer care. METHODS This is a retrospective study from a prospectively maintained database of 703 patients presenting for mechanical thrombectomy between 2017 and 2023. All patients who presented with a stroke and underwent a mechanical thrombectomy were included in this study. Patients who were deceased on discharge were excluded from this study. RESULTS Our study comprised 703 patients, mostly female (n = 402, 57.2%) with a mean age of 70.2 years ±15.4. The most common causes of readmission were cerebrovascular events (stroke [n = 21, 36.2%], intracranial hemorrhage [n = 9, 15.5%], and transient ischemic attack [n = 1, 1.7%]).Other causes of readmission included cardiovascular events (cardiac arrest [n = 4, 6.9%] and bradycardia [n = 1, 1.7%]), infection (wound infection postcraniectomy [n = 3, 5.2%], and pneumonia [n = 1, 1.7%]). On multivariate analysis, independent predictors of 30-day readmission were history of smoking (odds ratio [OR]: 2.2, 95% CI: 1.1-4.2) P = .01), distal embolization (OR: 3.2, 95% CI: 1.1-8.7, P = .03), decompressive hemicraniectomy (OR: 9.3, 95% CI: 3.2-27.6, P < .01), and intracranial stent placement (OR: 4.6, 95% CI: 2.4-8.7) P < .01). CONCLUSION In our study, the rate of 30-day readmission was 8.3%, and the most common cause of readmission was recurrent strokes. We identified a history of smoking, distal embolization, decompressive hemicraniectomy, and intracranial stenting as independent predictors of 30-day readmission in patients with stroke undergoing mechanical thrombectomy.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yazan Shamli Oghli
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Marc Ghanem
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Basel Musmar
- School of Medicine, An-Najah National University, Nablus, Palestine
| | - Omar El Fadel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdulaziz Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Reyoof Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Vinay Pedapati
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Eti Muharremi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jad El-Hajj
- Saint George's University School of Medicine, Saint George, Grenada
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Abbas R, Sweid A, Salem MM, Atallah E, Naamani KE, Amllay A, Sioutas GS, Sambangi A, Yudkoff CJ, Dougherty J, Weinberg JH, El-Hajj J, Alhussein A, Alhussein R, Herial NA, Tjoumakaris S, Gooch MR, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour P. Predictors of occlusion, long-term outcomes, and safety in a cohort of 674 aneurysms treated with the Pipeline embolization device. J Neurosurg 2024:1-9. [PMID: 38181513 DOI: 10.3171/2023.10.jns231837] [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: 08/09/2023] [Accepted: 10/27/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE By providing a more physiological approach to the treatment of intracranial aneurysms, the Pipeline embolization device (PED) has revolutionized the endovascular treatment of aneurysms. Although there are many flow diverters on the market, the authors report their experience with the PED, the first flow diverter to be approved by the Food and Drug Administration. They aimed to assess the efficacy and safety of PED flow diversion for the treatment of a wide range of aneurysms, as well as to look at factors affecting occlusion. METHODS This is a retrospective study of a prospectively maintained database of patients treated with the PED between January 2011 and December 2019. Charts were reviewed for patient, aneurysm, and procedure characteristics. The primary outcomes of interest were complication rates, occlusion outcomes (O'Kelly-Marotta grading scale), and functional outcomes (modified Rankin Scale [mRS]). Secondary outcomes included predictors of incomplete occlusion at 6 and 24 months of follow-up. RESULTS The study cohort included 581 patients with 674 aneurysms. Most aneurysms (90.5%) were in the anterior circulation and had a saccular morphology (85.6%). Additionally, 638 aneurysms (94.7%) were unruptured, whereas 36 (5.3%) were acutely ruptured. The largest mean aneurysm diameter was 8.3 ± 6.1 mm. Complications occurred at a rate of 5.5% (n = 32). The complete occlusion rate was 89.3% at 24 months' follow-up, and 94.8% of patients had a favorable neurological outcome (mRS score 0-2) at the last follow-up. On multivariate analysis, predictors of incomplete aneurysm occlusion at 6 months were hypertension (OR 1.7, p = 0.03), previous aneurysm treatment (OR 2.4, p = 0.001), and increasing aneurysm neck diameter (OR 1.2, p = 0.02), whereas a saccular morphology was protective (OR 0.5, p = 0.05). Predictors of incomplete occlusion at 24 months were increasing aneurysm neck diameter (OR 1.2, p = 0.01) and previous aneurysm treatment (OR 2.3, p = 0.01). CONCLUSIONS The study findings are corroborated by those of previous studies and trials. The complete occlusion rate was 89.3% at 24 months' follow-up, with 94.8% of patients having favorable functional outcomes (mRS score 0-2). Aneurysm treatment before PED deployment and an increasing aneurysm neck diameter increase the risk of incomplete occlusion at 6 and 24 months.
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Affiliation(s)
- Rawad Abbas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ahmad Sweid
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mohamed M Salem
- 2Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Abdelaziz Amllay
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Georgios S Sioutas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Abhijeet Sambangi
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Clifford J Yudkoff
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jaime Dougherty
- 3Rowan University School of Osteopathic Medicine, Stratford, New Jersey
| | - Joshua H Weinberg
- 4Department of Neurological Surgery, Ohio State College of Medicine, Columbus, Ohio; and
| | - Jad El-Hajj
- 5Saint George's University School of Medicine, St. George, Grenada
| | - Abdulaziz Alhussein
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ruyof Alhussein
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Hekmat Zarzour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Richard F Schmidt
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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8
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El Naamani K, Abbas R, Ghanem M, Mounzer M, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Resuming Anticoagulants in Patients With Intracranial Hemorrhage: A Meta-Analysis and Literature Review. Neurosurgery 2024; 94:14-19. [PMID: 37459580 DOI: 10.1227/neu.0000000000002625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/24/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intracerebral hemorrhage (ICH) is one of the most disabling cerebrovascular events. Several studies have discussed oral anticoagulant (OAC)-related ICH; however, the optimal timing of resuming OAC in patients with ICH is still a dilemma. In this literature review/meta-analysis, we will summarize, discuss, and provide the results of studies pertaining to OAC resumption in patients with ICH. METHODS Using PubMed, Ovid Medline, and Web science, a systemic literature review was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement on December 20, 2022. Inclusion criteria for the meta-analysis were all studies reporting mean, median, and standard deviation for the duration of anticoagulants resumption after ICH. Thirteen studies met the above criteria and were included in the meta-analysis. RESULTS Of the 271 articles found in the literature, pooled analysis was performed in 13 studies that included timing of OAC resumption after ICH. The pooled mean duration to OAC resumption after the index ICH was 31 days (95% CI: 13.7-48.3). There was significant variation among the mean duration to OAC resumption reported by the studies as observed in the heterogeneity test ( P -value ≈0). CONCLUSION Based on our meta-analysis, the average time of resuming OAC in patients with ICH is around 30 days. Several factors including the type of intracranial hemorrhage, the type of OAC, and the indication for OACs should be taken into consideration for future studies to try and identify the best time to resume OAC in patients with ICH.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Marc Ghanem
- The Lebanese American University Gilbert and Rose-Marie Chaghoury School of Medicine, Beirut, Lebanon
| | - Marc Mounzer
- Drexel University, Philadelphia , Pennsylvania , USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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9
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Sioutas GS, Sweid A, Chen CJ, Becerril-Gaitan A, Al Saiegh F, El Naamani K, Abbas R, Amllay A, Birkenstock L, Cain RE, Ruiz RL, Buxbaum M, Nauheim DO, Renslo B, Bassig J, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Surgical evacuation for chronic subdural hematoma: Predictors of reoperation and functional outcomes. World Neurosurg X 2024; 21:100246. [PMID: 38054079 PMCID: PMC10694339 DOI: 10.1016/j.wnsx.2023.100246] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 10/24/2023] [Indexed: 12/07/2023] Open
Abstract
Background Although chronic subdural hematoma (CSDH) incidence has increased, there is limited evidence to guide patient management after surgical evacuation. Objective To identify predictors of reoperation and functional outcome after CSDH surgical evacuation. Methods We identified all patients with CSDH between 2010 and 2018. Clinical and radiographic variables were collected from the medical records. Outcomes included reoperation within 90 days and poor (3-6) modified Rankin Scale score at 3 months. Results We identified 461 surgically treated CSDH cases (396 patients). The mean age was 70.1 years, 29.7 % were females, 298 (64.6 %) underwent burr hole evacuation, 152 (33.0 %) craniotomy, and 11 (2.4 %) craniectomy. Reoperation rate within 90 days was 12.6 %, whereas 24.2 % of cases had a poor functional status at 3 months. Only female sex was associated with reoperation within 90 days (OR = 2.09, 95 % CI: 1.17-3.75, P = 0.013). AMS on admission (OR = 5.19, 95 % CI: 2.15-12.52, P < 0.001) and female sex (OR = 3.90, 95 % CI: 1.57-9.70, P = 0.003) were independent predictors of poor functional outcome at 3 months. Conclusion Careful management of patients with the above predictive factors may reduce CSDH reoperation and improve long-term functional outcomes. However, larger randomized studies are necessary to assess long-term prognosis after surgical evacuation.
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Affiliation(s)
- Georgios S. Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Lyena Birkenstock
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rachel E. Cain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ramon L. Ruiz
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael Buxbaum
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David O. Nauheim
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Bryan Renslo
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jonathan Bassig
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M. Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A. Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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10
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El Naamani K, Syal A, Field NC, Teichner EM, Ghanem M, Herial NA, Tjoumakaris SI, Jabbour P, Rosenwasser RH, Paul AR, Gooch MR. The Enterprise stent…still useful after all these years. Interv Neuroradiol 2023:15910199231224004. [PMID: 38155430 DOI: 10.1177/15910199231224004] [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: 12/30/2023] Open
Abstract
BACKGROUND The Enterprise stent (Codman Neuro, Massachusetts, USA) received Food and Drug Administration (FDA) approval in 2007 for stent-assisted coiling (SAC). Since its introduction, newer stents and devices for aneurysm treatment have been developed resulting in a shift in the utilization of this stent from SAC to other off-label indications. OBJECTIVE To describe our experience with the Enterprise stent being used for SAC and other off-label indications. METHODS This is a multi-center retrospective review of the use of the Enterprise stent between 2018 and 2023. All patients in which the Enterprise stent was successfully deployed were included in the study. RESULTS Our study cohort comprised of 194 patients, mostly females (n = 112, 57.7%), with a mean age of 63.2 years ± 14.3. The Enterprise stent was used for SAC in only 24 (12.4%) patients and was used for rescue stenting in stroke in 101 patients (52.1%), treatment of intracranial stenosis in 53 patients (27.3%), treatment of in-stent stenosis in 1 patient (0.5%), and for treatment of dissections in 15 patients (7.7%). From 2018 to 2023, the use of Enterprise stents for SAC significantly decreased (p < 0.0001) while the use of Enterprise stents for non-SAC purposes was insignificantly variable (p = 0.05). CONCLUSION Our study shows that the Enterprise stent remains a reliable tool in neuroendovascular procedures, even if its original intended use has been supplanted by other devices.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Amit Syal
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas C Field
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Eric M Teichner
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Marc Ghanem
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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11
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El Naamani K, Hunt A, Jain P, Lawall CL, Yudkoff CJ, El Fadel O, Ghanem M, Mastorakos P, Momin AA, Alhussein A, Alhussein R, Atallah E, Abbas R, Zakar R, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. The Rate and Predictors of 30-Day Readmission in Patients Treated for Unruptured Cerebral Aneurysms: A Large Single-Center Study. Neurosurgery 2023; 93:1415-1424. [PMID: 37681971 DOI: 10.1227/neu.0000000000002663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/09/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Numerous studies of various populations and diseases have shown that unplanned 30-day readmission rates are positively correlated with increased morbidity and all-cause mortality. In this study, we aim to provide the rate and predictors of 30-day readmission in patients undergoing treatment for unruptured intracranial aneurysms. METHODS This is a retrospective study of 525 patients presenting for aneurysm treatment between 2017 and 2022. All patients who were admitted and underwent a successful treatment of their unruptured intracerebral aneurysms were included in the study. The primary outcome was the rate and predictors of 30-day readmission. RESULTS The rate of 30-day readmission was 6.3%, and the mean duration to readmission was 7.8 days ± 6.9. On univariate analysis, factors associated with 30-day readmission were antiplatelet use on admission (odds ratio [OR]: 0.4, P = .009), peri-procedural rupture (OR: 15.8, P = .007), surgical treatment of aneurysms (OR: 2.2, P = .035), disposition to rehabilitation (OR: 9.5, P < .001), and increasing length of stay (OR: 1.1, P = .0008). On multivariate analysis, antiplatelet use on admission was inversely correlated with readmission (OR: 0.4, P = .045), whereas peri-procedural rupture (OR: 9.5, P = .04) and discharge to rehabilitation (OR: 4.5, P = .029) were independent predictors of 30-day readmission. CONCLUSION In our study, risk factors for 30-day readmission were aneurysm rupture during the hospital stay and disposition to rehabilitation, whereas the use of antiplatelet on admission was inversely correlated with 30-day readmission. Although aneurysm rupture is a nonmodifiable risk factor, more studies are encouraged to focus on the correlation of antiplatelet use and rehabilitation disposition with 30-day readmission rates.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Charles L Lawall
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Clifford J Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Omar El Fadel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Marc Ghanem
- Gilbert and Rose-Marie Chaghoury School of Medicine, Lebanese American University, Byblos , Lebanon
| | - Panagiotis Mastorakos
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Abdulaziz Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Reyoof Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rida Zakar
- School of Medicine, Saint Joseph University, Beirut , Lebanon
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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12
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Ghanem M, El Naamani K, Rawad A, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Transverse Sinus Stenting for the Treatment of Idiopathic Intracranial Hypertension With a Pressure Gradient of 70 mm Hg: A Technical Note and Systematic Review. Oper Neurosurg (Hagerstown) 2023; 25:e338-e344. [PMID: 37589472 DOI: 10.1227/ons.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/05/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Venous sinus stenosis is believed to play a role in the pathogenesis of idiopathic intracranial hypertension (IIH). Venous stenting has emerged as a promising treatment option for patients with IIH because of venous sinus stenosis refractory to medical management or unsuitable for shunt placement. In this technical note, we present a case of IIH with the highest recorded pressure gradient to date. CLINICAL PRESENTATION This technical note presents the successful use of intracranial venous stenting in a patient with IIH because of severe venous sinus stenosis, leading to significant improvement in vision and reduction in intracranial pressure. A meticulous review of the literature revealed that our patient exhibited the highest recorded pressure gradient (70 mm Hg). This remarkable finding underscores the potential effectiveness of venous stenting as a viable treatment approach. The procedure involved the placement of a Zilver stent (Cook Medical) and balloon angioplasty after stenting of the right transverse sinus stenosis, resulting in a substantial decrease in pressure gradient. Following the procedure, another venous manometry showed no more gradient with a uniform pressure in the whole venous system at 18 mm Hg. CONCLUSION To our knowledge, this case presents the highest pressure gradient reported in the literature and contributes to the growing evidence supporting venous stenting in patients with IIH and venous sinus stenosis.
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Affiliation(s)
- Marc Ghanem
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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13
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Atallah E, El Naamani K, Momin AA, Abbas R, Jain P, Hunt A, Sambangi A, Carreras A, El Fadel O, Gooch MR, Tjoumakaris S, Zarzour H, Schmidt RF, Herial NA, Rosenwasser R, Jabbour P. Transradial versus transfemoral access routes for diagnostic cerebral angiography: a large single-center comparative cost-analysis study. J Neurosurg 2023:1-7. [PMID: 37976514 DOI: 10.3171/2023.9.jns23941] [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: 04/26/2023] [Accepted: 09/19/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Recently, the transradial (TR) approach has become a common alternative because of its safety profile and increased patient satisfaction compared with the transfemoral (TF) route. Both routes are associated with their respective associated costs, and differences typically emerge on the basis of patient anatomy, operator expertise, and occurrence of complications. The authors' objective was to compare the overall costs of diagnostic cerebral angiography via both routes and to shed light on the individual equipment costs of each route. METHODS This retrospective single-center study of 926 elective diagnostic angiograms was performed between December 2019 and March 2022. RESULTS The study comprised of 314 and 612 angiograms performed through the TF and TR routes, respectively. A significantly greater proportion of female patients were included in the TF cohort (79.3% vs 67.8%, p < 0.001), and most other demographic characteristics and baseline modified Rankin Scale scores were comparable between cohorts. The overall cost of patients utilizing the TR route was comparable to that of the TF route (mean ± SD $12,591.80 ± $19,128.00 vs $12,789.50 ± 18,424.00, p = 0.88). However, the median cost of catheters was significantly higher in TR group ($55.20 vs $12.40, p = 0.03), while the median costs of closure devices ($87.00 vs $20.20 p < 0.001) and sheaths ($44.60 ± 11.3 vs $41.10 ± 3.10, p < 0.001) were significantly higher in the TF group. CONCLUSIONS Overall, the authors' study showed that the TR approach can be a less expensive option for patients undergoing diagnostic cerebral angiography, especially if complications occur. Future studies may corroborate these findings and potentially lead to the adoption of TR as a low-cost, efficient, gold-standard technique for cerebral angiography.
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Affiliation(s)
- Elias Atallah
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Arbaz A Momin
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Rawad Abbas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Paarth Jain
- 2Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Adam Hunt
- 2Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Abhijeet Sambangi
- 2Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Angeleah Carreras
- 2Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Omar El Fadel
- 2Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Hekmat Zarzour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Richard F Schmidt
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Robert Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia; and
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14
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Gajjar AA, Rogers A, Ghosh R, Abbas R, Naamani KE, Gooch MR, Field N, Dalfino JC, Paul AR. Post-operative weight loss in venous sinus stenting patients: A multi-center review, systematic review, and meta-analysis. Interv Neuroradiol 2023:15910199231190596. [PMID: 37807823 DOI: 10.1177/15910199231190596] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION Idiopathic intracranial hypertension (IIH) can result in headaches, pulsatile tinnitus, papilledema, and other neurological symptoms. Weight loss can alleviate some symptoms of IIH. This study aims to investigate the effect of venous sinus stenting on post-operative weight and body mass index (BMI) changes among IIH patients. The secondary objective is to investigate the relationship between post-operative weight changes and papilledema resolution. METHODS Patients with papilledema undergoing venous sinus stenting for IIH were retrospectively reviewed from two comprehensive North American cerebrovascular centers. Patient demographics, surgical course, post-operative outcomes, and weight were analyzed. A systematic review and meta-analysis of post-operative weight in stented IIH patients was conducted. RESULTS Twenty-eight patients with a diagnosis of IIH and papilledema who underwent venous sinus stenting were identified across two institutions. Patients had a mean pre-operative weight of 103.2 kg, which decreased to 101.5 kg at 3-month follow up (p = 0.0757). Patients at 6-month follow-up saw a weight decrease to 97.4 kg (p = 0.0066). Patients who saw papilledema resolution saw a mean greater decrease in weight (-4.5%) at 6-month follow up than those whose papilledema did not resolve (-1.7%), although this was insignificant (p = 0.1091). A total of 41 patients were included in the meta-analysis. Patients had an average of 1.1 increase in BMI at 3-month follow up. CONCLUSIONS This study shows that venous sinus stenting leads to modest weight reduction in IIH patients, and those with resolved papilledema experience slightly greater weight loss. Further research is necessary to determine the clinical significance of these findings.
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Affiliation(s)
- Avi A Gajjar
- Department of Neurological Surgery, Albany Medical Center, Albany, NY, USA
| | - Aubrey Rogers
- Department of Neurological Surgery, Albany Medical Center, Albany, NY, USA
| | - Ritam Ghosh
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas Field
- Department of Neurological Surgery, Albany Medical Center, Albany, NY, USA
| | - John C Dalfino
- Department of Neurological Surgery, Albany Medical Center, Albany, NY, USA
| | - Alexandra R Paul
- Department of Neurological Surgery, Albany Medical Center, Albany, NY, USA
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15
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Sioutas GS, Mouchtouris N, Saiegh FA, Naamani KE, Amllay A, Becerril-Gaitan A, Velagapudi L, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Middle Meningeal Artery Embolization for Subdural Hematoma: An Institutional Cohort and Propensity Score-Matched Comparison with Conventional Management. Clin Neurol Neurosurg 2023; 233:107895. [PMID: 37556969 DOI: 10.1016/j.clineuro.2023.107895] [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: 05/17/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND The treatment of non-acute subdural hematoma (NASDH) is challenging due to its high recurrence rates and comorbidities of mostly elderly patients. Middle meningeal artery embolization (MMAE) recently emerged as an alternative to surgery in the treatment of NASDH. OBJECTIVE To describe a single center's experience of MMAE with Onyx for NASDH and compare it to a surgically treated historical cohort. METHODS We performed a retrospective analysis of patients undergoing MMAE for NASDH from 2019 to 2021. MMAE was performed with ethylene vinyl alcohol copolymer (Onyx). Comparisons were made with a historical cohort from 2010 to 2018 who underwent surgical evacuation only, before and after propensity score matching. Outcomes were assessed clinically and radiographically. RESULTS We included 44 consecutive patients (55 MMAEs) who underwent MMAE, with a median follow-up of 63.5 days. Twenty-four NASDHs underwent upfront embolization, 17 adjunctive, and 14 for recurrence after prior surgical evacuation, with no significant differences in hematoma and mRS reduction between them. Two patients died during hospitalization and 2 during follow-up, unrelated to the procedure. Mean SDH thickness decreased by 48.3% ± 38.1% (P < 0.001) on last follow-up, which did not correlate with the amount of Onyx injected. Six (13.6%) patients required surgical rescue after embolization. There were no procedure-related complications. The mean modified Rankin Scale (mRS) on admission was 2.8 ± 1.5, which decreased significantly to 1 [1,4] at the last follow-up (P = 0.033). The MMAE (41 hematomas; upfront and adjunctive embolization) and Surgical Evacuation-only (461 hematomas) cohorts were balanced with propensity score mathing. Matching was successful for 41 MMAE and 41 surgical-only hematoma pairs, and only hypertension remained significantly different between the two groups, but there was no significant difference in any outcome. CONCLUSION MMAE for NASDH seems safe and effective in appropriately selected patients, non-inferior to surgery, and may become a minimally-invasive alternative. Given our encouraging results, large-scale clinical randomized trials are warranted.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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16
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El Naamani K, Abbas R, Tjoumakaris SI, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM, Evans J, Gooch MR. Venous sinus stenting for idiopathic intracranial hypertension patients with functioning ventriculoperitoneal shunts: A case series. Clin Neurol Neurosurg 2023; 233:107894. [PMID: 37499303 DOI: 10.1016/j.clineuro.2023.107894] [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: 06/04/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a disease defined by increased intracranial pressure and associated with a variety of symptoms ranging from headaches to tinnitus. Ventricular peritoneal shunting has been the mainstay treatment for patients with IIH. Although VPS's have shown efficacy in treating IIH, some patients complain of refractory symptoms even with functioning VPS's. Venus stenting has emerged as a new technique for treating these refractory symptoms. Despite the scarce literature pertaining its efficacy and safety profile, several small studies have shown promising results. In this case series, four patients with IIH complained of refractory symptoms despite functioning VPS's and were treated with venous stenting.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Amllay A, Becerril-Gaitan A, Hunt A, Jain P, Chen CJ, El Naamani K, Abbas R, Rudick L, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation. World Neurosurg 2023; 176:e476-e484. [PMID: 37257646 DOI: 10.1016/j.wneu.2023.05.084] [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: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. OBJECTIVE Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. METHODS We included consecutive acute ischemic stroke patients treated with MT for 10 years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction] ≥ 2b), good functional outcome (modified Ranking Scale ≤ 2 at 3 months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. RESULTS Six hundred forty-six patients were included (54.5% women, median age 71 years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P = 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P = 0.07). However, the groups had similar functional outcomes and mortality rates at 3 months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. CONCLUSIONS MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.
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Affiliation(s)
- Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Levi Rudick
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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18
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El Naamani K, Khanna O, Syal A, Momin AA, Abbas R, Amllay A, Sambangi A, Hunt A, Dougherty J, Lawall CL, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Jabbour PM. A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting. Neurosurgery 2023; 93:445-452. [PMID: 36861988 DOI: 10.1227/neu.0000000000002437] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/04/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience. OBJECTIVE To assess outcomes of TF vs TR approach for CAS. METHODS This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study. RESULTS A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts. CONCLUSION The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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19
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Sioutas GS, Amllay A, Chen CJ, El Naamani K, Abbas R, Jain P, Garg A, Stine EA, Tjoumakaris SI, Herial NA, Gooch MR, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour P. The Impact of Weather and Mode of Transport on Outcomes of Patients With Acute Ischemic Stroke Undergoing Mechanical Thrombectomy. Neurosurgery 2023; 93:144-155. [PMID: 36757189 DOI: 10.1227/neu.0000000000002391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/06/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Efficient transfer to mechanical thrombectomy (MT)-capable centers is essential for patients with stroke. Weather may influence stroke risk, transportation, and outcomes. OBJECTIVE To investigate how weather affects stroke patient transfer and outcomes after MT. METHODS We retrospectively collected data for patients with stroke transferred from spoke to our hub hospital to undergo MT between 2017 and 2021. We examined associations between weather, transportation, and patient outcomes. RESULTS We included 543 patients with a mean age of 71.7 years. The median National Institutes of Health Stroke Score increased from 14 to 15 after transportation. The median modified Rankin Scale was 4 at discharge and 90 days, and 3 at the final follow-up (mean 91.7 days). Higher daily temperatures were associated with good outcome, whereas daily drizzle was associated with poor outcome. More patients were transferred by air when visibility was better, and by ground during heavier precipitation, higher humidity, rain, mist, and daily drizzle, fog, and thunder . Patient outcomes were not associated with transportation mode. Among the independent predictors of good outcome, none was a weather variable. Lower hourly relative humidity ( P = .003) and longer road distance ( P < .001) were independent predictors of using air transportation, among others. CONCLUSION During transportation, higher temperature was associated with good outcome, whereas daily drizzle was associated with poor outcome after MT. Although weather was associated with transportation mode, no differences in outcomes were found between transportation modes. Further studies are needed to modify transfer protocols, especially during cold and rainy days, and potentially improve outcomes.
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Affiliation(s)
- Georgios S Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ananya Garg
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Emily A Stine
- Psychology Department, College of Arts and Sciences, Arcadia University, Glenside, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
- Psychology Department, College of Arts and Sciences, Arcadia University, Glenside, Pennsylvania, USA
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20
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Patel PD, Khanna O, Gooch MR, Glener SR, Mouchtouris N, Momin AA, Sioutas G, Amllay A, Barsouk A, El Naamani K, Yudkoff C, Wyler DA, Jallo JI, Tjoumakaris S, Jabbour PM, Harrop JS. Clinical Outcomes After Ultra-Early Cranioplasty Using Craniectomy Contour Classification as a Patient Selection Criterion. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00661. [PMID: 37166197 DOI: 10.1227/ons.0000000000000689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/20/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Although not a technically difficult operation, cranioplasty is associated with high rates of complications. The optimal timing of cranioplasty to mitigate complications remains the subject of debate. OBJECTIVE To report outcomes between patients undergoing cranioplasty at ultra-early (0-6 weeks), intermediate (6 weeks to 6 months), and late (>6 months) time frames. We report a novel craniectomy contour classification (CCC) as a radiographic parameter to assess readiness for cranioplasty. METHODS A single-institution retrospective analysis of patients undergoing cranioplasty was performed. Patients were stratified into ultra-early (within 6 weeks of index craniectomy), intermediate (6 weeks to 6 months), and late (>6 months) cranioplasty cohorts. We have devised CCC scores, A, B, and C, based on radiographic criteria, where A represents those with a sunken brain/flap, B with a normal parenchymal contour, and C with "full" parenchyma. RESULTS A total of 119 patients were included. There was no significant difference in postcranioplasty complications, including return to operating room (P = .212), seizures (P = .556), infection (P = .140), need for shunting (P = .204), and deep venous thrombosis (P = .066), between the cohorts. Univariate logistic regression revealed that ultra-early cranioplasty was significantly associated with higher rate of functional independence at >6 months (odds ratio 4.32, 95% CI 1.39-15.13, P = .015) although this did not persist when adjusting for patient selection features (odds ratio 2.90, 95% CI 0.53-19.03, P = .234). CONCLUSION In appropriately selected patients, ultra-early cranioplasty is not associated with increased rate of postoperative complications and is a viable option. The CCC may help guide decision-making on timing of cranioplasty.
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Affiliation(s)
- Pious D Patel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven R Glener
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Barsouk
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Clifford Yudkoff
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David A Wyler
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jack I Jallo
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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21
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Bounajem MT, Joyce E, Scoville JP, Seinfeld J, Hoffman J, Grossberg JA, Waiters V, White AC, Nerva J, Burkhardt JK, Tonetti DA, El Naamani K, Gooch MR, Jabbour P, Tjoumakaris S, Ortega Gutierrez S, Levitt MR, Lang M, Ares WJ, Desai S, Mascitelli JR, Kilburg CJ, Budohoski KP, Couldwell WT, Gross BA, Grandhi R. Safety and efficacy of the Pipeline Flex embolization device with Shield Technology for the acute treatment of ruptured internal carotid artery pseudoaneurysms: a multi-institution case series. Neurosurg Focus 2023; 54:E4. [PMID: 37127036 DOI: 10.3171/2023.2.focus233] [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: 01/01/2023] [Accepted: 02/13/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. METHODS The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. RESULTS Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0-2. Complete occlusion at follow-up was observed in 82.6% of patients. CONCLUSIONS PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.
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Affiliation(s)
- Michael T Bounajem
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Evan Joyce
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Jonathan P Scoville
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Joshua Seinfeld
- 2Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jessa Hoffman
- 2Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | - Andrew C White
- 5Department of Endovascular Surgical Neuroradiology/Neuroendovascular Surgery, University of Texas Southwestern Medical School, Dallas, Texas
| | - John Nerva
- 6Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jan-Karl Burkhardt
- 7Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel A Tonetti
- 8Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Kareem El Naamani
- 9Department of Neurosurgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - M Reid Gooch
- 9Department of Neurosurgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 9Department of Neurosurgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 9Department of Neurosurgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Michael R Levitt
- 11Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Michael Lang
- 12Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - William J Ares
- 13Department of Neurosurgery, North Shore University Health System, Arlington Heights, Illinois
| | - Sohum Desai
- 14Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas; and
| | - Justin R Mascitelli
- 15Department of Neurosurgery, University of Texas Health Science Center at San Antonio, Texas
| | - Craig J Kilburg
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Karol P Budohoski
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
| | - Bradley A Gross
- 12Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ramesh Grandhi
- 1Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, Utah
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22
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Abbas R, Chen CJ, Atallah E, El Naamani K, Amllay A, Sioutas G, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris S. Mechanical Thrombectomy for Stroke Due to Acute Basilar Artery Occlusion, a Safety and Efficacy Analysis. Neurosurgery 2023; 92:772-778. [PMID: 36513024 DOI: 10.1227/neu.0000000000002261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute basilar artery occlusion accounts for 1% of all ischemic strokes but often leads to devastating neurological injury and mortality. Many institutions still opt for best medical therapy for these patients; however, there is increasing evidence that mechanical thrombectomy (MT) for these patients leads to better outcomes. OBJECTIVE To assess the safety and efficacy of MT for patients presenting with acute basilar artery occlusion (BAO). METHODS This study was a retrospective chart review of a prospectively maintained database for patients with acute BAO treated with MT from January 2014 through March 2022. RESULTS Our study included a total of 74 patients. The mean age was 62.7 years, and 55.4% were male. The most common comorbidity was hypertension (73%). The mean door to puncture time was 75 minutes, and the mean procedure time was 54 minutes. 86.5% of patients had a good modified treatment in cerebral ischemia score (≥2b). There were 4 patients who had procedural complications and 3 who had symptomatic intracerebral hemorrhage. At 90 days, 62.5% of patients had a modified Rankin Scale, 0 to 3. The mortality rate was 32.4% and 2% during hospital admission and 90 days, respectively. On univariate analysis, adjunctive angioplasty/stenting and higher presenting National Institutes of Health Stroke Scale score were associated with modified Rankin Scale 4 to 6 at 90 days ( P -value, .03 and <.001, respectively). Shorter procedure time was associated with modified treatment in cerebral ischemia score ≥ 2b ( P -value, .0015). CONCLUSION Our findings showed that MT is safe and effective for patients presenting with acute BAO and is in conjunction with previous literature. The results from upcoming trials should hopefully establish MT as gold standard for these patients.
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Affiliation(s)
- Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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23
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Al Saiegh F, Liu H, El Naamani K, Mouchtouris N, Chen CJ, Khanna O, Abbas R, Velagapudi L, Schmidt R, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Shi W, Jabbour P. 303 Frameless Angiography-Based Gamma Knife Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_303] [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: 03/18/2023] Open
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24
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Al Saiegh F, Velagapudi L, Khanna O, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour P. 111 Improved Functional Outcomes of Stroke Patients Undergoing Mechanical Thrombectomy After Arriving via Mobile Stroke Unit. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_111] [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: 03/18/2023] Open
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25
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Mouchtouris N, Alizadeh M, Ailes I, Piper K, Gooch MR, Tjoumakaris SI, Rosenwasser RH, Wu C, Jabbour P. 552 Quantifying the Blood-Brain Barrier in Acute Ischemic Stroke Using Novel MR Imaging. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_552] [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: 03/18/2023] Open
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26
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Shehabeldin M, Amllay A, Jabre R, Chen CJ, Schunemann V, Herial NA, Gooch MR, Mackenzie L, Choe H, Tjoumakaris S, Rosenwasser RH, Jabbour P, Kozak O. Onyx Versus Particles for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma. Neurosurgery 2022; 92:979-985. [PMID: 36700752 DOI: 10.1227/neu.0000000000002307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure. OBJECTIVE To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH. METHODS A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation. RESULTS Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P = .354. Hematoma thickness at late follow-up was significantly smaller in the PVA group 7.8 mm vs 4.6 mm, respectively; P = .017. CONCLUSION Both onyx and PVA as embolic agents for cSDH can be used safely and have comparable clinical and surgical outcomes.
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Affiliation(s)
- Mohamed Shehabeldin
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, Texas, USA
| | - Victoria Schunemann
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA.,Department of Neurosurgery, Abington Memorial Hospital, Abington, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Larami Mackenzie
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Hana Choe
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Osman Kozak
- Neurovascular Division, Abington Memorial Hospital, Jefferson Health, Abington, Pennsylvania, USA
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27
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Velagapudi L, Saiegh FA, Swaminathan S, Mouchtouris N, Khanna O, Sabourin V, Gooch MR, Herial N, Tjoumakaris S, Rosenwasser RH, Jabbour P. Machine learning for outcome prediction of neurosurgical aneurysm treatment: Current methods and future directions. Clin Neurol Neurosurg 2022; 224:107547. [PMID: 36481326 DOI: 10.1016/j.clineuro.2022.107547] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 11/02/2022] [Accepted: 11/24/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Machine learning algorithms have received increased attention in neurosurgical literature for improved accuracy over traditional predictive methods. In this review, the authors sought to assess current applications of machine learning for outcome prediction of neurosurgical treatment of intracranial aneurysms and identify areas for future research. METHODS A PRISMA-compliant systematic review of the PubMed, MEDLINE, and EMBASE databases was conducted for all studies utilizing machine learning for outcome prediction of intracranial aneurysm treatment. Patient characteristics, machine learning methods, outcomes of interest, and accuracy metrics were recorded from included studies. RESULTS 16 studies were ultimately included in qualitative synthesis. Studies primarily analyzed angiographic outcomes, functional outcomes, or complication prediction using clinical, radiological, or composite variables. The majority of included studies utilized supervised learning algorithms for analysis of dichotomized outcomes. CONCLUSIONS Commonly included variables were demographics, presentation variables (including ruptured or unruptured status), and treatment used. Areas for future research include increased generalizability across institutions and for smaller datasets, as well as development of front-end tools for clinical applicability of published algorithms.
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Affiliation(s)
- Lohit Velagapudi
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Shreya Swaminathan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | | | - Omaditya Khanna
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Victor Sabourin
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Nabeel Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | | | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.
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Khanna O, Al Saiegh F, Mouchtouris N, Sajja K, Baldassari MP, El Naamani K, Tjoumakaris S, Gooch MR, Rosenwasser RH, Starke RM, Jabbour PM. Coil Embolization with Subsequent Subacute Flow Diversion Before Hospital Discharge as a Treatment Paradigm for Ruptured Aneurysms. World Neurosurg 2022; 167:e583-e589. [PMID: 35987457 DOI: 10.1016/j.wneu.2022.08.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/20/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subtotal coil embolization followed by subsequent flow diversion is often pursued for treatment of acutely ruptured aneurysms. Owing to the need for anti-platelet therapy, the optimal time of safely pursuing flow diversion treatment has not been fully elucidated. In this study, we aim to demonstrate the safety and feasibility of staged treatment of acutely ruptured aneurysms with early coil embolization followed by flow diversion prior to discharge. METHODS A retrospective study to evaluate clinical outcomes of patients who presented with aneurysmal subarachnoid hemorrhage and underwent coil embolization followed by subacute flow diversion treatment during the same hospitalization. RESULTS A total of 18 patients are included in our case series. Eight patients presented with Hunt-Hess (H-H) grade 2 bleed, 6 patients with H-H grade 3, and 2 patients each with H-H grade 4 and H-H grade 1. Eight patients required placement of an external ventricular drain on admission. After initial coil embolization, 12 achieved Raymond-Roy grade 2 occlusion, and 6 attained grade 3a/b occlusion. The mean duration between coil embolization and subsequent flow diversion was 9.83 days (range: 1-30). There were no instances of re-hemorrhage between initial coil embolization and subsequent flow diversion treatment. Sixteen patients had a minimum of 6-month follow-up, of which 15 were found to have complete occlusion, and 1 required subsequent clipping. CONCLUSIONS Subtotal coil embolization followed by definitive treatment using flow diversion during the same hospitalization is feasible and achieves excellent aneurysm occlusion rates while avoiding dual anti-platelet therapy during the initial hemorrhage period.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kalyan Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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Al Saiegh F, Velagapudi L, Khanna O, Baldassari MP, Mouchtouris N, Hafazalla K, Roussis J, DePrince M, Tjoumakaris S, Gooch MR, Herial N, Rosenwasser RH, Jabbour P. Improved Functional Outcomes of Stroke Patients Undergoing Mechanical Thrombectomy After Arriving via a Mobile Stroke Unit. World Neurosurg 2022; 166:e546-e550. [PMID: 35863651 DOI: 10.1016/j.wneu.2022.07.047] [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: 03/30/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data are lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). Here, we include patients from our stroke network MSU and compare them to patients who arrived conventionally. METHODS A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via an MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means. RESULTS Seven patients were treated with MT after arriving by an MSU. These patients were compared to 50 date-matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, comorbidities, stroke characteristics, or tissue plasminogen activator administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33 minutes ±77.53 vs. 483.51 minutes ±322.66, P = 0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by using the modified Rankin Scale (1.86 ± 1.35 vs. 3.57 ± 1.88, P = 0.024). No significant difference in final thrombolysis in cerebral infarction score, complications, length of stay, or mortality was observed. CONCLUSIONS Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in the discharge modified Rankin Scale score. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA.
| | - Lohit Velagapudi
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Omaditya Khanna
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karim Hafazalla
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Roussis
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maureen DePrince
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Ilyas A, Chen CJ, Abecassis IJ, Al-Saiegh F, Ironside N, Jabbour PM, Tjoumakaris S, Gooch MR, Lee CC, Sheehan JP, Ding D. Stereotactic Radiosurgery for A Randomized Trial of Unruptured Brain Arteriovenous Malformations-Eligible Patients: A Meta-Analysis. Neurosurgery 2022; 91:684-692. [PMID: 36001787 DOI: 10.1227/neu.0000000000002115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) were controversial, and they suggested that intervention is inferior to medical management for unruptured brain arteriovenous malformations (AVMs). However, several studies have shown that stereotactic radiosurgery (SRS) is an acceptable therapy for unruptured AVMs. OBJECTIVE To test the hypothesis that ARUBA intervention arm's SRS results are meaningfully inferior to those from similar populations reported by other studies. METHODS We performed a literature review to identify SRS studies of patients who met the eligibility criteria for ARUBA. Patient, AVM, treatment, and outcome data were extracted for statistical analysis. Regression analyses were pooled to identify factors associated with post-SRS obliteration and hemorrhage. RESULTS The study cohort included 8 studies comprising 1620 ARUBA-eligible patients who underwent SRS. At the time of AVM diagnosis, 36% of patients were asymptomatic. The mean follow-up duration was 80 months. Rates of radiologic, symptomatic, and permanent radiation-induced changes were 45%, 11%, and 2%, respectively. The obliteration rate was 68% at last follow-up. The post-SRS hemorrhage and mortality rates were 8%, and 2%, respectively. Lower Spetzler-Martin grade (odds ratios [OR] = 0.84 [0.74-0.95], P = .005), lower radiosurgery-based AVM score (OR = 0.75 [0.64-0.95], P = .011), lower Virginia Radiosurgery AVM Scale (OR = 0.86 [0.78-0.95], P = .003), and higher margin dose (OR = 1.13 [1.02-1.25], P = .025) were associated with obliteration. CONCLUSION SRS carries a favorable risk to benefit profile for appropriately selected ARUBA-eligible patients, particularly those with smaller volume AVMs. Our findings suggest that the results of ARUBA do not reflect the real-world safety and efficacy of SRS for unruptured AVMs.
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Affiliation(s)
- Adeel Ilyas
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Fadi Al-Saiegh
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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31
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Jabbour P, Dmytriw AA, Sweid A, Piotin M, Bekelis K, Sourour N, Raz E, Linfante I, Dabus G, Kole M, Martínez-Galdámez M, Nimjee SM, Lopes DK, Hassan AE, Kan P, Ghorbani M, Levitt MR, Escalard S, Missios S, Shapiro M, Clarençon F, Elhorany M, Vela-Duarte D, Tahir RA, Youssef PP, Pandey AS, Starke RM, El Naamani K, Abbas R, Hammoud B, Mansour OY, Galvan J, Billingsley JT, Mortazavi A, Walker M, Dibas M, Settecase F, Heran MKS, Kuhn AL, Puri AS, Menon BK, Sivakumar S, Mowla A, D'Amato S, Zha AM, Cooke D, Goyal M, Wu H, Cohen J, Turkel-Parrella D, Xavier A, Waqas M, Tutino VM, Siddiqui A, Gupta G, Nanda A, Khandelwal P, Tiu C, Portela PC, Perez de la Ossa N, Urra X, de Lera M, Arenillas JF, Ribo M, Requena M, Piano M, Pero G, De Sousa K, Al-Mufti F, Hashim Z, Nayak S, Renieri L, Aziz-Sultan MA, Nguyen TN, Feineigle P, Patel AB, Siegler JE, Badih K, Grossberg JA, Saad H, Gooch MR, Herial NA, Rosenwasser RH, Tjoumakaris S, Tiwari A. Characteristics of a COVID-19 Cohort With Large Vessel Occlusion: A Multicenter International Study. Neurosurgery 2022; 90:725-733. [PMID: 35238817 PMCID: PMC9514728 DOI: 10.1227/neu.0000000000001902] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 06/22/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke. OBJECTIVE To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort. METHODS We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020. RESULTS The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002). CONCLUSION COVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.
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Affiliation(s)
- Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Adam A. Dmytriw
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France;
| | - Kimon Bekelis
- Department of Neurosurgery, Good Samaritan Hospital Medical Center, West Islip, New York, USA
| | - Nader Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Eytan Raz
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida, USA
| | - Max Kole
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA;
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain;
| | - Shahid M. Nimjee
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA;
| | - Demetrius K. Lopes
- Department of Neurosurgery, Advocate Aurora Health, Chicago, Illinois, USA
| | - Ameer E. Hassan
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Michael R. Levitt
- Departments of Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA;
| | - Simon Escalard
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France;
| | - Symeon Missios
- Department of Neurosurgery, Good Samaritan Hospital Medical Center, West Islip, New York, USA
| | - Maksim Shapiro
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Mahmoud Elhorany
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Daniel Vela-Duarte
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida, USA
| | - Rizwan A. Tahir
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA;
| | - Patrick P. Youssef
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA;
| | - Aditya S. Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert M. Starke
- Department of Neurosurgery & Neuroradiology, University of Miami & Jackson Memorial Hospital, Miami, Florida, USA;
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Bassel Hammoud
- Department of Biomedical Engineering, American University of Beirut, Beirut, Lebanon;
| | - Ossama Y. Mansour
- Department of Neurology and Neuroradiology, Alexandria University Hospital, Al Attarin, Egypt;
| | - Jorge Galvan
- Department of Interventional Neuroradiology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain;
| | | | - Abolghasem Mortazavi
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Melanie Walker
- Departments of Neurological Surgery and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA;
| | - Mahmoud Dibas
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabio Settecase
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, USA
| | - Manraj K. S. Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, USA
| | - Anna L. Kuhn
- Division of Neurointerventional Radiology, Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Ajit S. Puri
- Division of Neurointerventional Radiology, Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Bijoy K. Menon
- Calgary Stroke Program, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Sanjeev Sivakumar
- Department of Neurosurgery & Neuroradiology, University of Miami & Jackson Memorial Hospital, Miami, Florida, USA;
| | - Ashkan Mowla
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
| | - Salvatore D'Amato
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Alicia M. Zha
- Department of Neurology, UT Health Science Center, Houston, Texas, USA
| | - Daniel Cooke
- Department of Neurointerventional Radiology, San Francisco General Hospital, San Francisco, California, USA
| | - Mayank Goyal
- Calgary Stroke Program, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hannah Wu
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - Jake Cohen
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - David Turkel-Parrella
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - Andrew Xavier
- Department of Neurology, Sinai Grace Hospital, Detroit, Michigan, USA
- Department of Neurology, St. Joseph Mercy Health, Ann Arbor, Michigan, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Vincent M. Tutino
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Gaurav Gupta
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Priyank Khandelwal
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Cristina Tiu
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Pere C. Portela
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Natalia Perez de la Ossa
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain;
| | - Xabier Urra
- Department of Neurology, Hospital Clínic, Barcelona, Spain;
| | - Mercedes de Lera
- Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain;
| | - Juan F. Arenillas
- Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain;
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain;
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain;
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Mariangela Piano
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Guglielmo Pero
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Keith De Sousa
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Fawaz Al-Mufti
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain;
| | - Zafar Hashim
- Department of Radiology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Sanjeev Nayak
- Department of Neurology, Hospital Clínic, Barcelona, Spain;
| | - Leonardo Renieri
- Department of Radiology, Neurovascular Unit, Careggi University Hospital, Florence, Italy
| | - Mohamed A. Aziz-Sultan
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Thanh N. Nguyen
- Departments of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA;
| | - Patricia Feineigle
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Aman B. Patel
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Khodr Badih
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | | | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - M. Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Nabeel A. Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Ambooj Tiwari
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
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32
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Schmidt RF, Sweid A, Mouchtouris N, Velagapudi L, Chalouhi N, Gooch MR, Rosenwasser RH, Jabbour PM, Tjoumakaris SI. Predictors of first-pass reperfusion for mechanical thrombectomy in acute ischemic stroke. Clin Neurol Neurosurg 2022; 219:107314. [PMID: 35662056 DOI: 10.1016/j.clineuro.2022.107314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 09/21/2021] [Revised: 05/26/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Rapid reperfusion of ischemic penumbra in patients with acute stroke is critical to neurological recovery. Achieving reperfusion after first-pass mechanical thrombectomy has been associated with improved patient outcomes. However, the predictors for obtaining first-pass reperfusion are not well known. METHODS A single-institution retrospective study of all patients who underwent mechanical thrombectomy at a tertiary care center from January 2010 until March 2019 was conducted to assess for predictors of first-pass reperfusion. RESULTS A total of 257 patients were reviewed. Successful reperfusion was obtained in 63.4% of patients, and in 38% of patients on the first pass. On multivariate analysis, increasing door-to-puncture time was a negative predictor of FPR (OR 0.989, 95% CI = 0.980-0.997) and use of combined thrombectomy technique with stent-retriever and aspiration was a positive predictor of FPR compared to aspiration or stent-retriever alone (OR 4.441, 95% CI = 1.001-19.699). CONCLUSIONS Combination therapy using stent-retriever and aspiration may increase the chance of obtaining FPR, whereas delays in starting the procedure after patient arrival may decrease the odds of FPR. Rapid thrombectomy initiation and procedural technique may play in optimizing rates of FPR and ultimately patient outcomes, however, randomized controlled trials assessing these variables are necessary to determine optimal treatment strategies.
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Affiliation(s)
- Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, University of Florida, Gainesville, FL, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Al Saiegh F, Liu H, El Naamani K, Mouchtouris N, Chen CJ, Khanna O, Abbas R, Velagapudi L, Baldassari MP, Reyes M, Schmidt RF, Tjoumakaris S, Gooch MR, Rosenwasser RH, Shi W, Jabbour P. Frameless Angiography-Based Gamma Knife Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Proof-of-Concept Study. World Neurosurg 2022; 164:e808-e813. [PMID: 35580781 DOI: 10.1016/j.wneu.2022.05.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 03/29/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Traditional Gamma Knife radiosurgery (GKRS) of brain arteriovenous malformations (AVMs) using digital subtraction angiography (DSA) requires head immobilization using a stereotactic frame. OBJECTIVE We describe our protocol of frameless GKRS using DSA while maintaining high spatial resolution for precision. METHODS This study is a retrospective review of patients with unruptured AVMs who underwent frameless GKRS. Magnetic resonance imaging and 3-dimensional DSA were obtained without a stereotactic frame for all patients. The imaging studies were merged for contouring of the AVM nidus. During GKRS treatment, patients were immobilized using an individually molded thermoplastic mask. RESULTS Thirty-one patients were included in the analysis. The median age is 45.0 years (interquartile range [IQR]: 28.0-55.0). The median nidus size is 3.0 cm (IQR: 2.0-3.4). One patient had a Spetzler-Martin grade I, 11 had a grade II, 11 had a grade III, 6 had a grade IV, and 2 had a grade V AVM. Eleven patients underwent preradiosurgical embolization, 3 patients had previous microsurgical resection and/or embolization, and 1 patient had prior radiosurgery. The median administered dose was 20 Gy (IQR: 18.0-21.0). All patients completed their treatment with the planned radiation dose without complications. CONCLUSION This is the first study that integrates DSA in the treatment planning of brain AVMs using GKRS without utilizing a stereotactic head frame. Frameless GKRS provides numerous advantages over frame-based techniques including improved patient experience and the capability of fractionation and thus expanding the eligibility of more AVMs for radiosurgery, while maintaining high spatial resolution of the AVM using angiography data.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Haisong Liu
- Director of Radiosurgery Physics, Jefferson Hospital for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maikerly Reyes
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Sweid A, El Naamani K, Abbas R, Starke RM, Badih K, El Hajjar R, Saad H, Hammoud B, Andrews C, Rahm SP, Atallah E, Ramesh S, Tjoumakaris S, Gooch MR, Herial N, Hasan D, Rosenwasser RH, Jabbour P. Clipping Could Be the Best Treatment Modality for Recurring Anterior Communicating Artery Aneurysms Treated Endovascularly. Neurosurgery 2022; 90:627-635. [PMID: 35285450 PMCID: PMC9514745 DOI: 10.1227/neu.0000000000001905] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The anterior communicating artery (AcoA) is the most common location for intracranial aneurysms. OBJECTIVE To present occlusion outcomes, complication rate, recurrence rate, and predictors of recurrence in a large cohort with AcoA aneurysms treated primarily with endosaccular embolization. We also attempt to present data on the most effective treatment modality for recurrent AcoA aneurysms. METHODS This is a retrospective, single-center study, reviewing the outcomes of 463 AcoA aneurysms treated endovascularly between 2003 and 2018. RESULTS The study cohort consisted of 463 patients. Adequate immediate occlusion was achieved in 418 (90.3%). Independent functional status at discharge was observed in 269 patients (58.0%), and the mortality rate was 6.8% (31). At 6 months, adequate occlusion was achieved in 418 (90.4%). Of all the patients, recurrence was observed in 101 cases (21.8%), and of those, 98 (22.4%) underwent retreatment. The combined frequency of retreatment for the coiling group was 42.4%, which was significantly higher than the 0 incident of retreatment in the clipping group (P < .0001). Among the retreatment cohort, there was a significantly higher subsequent retreatment rate in the endovascular group (0% in the clipping group vs 42.4% in the endovascular group, P < .0001). CONCLUSION Coiling with and without stent/balloon assistance is a relatively safe and effective modality for the treatment of AcoA aneurysms; however, in the setting of recurrence, microsurgical reconstruction leads to improved outcomes regarding durable occlusion, thus avoiding the potential for multiple interventions in the future.
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Affiliation(s)
- Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Hospital, Miami, Florida, USA;
| | - Khodr Badih
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Rayan El Hajjar
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA;
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA;
| | - Bassel Hammoud
- Department of Biomedical Engineering, American University of Beirut, Beirut, Lebanon;
| | - Carrie Andrews
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Sage P. Rahm
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA;
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Sunidhi Ramesh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - M. Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA;
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
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Naamani KE, Chen CJ, Abbas R, Sweid A, Sioutas GS, Badih K, Ramesh S, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Woven EndoBridge versus stent-assisted coil embolization of cerebral bifurcation aneurysms. J Neurosurg 2022; 137:1786-1793. [PMID: 35535832 DOI: 10.3171/2022.3.jns2217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/03/2022] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices. METHODS This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography. RESULTS The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385-6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107-0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116-0.795], p = 0.015) and multiple imputations. CONCLUSIONS Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.
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Affiliation(s)
- Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Rawad Abbas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Ahmad Sweid
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Georgios S Sioutas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Khodr Badih
- 2Department of Physics, University of Toronto, Ontario, Canada
| | - Sunidhi Ramesh
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Stavropoula I Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Hekmat Zarzour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Richard F Schmidt
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Pascal M Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
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Abbas R, El Naamani K, Sweid A, Birkenstock L, Ruiz R, Tjoumakaris S, Gooch MR, Herial NA, Rosenwasser RH, Jabbour P. Retreatment Strategies in Aneurysm Woven Endobridge Recurrences: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:201-207. [PMID: 35240675 DOI: 10.1227/ons.0000000000000115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The treatment of wide-necked and bifurcation aneurysms has become a common indication for the Woven Endobridge (WEB) device. In many instances, WEB embolization fails and retreatment strategies for the recanalized aneurysms have not been established and may be challenging. OBJECTIVE To report an experience with retreatment strategies after WEB failure in 7 cases involving various aneurysm shapes, sizes, and location using multiple strategies including endovascular modalities and microsurgical clip ligation. METHODS Data were retrospectively collected from 1 high-volume cerebrovascular center for 7 patients treated with a WEB device for an aneurysm who subsequently required retreatment for that same aneurysm from 2015 through January 2021. RESULTS We identified 7 patients with WEB recurrences over a period of 6 years. Four patients initially presented with incidental findings, whereas 3 patients presented with subarachnoid hemorrhage. One patient was lost to follow-up and presented with a rerupture, whereas the 6 other patients were diagnosed with routine follow-up. Two patients received clip ligation, 2 had simple coil embolization, 1 had stent-assisted coil embolization, 1 had a flow-diverting stent, and 1 patient required 2 retreatments; he received stent-assisted coil embolization for the first retreatment and a simple coil embolization for the second retreatment. All patients had excellent angiographic outcomes and no complications. CONCLUSION The authors conclude that aneurysm recurrence after WEB is very diverse, and no single modality can properly address all recurrences. Rather, an individualized approach based on aneurysm features, neurointerventionalist expertise, and patient preference should be implemented.
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Affiliation(s)
- Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Lyena Birkenstock
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ramon Ruiz
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Sweid A, Sajja KC, Mouchtouris N, Weinberg JH, Shivashankar K, Saad H, Abbas R, El Naamani K, Ramesh S, Schaefer J, Saiegh FA, Jabbour P, Herial NA, Zarzour H, Tjoumakaris S, Romo V, Rosenwasser RH, Gooch MR. Rescue stenting for acute ischemic stroke with Refractory Emergent Large vessel occlusion in the modern thrombectomy era. Clin Neurol Neurosurg 2022; 215:107183. [DOI: 10.1016/j.clineuro.2022.107183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/20/2022] [Accepted: 02/19/2022] [Indexed: 11/03/2022]
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Abbas R, Al Saiegh F, El Naamani K, Chen CJ, Velagapudi L, Sioutas GS, Weinberg JH, Tjoumakaris S, Gooch MR, Herial NA, Rosenwasser RH, Jabbour P. Robot-assisted carotid artery stenting: outcomes, safety, and operational learning curve. Neurosurg Focus 2022; 52:E17. [PMID: 34973670 DOI: 10.3171/2021.10.focus21504] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution. METHODS A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period. RESULTS A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively). CONCLUSIONS Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.
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Affiliation(s)
- Rawad Abbas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Fadi Al Saiegh
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Lohit Velagapudi
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Georgios S Sioutas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Joshua H Weinberg
- 2Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
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Oneissi M, Sweid A, Tjoumakaris S, Hasan D, Gooch MR, Rosenwasser RH, Jabbour P. Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies. Neurosurgery 2021. [DOI: 10.1093/neuros/opaa096_s146] [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: 11/14/2022] Open
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40
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Sweid A, Herial N, Sajja K, Chalouhi N, Velagapudi L, Doermann A, Kardon A, Tjoumakaris S, Zarzour H, Smith MJ, Choe H, Shah Q, Mackenzie L, Kozak O, Rosenwasser RH, Jabbour P, Gooch MR. Early Multicenter Experience With the Neuroform Atlas Stent: Feasibility, Safety, and Efficacy. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa143_s015] [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: 11/15/2022] Open
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41
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Sweid A, Daou BJ, Weinberg JH, Starke RM, Sergott RC, Schaefer J, Hauge J, Elizabeth C, Chalouhi N, Gooch MR, Herial N, Zarzour H, Jabbour P, Rosenwasser RH, Tjoumakaris S. In Reply: Experience With Ventriculoperitoneal and Lumboperitoneal Shunting for the Treatment of Idiopathic Intracranial Hypertension: A Single Institution Series. Oper Neurosurg (Hagerstown) 2021; 21:E579-E580. [PMID: 34791406 DOI: 10.1093/ons/opab359] [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: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ahmad Sweid
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Badih J Daou
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan, USA
| | - Joshua H Weinberg
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery University of Miami Hospital Miami, Florida, USA
| | - Robert C Sergott
- Neuro-Ophthalmology Service Wills Eye Hospital and Thomas Jefferson University Philadelphia, Pennsylvania, USA
| | - Joseph Schaefer
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Julie Hauge
- University of Pennsylvania Philadelphia, Pennsylvania, USA
| | | | - Nohra Chalouhi
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery Thomas Jefferson University and Jefferson Hospital for Neuroscience Philadelphia, Pennsylvania, USA
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Baldassari MP, Mouchtouris N, Velagapudi L, Nauheim D, Sweid A, Saiegh FA, Khanna O, Ghosh R, Herman M, Wyler D, Gooch MR, Tjoumakaris S, Jabbour P, Rosenwasser R, Romo V. Comparison of Anesthetic Agents Dexmedetomidine and Midazolam During Mechanical Thrombectomy. J Stroke Cerebrovasc Dis 2021; 30:106117. [PMID: 34656971 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106117] [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: 07/11/2021] [Revised: 09/02/2021] [Accepted: 09/10/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The ideal anesthetic for mechanical thrombectomy (MT) is a subject of debate. Recent studies have supported the use of monitored anesthesia care (MAC), but few have attempted to compare MAC neuroanesthetics. Our study directly compares midazolam and dexmedetomidine (DEX) on blood pressure control during thrombectomy and functional outcomes at discharge. MATERIALS AND METHODS We performed a retrospective review of an MT database, which consisted of 612 patients admitted between 2010-2019 to our tertiary stroke center. 193 patients who received either midazolam or DEX for MAC induction were identified. Primary and secondary outcomes were >20% maximum decrease in mean arterial pressure during MT and functional independence respectively. RESULTS 146 patients were administered midazolam, while 47 were administered DEX. Decrease in blood pressure (BP) during MT was associated with lower rates of functional independence at last follow-up (p=0.034). When compared to midazolam, DEX had significantly higher rates of intraprocedural decrease in MAP at the following cut-offs: >20% (p<0.001), >30% (p=0.001), and >40% (p=0.006). On multivariate analysis, DEX was an independent predictor of >20% MAP decrease (OR 7.042, p<0.001). At time of discharge, NIHSS scores and functional independence (mRS 0-2) were statistically similar between DEX and midazolam. Functional independence at last known follow-up was statistically similar between DEX and midazolam (p = 0.643). CONCLUSIONS Use of DEX during MT appears to be associated with increased blood pressure volatility when compared to midazolam. Further investigation is needed to determine the impact of MAC agents on functional independence.
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Affiliation(s)
- Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - David Nauheim
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Ritam Ghosh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Mary Herman
- Department of Anesthesiology, Division of Neurological Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - David Wyler
- Department of Anesthesiology, Division of Neurological Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Robert Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107
| | - Victor Romo
- Department of Anesthesiology, Division of Neurological Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA, USA, 19107.
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43
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Mouchtouris N, Hasan D, Samaniego EA, Saiegh FA, Sweid A, Abbas R, Naamani KE, Tahir R, Zanaty M, Khanna O, Chalouhi N, Tjoumakaris S, Gooch MR, Rosenwasser R, Jabbour P. The Woven EndoBridge (WEB) device: feasibility, techniques, and outcomes after FDA approval. J Neurosurg 2021:1-7. [PMID: 34624864 DOI: 10.3171/2021.5.jns21889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/05/2021] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Wide-neck bifurcation cerebral aneurysms have historically required either clip ligation or stent- or balloon-assisted coil embolization. This predicament led to the development of the Woven EndoBridge (WEB) aneurysm embolization system, a self-expanding mesh device that achieves intrasaccular flow disruption and does not require antithrombotic medications. The authors report their operative experience and 6-month follow-up occlusion outcomes with the first 115 aneurysms they treated via WEB embolization. METHODS The authors reviewed the first 115 cerebral aneurysms they treated by WEB embolization after FDA approval of the WEB embolization device (from February 2019 to January 2021). Data were collected on patient demographics and clinical presentation, aneurysm characteristics, procedural details, postembolization angiographic contrast stasis, and functional outcomes. RESULTS A total of 110 patients and 115 aneurysms were included in our study (34 ruptured and 81 unruptured aneurysms). WEB embolization was successful in 106 (92.2%) aneurysms, with a complication occurring in 6 (5.5%) patients. Contrast clearance was seen in the arterial phase in 14 (12.2%) aneurysms, in the capillary phase in 16 (13.9%), in the venous phase in 63 (54.8%), and no contrast was seen in 13 (11.3%) of the aneurysms studied. Follow-up angiography was performed on 60 (52.6%) of the aneurysms, with complete occlusion in 38 (63.3%), neck remnant in 14 (23.3%), and aneurysmal remnant in 8 (13.3%). Six (5.5%) patients required re-treatment for persistent aneurysmal residual on follow-up angiography. CONCLUSIONS The WEB device has been successfully used for the treatment of both unruptured and ruptured wide-neck bifurcation aneurysms by achieving intrasaccular flow diversion. Here, the authors have shared their experience with its unique technical considerations and device size selection, as well as critically reviewed complications and aneurysm occlusion rates.
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Affiliation(s)
- Nikolaos Mouchtouris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | | | - Edgar A Samaniego
- Departments of2Neurological Surgery and.,3Neurology, University of Iowa, Iowa City, Iowa
| | - Fadi Al Saiegh
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Ahmad Sweid
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Rawad Abbas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Rizwan Tahir
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | | | - Omaditya Khanna
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Robert Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
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44
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Schmidt RF, Vibbert MD, Vernick CA, Mendelson AM, Harley C, Labella G, Houser J, Becher P, Simko E, Jabbour PM, Tjoumakaris SI, Gooch MR, Sharan AD, Farrell CJ, Harrop JS, Rosenwasser RH, Jaffe RC, Jallo J. Standardizing postoperative handoffs using the evidence-based IPASS framework through a multidisciplinary initiative improves handoff communication for neurosurgical patients in the neuro-intensive care unit. J Clin Neurosci 2021; 92:67-74. [PMID: 34509265 DOI: 10.1016/j.jocn.2021.07.039] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 11/25/2022]
Abstract
Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.
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Affiliation(s)
- Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Matthew D Vibbert
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Coleen A Vernick
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Andrew M Mendelson
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Caitlin Harley
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Giuliana Labella
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jessica Houser
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Patrick Becher
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Erin Simko
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | | | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Ashwini D Sharan
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rebecca C Jaffe
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jack Jallo
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
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45
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Al Saiegh F, Velagapudi L, Khanna O, Sweid A, Mouchtouris N, Baldassari MP, Theofanis T, Tahir R, Schunemann V, Andrews C, Philipp L, Chalouhi N, Tjoumakaris SI, Hasan D, Gooch MR, Herial NA, Rosenwasser RH, Jabbour P. Predictors of aneurysm occlusion following treatment with the WEB device: systematic review and case series. Neurosurg Rev 2021; 45:925-936. [PMID: 34480649 DOI: 10.1007/s10143-021-01638-7] [Citation(s) in RCA: 6] [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: 06/21/2021] [Revised: 08/18/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022]
Abstract
The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thana Theofanis
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rizwan Tahir
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Victoria Schunemann
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Carrie Andrews
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lucas Philipp
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, University of Florida, Gainesville, FL, USA
| | | | - David Hasan
- Department of Neurological Surgery, University of Iowa Hospitals, Iowa City, IA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
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46
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Sweid A, Weinberg JH, Khanna O, Das S, Kim J, Curtis D, Hammoud B, El Naamani K, Abbas R, Majmundar S, Sajja KC, Chalouhi N, Saiegh FA, Mouchtouris N, Atallah E, Gooch MR, Herial NA, Tjoumakaris S, Romo V, Rosenwasser RH, Jabbour P. Lessons Learned After 760 Neurointerventions via the Upper Extremity Vasculature: Pearls and Pitfalls. Neurosurgery 2021; 88:E510-E522. [PMID: 33862629 DOI: 10.1093/neuros/nyab084] [Citation(s) in RCA: 6] [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: 06/09/2020] [Accepted: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The radial approach has been gaining more widespread use by neurointerventionalists fueled by data from the cardiology literature showing better safety and overall reduced morbidity. OBJECTIVE To present our institution's experience with the radial approach for neuroendovascular interventions in 614 consecutive patients who underwent a cumulative of 760 procedures. METHODS A retrospective analysis was performed and identified neuroendovascular procedures performed via the upper extremity vasculature access site. RESULTS Amongst 760 procedures, 34.2% (260) were therapeutic, and 65.7% (500) were nontherapeutic angiograms. Access sites were 71.5% (544) via a conventional radial artery, 27.8% (211) via a distal radial artery, 0.5% (4) via an ulnar artery, and 0.1% (1) via the brachial artery. Most of the procedures (96.9%) were performed via the right-sided (737), 2.9% (22) via the left-sided, and 0.1% (1) via a bilateral approach. Major access site complications occurred at a rate of 0.9% (7). The rate of transfemoral conversion was 4.7% (36). There was a statistically higher incidence of transfemoral conversion when repeat procedures were performed using the same access site. Also, there was no significant difference between nontherapeutic procedures performed using the right and left radial access, and conventional versus distal radial access. Procedural metrics improved after completion of 14 procedures, indicating a learning curve that should be surpassed by operators to reach optimal outcomes. CONCLUSION Radial artery catheterization is a safe and effective means of carrying out a wide range of neuroendovascular procedures associated with excellent clinical outcomes and an overall low rate of periprocedural complications.
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Affiliation(s)
- Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Joshua H Weinberg
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Somnath Das
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julie Kim
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Darcy Curtis
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Batoul Hammoud
- Department of Pediatric Endocrinology, Children Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.,American University of Beirut Faculty of Medicine, Beirut, Lebanon
| | - Shyam Majmundar
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kalyan C Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.,Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Victor Romo
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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47
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Al Saiegh F, Sweid A, Chalouhi N, Philipp L, Mouchtouris N, Khanna O, Avery MB, Schmidt RF, Ghosh R, Hafazalla K, Weinberg JH, Starke RM, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour P. Comparison of Transradial vs Transfemoral Access in Neurovascular Fellowship Training: Overcoming the Learning Curve. Oper Neurosurg (Hagerstown) 2021; 21:E3-E7. [PMID: 33571372 DOI: 10.1093/ons/opab018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 07/22/2020] [Accepted: 12/11/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The transradial access (TRA) is rapidly gaining popularity for neuroendovascular procedures as there is strong evidence for its benefits compared to the traditional transfemoral access (TFA). However, the transition to TRA bears some challenges including optimization of the interventional suite set-up and workflow as well as its impact on fellowship training. OBJECTIVE To compare the learning curves of TFA and TRA for diagnostic cerebral angiograms in neuroendovascular fellowship training. METHODS We prospectively collected diagnostic angiogram procedural data on the performance of 2 neuroendovascular fellows with no prior endovascular experience who trained at our institution from July 2018 until June 2019. Metrics for operator proficiency were minutes of fluoroscopy time, procedure time, and volume of contrast used. RESULTS A total of 293 diagnostic angiograms were included in the analysis. Of those, 57.7% were TRA and 42.3% were TFA. The median contrast dose was 60 cc, and the median radiation dose was 14 000 μGy. The overall complication rate was 1.4% consisting of 2 groin hematomas, 1 wrist hematoma, and 1 access-site infection using TFA. The crossover rate to TFA was 2.1%. Proficiency was achieved after 60 femoral and 95 radial cases based on fluoroscopy time, 52 femoral and 77 radial cases based on procedure time, and 53 femoral and 64 radial cases based on contrast volume. CONCLUSION Our study demonstrates that the use of TRA can be safely incorporated into neuroendovascular training without causing an increase in complications or significantly prolonging procedure time or contrast use.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, University of Florida, Gainesville, Florida, USA
| | - Lucas Philipp
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Michael B Avery
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Ritam Ghosh
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Karim Hafazalla
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Joshua H Weinberg
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Hospital, Miami, Florida, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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48
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Laurent D, Dodd WS, Small C, Gooch MR, Ghosh R, Goutnik M, Blatt T, Porche K, Geh N, Adamczak S, Polifka AJ, Brzezicki G, Hoh B, Chalouhi N. Ticagrelor resistance: a case series and algorithm for management of non-responders. J Neurointerv Surg 2021; 14:179-183. [PMID: 34215660 DOI: 10.1136/neurintsurg-2021-017638] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023]
Abstract
The placement of cervical and intracranial stents requires the administration of antiplatelet drugs to prevent thromboembolic complications. Ticagrelor has emerged as the most widely used alternative in clopidogrel non-responders owing to its potent antiplatelet effects. Because ticagrelor does not require hepatic activation, many neurointerventionalists choose to forgo laboratory testing of platelet inhibition. In rare instances, patients may not achieve adequate platelet inhibition following ticagrelor administration. In this paper we review the mechanism of action of ticagrelor and its use in cerebrovascular procedures. We present two cases of ticagrelor non-responsiveness from two high-volume cerebrovascular centers, discuss their management, and propose an algorithm for managing ticagrelor non-responsiveness.
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Affiliation(s)
- Dimitri Laurent
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - William S Dodd
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Coulter Small
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - M Reid Gooch
- Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ritam Ghosh
- Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Michael Goutnik
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | | | - Ken Porche
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Ndi Geh
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Stephanie Adamczak
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Grzegorz Brzezicki
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Brian Hoh
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Nohra Chalouhi
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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49
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Khanna O, Hafazalla K, Saiegh FA, Tahir R, Schunemann V, Theofanis TN, Mouchtouris N, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour PM. Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19. Clin Neurol Neurosurg 2021; 206:106677. [PMID: 34020326 PMCID: PMC8117485 DOI: 10.1016/j.clineuro.2021.106677] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Karim Hafazalla
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rizwan Tahir
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Victoria Schunemann
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Thana N Theofanis
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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50
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Velagapudi L, Mouchtouris N, Baldassari MP, Nauheim D, Khanna O, Saiegh FA, Herial N, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour P. Discrepancies in Stroke Distribution and Dataset Origin in Machine Learning for Stroke. J Stroke Cerebrovasc Dis 2021; 30:105832. [PMID: 33940363 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/28/2021] [Revised: 04/11/2021] [Accepted: 04/11/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Machine learning algorithms depend on accurate and representative datasets for training in order to become valuable clinical tools that are widely generalizable to a varied population. We aim to conduct a review of machine learning uses in stroke literature to assess the geographic distribution of datasets and patient cohorts used to train these models and compare them to stroke distribution to evaluate for disparities. AIMS 582 studies were identified on initial searching of the PubMed database. Of these studies, 106 full texts were assessed after title and abstract screening which resulted in 489 papers excluded. Of these 106 studies, 79 were excluded due to using cohorts from outside the United States or being review articles or editorials. 27 studies were thus included in this analysis. SUMMARY OF REVIEW Of the 27 studies included, 7 (25.9%) used patient data from California, 6 (22.2%) were multicenter, 3 (11.1%) were in Massachusetts, 2 (7.4%) each in Illinois, Missouri, and New York, and 1 (3.7%) each from South Carolina, Washington, West Virginia, and Wisconsin. 1 (3.7%) study used data from Utah and Texas. These were qualitatively compared to a CDC study showing the highest distribution of stroke in Mississippi (4.3%) followed by Oklahoma (3.4%), Washington D.C. (3.4%), Louisiana (3.3%), and Alabama (3.2%) while the prevalence in California was 2.6%. CONCLUSIONS It is clear that a strong disconnect exists between the datasets and patient cohorts used in training machine learning algorithms in clinical research and the stroke distribution in which clinical tools using these algorithms will be implemented. In order to ensure a lack of bias and increase generalizability and accuracy in future machine learning studies, datasets using a varied patient population that reflects the unequal distribution of stroke risk factors would greatly benefit the usability of these tools and ensure accuracy on a nationwide scale.
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Affiliation(s)
- Lohit Velagapudi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | | | | | - David Nauheim
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | - Omaditya Khanna
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | - Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | - Nabeel Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | | | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA.
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