Publications (81) View all
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Article: Visual and Neurological Outcomes Following Endovascular Stenting for Pseudotumor Cerebri Associated With Transverse Sinus Stenosis.
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ABSTRACT: BACKGROUND:: Pseudotumor cerebri (PTC) is characterized by raised intracranial pressure (ICP) without an identifiable mass, evidence of hydrocephalus, or abnormal cerebrospinal fluid content. In the past, most cases of PTC appeared to have no identifiable etiology, and thus, they were classified as "idiopathic intracranial hypertension" (IIH). Recently, however, a subset of patients with presumed IIH has been found to have evidence of cerebral dural sinus stenoses, particularly involving one or both transverse sinuses (TS). The belief that the stenoses are the cause, rather than an effect of the increased ICP, has led investigators to recommend stenting of the stenosed sinus for the treatment of the condition. We describe detailed visual and neurological outcomes after stenting for PTC associated with hemodynamically significant dural sinus stenosis. METHODS:: All patients with PTC had initial neurological, neuro-ophthalmological, and imaging assessments. Regardless of the findings, all were treated with medical therapy. If medical therapy failed and TS stenosis was detected on contrast-enhanced magnetic resonance or computed tomographic venography, catheter cerebral angiography with venous manometry was performed. If a mean pressure gradient (MPG) of 4 mm Hg or greater was present, unilateral transverse sinus stenting was performed. RESULTS:: Twelve patients with PTC and TS stenosis associated with an MPG of >4 mm Hg who failed medical therapy were identified. TS stenting significantly decreased the pressure gradient in all cases. Unilateral stenting was sufficient to reduce pressure gradients even when the stenosis was bilateral. At a mean follow-up of 16 months (range, 9-36 months), tinnitus had improved in all patients, and 10 of 12 patients had improvement in visual function. Seven patients had significant improvement in headaches. CONCLUSION:: In this small series of patients with PTC associated with TS stenosis, endovascular stent placement was generally effective in treating visual dysfunction and tinnitus, although not headaches. The optimum gradient and vascular characteristics amenable for selection of patients for stenting needs further research.Journal of neuro-ophthalmology: the official journal of the North American Neuro-Ophthalmology Society 03/2013; · 1.09 Impact Factor -
Article: Management of hemorrhage from cavernous malformations.
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ABSTRACT: Cavernous Malformations (CMs) are immature vessels consisting of endothelium-lined sinusoids. Often diagnosed incidentally, they remain clinically silent in the vast majority of patients. Their natural history is now largely believed to follow a benign course that should be conservatively managed in the majority of cases. The exception is the treatment of deep lesions. Here there is not a consensus but the general inclination is towards radiosurgical treatment of inaccessible lesions. However, the results of radiosurgical or gross surgical resection have not been shown to be significantly better than many patients who were managed conservatively. In view of this, an understanding of the natural history of CM and the various outcomes from surgery, radiosurgery and conservative management are essential to define the goals for patients and to individualize treatment strategy.Current Atherosclerosis Reports 06/2012; 14(4):360-5. · 2.66 Impact Factor -
Article: Predictors of surgery-free outcome in adult endoscopic third ventriculostomy.
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ABSTRACT: Endoscopic third ventriculostomy (ETV) is being used increasingly in adults as an alternative to cerebrospinal fluid (CSF) shunting. We analyze patient, radiographic, and operative factors associated with CSF diversion surgery-free outcomes after ETV. One hundred twenty four consecutive adult patients (>18 years) treated with ETV at an academic institution were retrospectively reviewed according to demographic, clinical, operative, radiographic, and follow-up variables. After excluding patients with unclear etiologies or complex previous CSF shunting regimens, there remained 103 patients undergoing ETV for obstructive hydrocephalus, either as initial intervention or in the setting of shunt failure. The primary end point used to assess ETV failure was return to the operating room for CSF diversion. Return of radiographic findings consistent with uncompensated hydrocephalus was considered as a secondary end point. Associations with ETV failure were assessed via Cox proportionate-hazards regression analysis. Clinical improvement was seen in 76 (74%) patients within a median of one month after surgery. Radiographic improvement was seen in 59 (57%) patients within a median of two months after surgery. Fifty-seven (55%) of the patients remained symptom and surgery-free through last follow-up, a median of 5 [2-9] years after ETV. Lasting morbidity and mortality occurred in less than 1%. Multivariate, independent associations with ETV failure included perioperative steroid use, intraoperative image guidance, and time to radiographic improvement. Patients who had image-guided surgery or perioperative steroid treatment were approximately 2.5 times less likely to experience ETV failure. ETV is a safe and effective procedure in adult patients. Perioperative factors, intraoperative image guidance, and steroid treatment may lower ETV failure rates.World Neurosurgery 11/2011; 78(3-4):312-7. · 0.68 Impact Factor -
Article: Comparison of hospital cost and resource use associated with antibiotic-impregnated versus standard shunt catheters.
Neurosurgery 09/2011; 69 Suppl Operative:122-5. · 2.79 Impact Factor -
Article: Radiosurgery of glomus jugulare tumors: a meta-analysis.
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ABSTRACT: During the past two decades, radiosurgery has arisen as a promising approach to the management of glomus jugulare. In the present study, we report on a systematic review and meta-analysis of the available published data on the radiosurgical management of glomus jugulare tumors. To identify eligible studies, systematic searches of all glomus jugulare tumors treated with radiosurgery were conducted in major scientific publication databases. The data search yielded 19 studies, which were included in the meta-analysis. The data from 335 glomus jugulare patients were extracted. The fixed effects pooled proportions were calculated from the data when Cochrane's statistic was statistically insignificant and the inconsistency among studies was <25%. Bias was assessed using the Egger funnel plot test. Across all studies, 97% of patients achieved tumor control, and 95% of patients achieved clinical control. Eight studies reported a mean or median follow-up time of >36 months. In these studies, 95% of patients achieved clinical control and 96% achieved tumor control. The gamma knife, linear accelerator, and CyberKnife technologies all exhibited high rates of tumor and clinical control. The present study reports the results of a meta-analysis for the radiosurgical management of glomus jugulare. Because of its high effectiveness, we suggest considering radiosurgery for the primary management of glomus jugulare tumors.International journal of radiation oncology, biology, physics 06/2011; 81(4):e497-502. · 4.59 Impact Factor
