Publications (84) View all
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Article: Transvenous embolization of a dural arteriovenous fistula of the laterocavernous sinus through the pterygoid plexus.
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ABSTRACT: We present a novel access for transvenous embolization of a dural arteriovenous fistula of the laterocavernous sinus through the external jugular vein and the pterygoid plexus. The anatomy of the laterocavernous sinus is reviewed, and its clinical implications discussed in light of the case of a patient whose management was modified after identifying this anatomical variation.Neuroradiology 09/2007; 49(8):665-8. · 2.82 Impact Factor -
Article: Evaluation of a distal pericallosal aneurysm visualized with 3-dimensional digital subtraction angiography: case report and treatment implications.
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ABSTRACT: Digital subtraction angiography (DSA) is considered the gold standard in the evaluation of cerebrovascular structures. Recently, 3-dimensional DSA (3D-DSA) has been increasingly used to obtain detailed information about the morphology and dimensions of intracranial aneurysms. We report the case of a patient who presented with a distal pericallosal artery aneurysm, which appeared by 2D imaging to be a fusiform, possible mycotic aneurysm. This was then revealed to be a saccular bifurcation aneurysm by 3D-DSA. This additional information changed the treatment plan for this patient from medical management to a surgical approach. The patient is a 56-year-old man with a history of hypertension and alcohol abuse with withdrawal seizures, who presented with a large intracranial hemorrhage on initial computed tomography scan. After stabilization with intracranial pressure management, the patient underwent magnetic resonance angiography and 4-vessel DSA. These initial studies showed a distal, fusiform pericallosal aneurysm consistent with a mycotic aneurysm. Rotational DSA was then used to generate 3D images of the structure that revealed a saccular bifurcation aneurysm. This enabled the decision to offer operative treatment rather than conservative medical management. This report highlights the value of 3D-DSA in establishing the appropriate treatment plan for patients with unique cerebral aneurysms. The higher resolution images used in this case provided information that was crucial in shifting the treatment focus from medical management, for what appeared to be a mycotic aneurysm by traditional DSA, to surgical intervention, for a clear hemodynamic aneurysm at a vessel bifurcation seen with 3D-DSA. Accurate pre-interventional evaluation and differential diagnosis are critical to designing the most effective lowest risk treatment plan. The standard method in the diagnosis of cerebral aneurysms has been DSA. Yet, higher resolution images of unclear or high-risk aneurysms are often required to guide clinical decision making. The emergence of new, less invasive endovascular techniques for securing intracranial aneurysms has placed greater emphasis on precisely defining the shape and dimensions of an aneurysm. Three-dimensional DSA is currently the highest resolution imaging modality available for the evaluation of intracranial aneurysms. 3D-DSA was used to evaluate a small, distal pericallosal artery aneurysm and revealed a saccular bifurcation aneurysm not visualized with magnetic resonance angiography and conventional DSA. This additional resolution permitted the team to consider a surgical approach for a patient who would otherwise have been treated medically. This high-resolution technique is particularly useful in guiding clinical decision making in the context of aneurysms that carry a relatively broad differential diagnosis, potentially high interventional risk, and unclear morphology.Surgical Neurology 11/2005; 64(4):321-4. · 1.67 Impact Factor -
Article: Galbraith Award: simvastatin attenuates experimental cerebral vasospasm and ameliorates serum markers of neuronal and endothelial injury in patients after subarachnoid hemorrhage: a dose-response effect dependent on endothelial nitric oxide synthase.
Clinical neurosurgery 02/2005; 52:371-8. -
Article: Vascular Malformations of the Posterior Fossa: Clinical Features, Treatment, and Outcomes
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ABSTRACT: Vascular malformations affecting the cerebral hemispheres are a relatively common clinical entity. In contrast, vascular malformations of the posterior fossa are rare, and there are few documented series involving a large number of patients. Our experience with 93 patients encountered at The Johns Hopkins Hospital is reported. The records of all patients admitted with a radiologically verified diagnosis of posterior circulation vascular malformation from January 1986 through December 2000 were retrospectively reviewed. There were a total of 712 cases of vascular malformations. Of these, 93 cases localized to the posterior fossa (13%). The pathologic findings were consistent with an arteriovenous malformation in 38 patients (41%), cavernous malformation in 20 patients (22%), venous malformation (VM) in 17 patients (18%), and dural arteriovenous fistula in 18 patients (19%). All patients, except for those with VMs, were treated by means of surgery, radiosurgery, or neuroradiologic intervention. Sixty-six percent of patients showed excellent recovery, with 18% more exhibiting only mild neurologic deficits. The overall morbidity in this series was 10.5%, with a mortality rate of 5.3%. Management of vascular malformations in the posterior fossa can pose significant problems. In our experience, patients who are symptomatic, have a prior history of hemorrhage, and are at increased risk for future bleeds are best treated by surgery ± preoperative embolization. On the other hand, patients who are asymptomatic or who harbor small lesions in relatively inaccessible areas benefit the most from radiosurgery. This approach has led to excellent clinical outcomes, with the majority of patients remaining neurologically intact. Vascular malformations-arteriovenous, cavernous, venous, and dural-of the posterior fossa are rare, and limited experience exists regarding their presentation, evaluation, and treatment. In the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage, only 38 of 545 patients (7%) had arteriovenous malformations (AVMs) that localized to the posterior fossa. 1 In other studies involving fewer patients, the reported frequencies range from 10% to 20%. 2-5 Due to the rare nature of these abnormal vascular structures, not only is there a lack of understanding of their natural history but surgical as well as interventional experience is generally limited. Results of treatment in the published series indicate a rate of death and disability about twice that for the general series of supratentorial AVMs. 2,3 Whether this elevated rate is due to difficulty with diagnosis or due to subsequent problems involving medical and surgical management is difficult to establish. In this study, we reviewed our experience with the management of all posterior fossa vascular malformations to provide more insight regarding the management of these difficult lesions.Neurosurgery Quarterly 11/2003; 13(4):257-267. · 0.10 Impact Factor -
Article: De novo aneurysm formation 6 and 22 months after initial presentation in two patients.
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ABSTRACT: Two cases of angiographically and surgically documented de novo intracranial aneurysm formation are reported. The first patient, a 32-year-old woman, developed two new aneurysms within a 6-month period, and the second patient, a 27-year-old woman, developed two new aneurysms within a 22-month period. In both patients, the new aneurysms were symptomatic, causing stroke and subarachnoid hemorrhage, respectively. The development of aneurysms de novo over such a short period of time has important implications for periodic imaging in patients considered to be at high risk for intracranial aneurysm formation.American Journal of Neuroradiology 11/2003; 24(9):1811-3. · 2.93 Impact Factor
