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ABSTRACT: Compromise of blood flow to the brain leads to cerebral ischemia, which if left untreated may even result in cerebral infarction. This has been the main cause of major morbidity and mortality over the years in the US and around the world. Cerebral ischemia to the posterior fossa is more critical and difficult to treat. This is primarily due to complex anatomy and physiology of the posterior fossa cerebal circulation. There has been multiple modalities tested over the years to treat posterior fossa ischemia which have definitely contributed in the outcome in patients with this complex problem. Improving the blood flow in the areas of brain at risk in properly selected patients could prevent impending cerebral ischemia and infarction. Today, there are mainly three types of treatment offered to patients with posterior cerebral ischemia. These are (a) medical, (b) endovascular and (c) surgical. The recent advances in technology, the diagnosis and mode of therapy, has definitely improved the outcomes of cerebral ischemia. We discuss the multidisciplinary treatment of posterior circulation ischemia. Various pre-operative and operative techniques involved in treating patients with posterior cerebral ischemia are discussed.
Neurological Research 02/2004; 26(1):67-73. · 1.52 Impact Factor
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ABSTRACT: The purpose of this retrospective study was to evaluate the results of external ventricular drain (EVD) placement for the management of hydrocephalus. We present our experience with 103 consecutive cases over one year, 56 of which had subarachnoid hemorrhage (SAH). Short tunnel ventriculostomy was performed at the bedside in the neurosurgical intensive care unit (NSICU), using sterile technique. Long-term care included meticulous site care by a dedicated NSICU nurse, daily cultures and prophylactic antibiotics. The average duration of EVD was 10.7 days (range 1-28 days). There was one case of positive cerebrospinal fluid (CSF) culture. Additional complications included one small intraparenchymal hematoma and two cases of EVD disconnection. No patient died form EVD-associated complications. No rebleed from aneurysmal SAH was seen. There was no correlation between the duration of EVD and infection. We conclude that placement of short EVD in the NSICU is safe and can be maintained for the required duration of treatment with minimum infection rate.
British Journal of Neurosurgery 09/2001; 15(4):324-7. · 0.88 Impact Factor
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ABSTRACT: Recent advances in techniques of cardiopulmonary bypass permitted hypothermic circulatory arrest (HCA) using groin cannulation with the chest closed (CC-HCA) and without direct access to the heart. Herein we describe our experience with this technique for complex intracranial aneurysms.
Between 1992 and 1999, 16 patients (4 men and 12 women) with a mean age of 52 years (range 32 to 61 years) with complex intracranial aneurysms underwent resection or clipping of their aneurysms at our institution using the technique of CC-HCA and groin cannulation. Groin access was obtained with 16F to 19F arterial and 18F to 20F venous cannulas placing the tips at the aortoiliac and atriocaval junctions, respectively. Patients were cooled to a nasopharyngeal temperature of 16 degrees C.
Mean circulatory arrest time was 32 minutes. No patient required conversion to standard sternotomy and central cannulation. There were no intraoperative deaths. The 30-day hospital mortality was 2 of 16 patients (12%). Of the 14 surviving patients (88%), 1 developed bilateral third nerve palsy and another left hemiparesis that improved on follow-up. Both were discharged to an extended care facility and continued to do well at home after discharge. Two patients developed deep venous thrombosis postoperatively and required anticoagulation. All patients continued to do well at a mean follow-up of 42 months.
The less invasive technique of CC-HCA through groin cannulation avoids complications associated with a sternotomy, is safe and is associated with little morbidity, reduced operative time, and early hospital discharge and rehabilitation.
The Annals of Thoracic Surgery 07/2001; 71(6):1900-4. · 3.74 Impact Factor
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ABSTRACT: Spontaneous rupture of cerebral aneurysms typically results in subarachnoid hemorrhage. The primary goal of treatment of cerebral aneurysms is to prevent future rupture. Surgical clipping had been the mainstay of treatment of both ruptured and unruptured cerebral aneurysms. In 1991, Guglielmi detachable coil (GDC) embolization was introduced as an alternative method for treating selected patients with aneurysm. The goal of the treatment is prevent the flow of blood into the aneurysm sack by filling the aneurysm with coils and thrombus. Theoretically, there are several advantages of GDC over surgery. These procedures are performed under general anesthesia with the standard transfemoral approaches used in diagnostic angiography. Since its inception, GDC embolization has evolved as a result of both clinical experience and the introduction of technological improvements. We are now better at selecting aneurysms appropriate for coiling, which also have wide necks. Advances in GDC technology have also improved this method of treatment. Over the last several years, the number of coil sizes has been increased, multidimensional coils allowing safer initial coil placement have become available, and, more recently, softer coils have been introduced. Our current approach is to have both surgical and endovascular options for patients.
Archives of Neurology 05/2001; 58(4):559-64. · 7.58 Impact Factor
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J I Ausman
Surgical Neurology 05/2001; 55(4):204-8. · 1.67 Impact Factor
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Surgical Neurology 01/2001; 54(6):465-70. · 1.67 Impact Factor
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ABSTRACT: The purpose of the present study was to assess brain tissue monitoring for detection of ischemia due to vasospasm in aneurysmal subarachnoid hemorrhage (SAH) patients.
After obtaining informed consent, a burr hole was made in 10 patients and a Neurotrend 7 probe was inserted ipsilateral to the region of SAH. In eight patients the probe was inserted during surgery for clipping the aneurysm and in two patients the probe was inserted in the neurosurgery ICU. Brain tissue gases and pH were collected over 6-hour periods for 7 to 10 days until the termination of monitoring. The onset of vasospasm was confirmed by angiography and xenon computed tomography (Xe/CT) cerebral blood flow studies.
Seven patients did not develop vasospasm during monitoring and were considered as controls. In this group, brain tissue oxygen pressure (PO(2)) remained above 20 mmHg, carbon dioxide pressure (PCO(2)) stabilized at 40 mmHg and pH remained between 7.1 and 7.2. In three patients who developed vasospasm during monitoring, PO(2) was not different from the control group. However, PCO(2) increased to 60 mmHg and pH decreased to 6.7 (p < 0.001).
In this study, patients with SAH who developed vasospasm had significantly lower brain tissue pH and higher PCO(2) compared to controls. However, there was no significant change in PO(2) levels associated with vasospasm. Brain tissue monitoring can provide an indication of ischemia during vasospasm.
Surgical Neurology 01/2001; 54(6):432-7; discussion 438. · 1.67 Impact Factor
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ABSTRACT: Surgery for intracranial aneurysms that have been treated by endovascular coiling is a new challenge for neurosurgeons and the need for it will undoubtedly continue to increase. The indications for, timing, and technique of surgery in our experience are described.
We have reviewed our experience with 11 patients who underwent surgery following endovascular coiling with Guglielmi detachable coils (GDCs) of an aneurysm. We analyzed the indications for surgery, surgical techniques used, and patient outcome.
There were nine female and two male patients. The mean age was 49 years (range 13 to 67 years). The intervals between coiling and surgery were 1, 2, 3, 4, 7, 7, 10, and 14 days, 6 weeks, 2, 18, and 25 months. The indications for surgery were partial treatment (3), growth of residual neck (2), persistent mass effect of a giant aneurysm (1), mass effect from the coil ball (2), coil migration (2), and coil protrusion with embolic event (1). The coils were removed at the time of surgery from 9 of 11 aneurysms before clipping. In two cases it was possible to place a clip across the neck of the aneurysm without removing the coils, as the coils no longer occupied the neck. There were two permanent deficits directly related to the endovascular procedures. Two other patients who presented with subarachnoid hemorrhage had residual neurological deficits post surgery and one patient with a giant aneurysm had persistent visual loss.
Surgery remains a viable option at any time for treating aneurysms that have been previously treated by GDC placement. The operative approach is determined by the need for coil removal and the duration since coiling.
Surgical Neurology 12/2000; 54(5):352-60. · 1.67 Impact Factor
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ABSTRACT: Patients with intracranial arteriosclerotic disease have significant morbidity and mortality rates, and some are unresponsive to medical treatment and have unacceptable surgical risks. Percutaneous transluminal angioplasty of the intracranial vessels is a possible alternative to surgery.
To present our experience with percutaneous transluminal angioplasty and to summarize our data.
Sixteen patients underwent intracranial percutaneous transluminal angioplasty for high-grade arteriosclerotic stenosis based on strict inclusion and exclusion criteria. All patients had symptoms referable to the stenosis except one. Angioplasty was performed in 6 intracranial vertebral arteries, 3 basilar arteries, 5 middle cerebral arteries, and 3 distal internal carotid arteries. One patient had concomitant stent placement.
There was 1 treatment failure secondary to tortuous vascular anatomy. Vessel caliber was increased to more than 80% of normal in 6 patients and to 50% to 70% of normal in 6 patients, with a reduction of symptoms. Three intimal dissections occurred during angioplasty; one of these, in a precavernous segment of the internal carotid artery, was stented. One patient restenosed within 1 month of treatment. The remaining treated arteries remained patent during follow-up of 3 months to 2 years. Stroke as a complication occurred in 2 patients, 1 mild and 1 severe. There was no mortality.
Occlusive arteriosclerotic disease involving the intracranial cerebral vessels can be managed medically with antiplatelet and anticoagulant drug therapy or surgically. However, in patients who are unresponsive to medical therapy or who have unacceptable surgical risks, percutaneous transluminal angioplasty is an attractive alternative that can be performed in selected patients with relatively low risk and good clinical outcome.
Archives of Neurology 12/2000; 57(11):1625-30. · 7.58 Impact Factor
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ABSTRACT: Paraclinoid aneurysms include those that are distal to the cavernous segment of the internal carotid artery and proximal to the posterior communicating artery. The purpose of this study was to review our experience with the endovascular treatment of this group of aneurysms, which are difficult to treat surgically.
Between June 1994 and April 1999, 66 patients (56 female, 10 male) with a mean age of 50.1 years (range 13-75, median 51) underwent endovascular treatment for 71 paraclinoid aneurysms. The mean size of the dome was 8.9 mm (range 3-25 mm, median 7) and the of neck was 3.8 mm (range 1.4-8 mm, median 4). Thirteen patients presented with acute subarachnoid hemorrhage, and 4 with previous subarachnoid hemorrhage. Six aneurysms produced mass effect with visual symptoms, 4 presented with transient ischemic attacks, and 44 were incidental. Nine patients had had previous unsuccessful surgery. All procedures were performed under general anesthesia and with systemic heparinization.
Ninety endovascular procedures were performed on 71 aneurysms: GDC coiling in 78 (including 45 with the remodeling technique), permanent balloon occlusion in 9, and 3 had both GDC coiling and permanent balloon occlusion. In ten aneurysms it was not possible to place coils in the lumen of the aneurysm with the available technology and balloon occlusion was not indicated. Five of these were treated surgically and 5 remain untreated. All patients had immediate post procedure angiography. Of the 61 aneurysms that were treated, 46 (75%) have angiographic follow-up of 6 months or more. Morphological outcome following endovascular therapy for 61 aneurysms at last available follow-up showed > 95% occlusion in 52/61 (85.2%) and <95% in 9/61 (14.8%). Eight patients required surgery, 2 for partial coiling, 2 for refilling of a neck remnant, 2 for persistent mass effect and 2 for coil protrusion. In the 90 procedures performed, 2 (2.2%) patients had major permanent deficits (1 monocular blindness, 1 hemiparesis), 1 (1.1%) had a minor visual field cut, and 2 (2.2%) patients died from major embolic events.
Properly selected paraclinoid aneurysms can be successfully treated by endovascular technology. The morbidity and mortality rate of the endovascular approach in our experience is equal to or better than the published surgical series of similar aneurysms. We recommend that the endovascular approach be given primary consideration in the treatment of paraclinoid aneurysms.
Surgical Neurology 11/2000; 54(4):288-99. · 1.67 Impact Factor
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ABSTRACT: Recent publications have pointed out the importance of evaluating patients with in-tandem stenosis and in particular the association of moderate stenosis of the extracranial internal carotid artery (ICA) with moderate or severe stenosis of the intracranial internal carotid artery. Such evaluations are needed in symptomatic patients before planning carotid endarterectomies because observations have shown that in some cases the removal of an extracranial lesion does not necessarily improve these symptoms. This paper examines the hemodynamic effects of in-tandem stenosis in the internal carotid artery.
Equations describing flow in arteries are modified to accommodate two regions of stenosis in tandem. An equivalent value of stenosis is derived such that two stenoses in tandem behave as a single stenosis with similar hemodynamic properties. The solution to this problem is solved mathematically and this was used to analyze the observations made in five studies published on in-tandem stenosis of the internal carotid artery.
Equivalent stenoses for various values of extracranial and intracranial stenoses are presented. It was found that two stenotic lesions in tandem are not equivalent to a simple summation of both values. A graphical solution is presented to show the hemodynamic effects of both stenoses.
The most critical determinant of hemodynamic compromise when two lesions are in tandem is the larger one. Hence removal of a more proximal lesion may have little effect on a larger distal lesion if the symptoms are due to hypoperfusion. It is important that one distinguish between hypoperfusion and thromboembolic causes of the symptoms. No conclusions about the risk of thromboembolic events after a carotid endarterectomy in the setting of a distal stenosis can be made from this study.
Surgical Neurology 09/2000; 54(2):145-52; discussion 152-3. · 1.67 Impact Factor
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ABSTRACT: Reports in the literature have offered discussions of the feasibility, efficacy, and safety of balloon-assisted Guglielmi detachable coil (GDC) placement in wide-necked intracranial aneurysms, which was first described by Jacques Moret as the "remodeling technique." In this article the authors summarize their results in a subset of aneurysms treated with GDCs using the remodeling technique.
This report contains a retrospective analysis of 72 patients with 75 aneurysms who underwent 79 endovascular procedures performed using the remodeling technique. Morphological outcome was determined at the end of each procedure and by reviewing available follow-up angiograms. Clinical assessments and outcomes are reported using a modified Glasgow Outcome Scale. Coils were placed in 66 (88%) of 75 aneurysms selected for treatment. In eight aneurysms (11%) treatment failures occurred due to the tortuosity of the vessel used to reach the aneurysms or because of balloon inadequacies. Incorporating all available follow-up data the authors found that 50 (78%) of 64 aneurysms were completely or subtotally (> 95%) occluded and eight (12%) of 64 were incompletely (< 95%) occluded. Since the time of coil placement, eight aneurysms have progressed to complete occlusion and another five have exhibited progressive thrombosis on follow-up angiograms. In three aneurysms there has been neck remnant growth. Surgical clipping was performed to treat six aneurysms after an initial coil placement procedure. Permanent incidences of morbidity were limited to four patients and there were three deaths directly related to the procedure.
The remodeling technique shows promise in increasing the number of cerebral aneurysms amenable to treatment by endovascular coil placement, and offers an alternative approach to aneurysms that have met with failed surgical treatment or are surgically inaccessible. Long-term follow-up review is needed to determine the final outcome of aneurysms treated by this technique.
Journal of Neurosurgery 09/2000; 93(3):388-96. · 2.96 Impact Factor
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ABSTRACT: To determine the angiographically proven rate and persistence of occlusion of intracranial aneurysms after surgical clipping as reported in the literature. This should establish a basis for comparing surgery with new endovascular methods of treatment.
We reviewed the literature published during the period from 1979 through 1999, dividing the articles into two groups. The first group of articles reported patients undergoing surgical treatment with immediate postoperative angiography. The second group of articles documented symptomatic recurrence or regrowth of aneurysms that were surgically treated previously. The data from these articles are presented for analysis.
During the period 1979 to 1999, six series of patients undergoing surgical treatment of aneurysms with immediate postoperative angiography were reported. These reported series comprised a total of 1,397 patients, of whom 1,370 underwent postoperative angiography demonstrating 1,569 clipped aneurysms. Residual filling was found in 82 aneurysms (5.2%) on postoperative angiography. Of the 1,370 patients, only 124 patients with 169 aneurysms were reported to have had any long-term angiographic follow-up. The second group consisted of 226 patients representing six reported groups of patients, who either presented up to 24 years after aneurysm clipping with recurrent symptoms of hemorrhage or mass effect, or had important findings on intraoperative and postoperative angiograms.
The lack of information regarding both the frequency of residual filling or regrowth and long-term angiographic follow-up of patients with surgically treated aneurysms makes meaningful comparison between surgical treatments and new treatment methods for intracranial aneurysms difficult or impossible. Detailed analysis with high-quality angiography should be performed to determine the success of surgical treatment.
Neurosurgery 07/2000; 46(6):1294-8; discussion 1298-300. · 2.79 Impact Factor
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Surgical Neurology 07/2000; 53(6):552-3. · 1.67 Impact Factor
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Surgical Neurology 04/2000; 53(3):290-2. · 1.67 Impact Factor
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ABSTRACT: More than 200 aneurysms have been coiled at the UIC Medical Center within the last 5 years. We describe in detail the technical factors that increase the chance of complete occlusion of a cerebral aneurysm with coils. Aneurysms selected for coiling have good geometry or are in a location that is difficult to reach surgically. Patients with medical conditions that preclude surgical treatment may also undergo coiling.
Patients with aneurysms, either ruptured or unruptured, are treated under general anesthesia, fully anticoagulated and deeply paralyzed. Coiling is done under simultaneous biplane roadmapping. After the first coil has created a mesh, the aneurysm is densely packed with soft coils of decreasing diameter, until no more coils can be deployed into the aneurysm.
The morbidity and mortality rates associated with the coiling procedure have continuously decreased over the last 5 years. The morphological outcomes have improved, due to extensive use of the remodeling technique and to advancements in materials, such as refinements in the coils themselves or the availability of over-the-wire balloon catheters in different sizes and hydrophilic wires with complex tip configurations. Twenty-one percent of the aneurysms were considered to be incompletely occluded immediately after coiling. Of this group, one-third of the aneurysms were found to be completely occluded on follow-up angiograms by 6 months; these have remained occluded. One-third were more than 95% occluded after the coiling procedure; in these patients, the dome was completely occluded, but there was a small neck remnant, which has remained stable in all patients on control angiograms obtained at 6 months and 1, 2, and 4 years; none have rebled. These patients are followed medically. The remaining one-third of the aneurysms in this subgroup were less than 95% occluded, although the dome was completely thrombosed. None of them have rebled, but the neck remnant in most has regrown over a period ranging from 6 months to 2 years. These patients have undergone a second treatment-either surgical clipping, permanent occlusion of the parent vessel, or repeat coiling using the remodeling technique. The overall rebleeding rate of incompletely occluded aneurysms is extremely low (less than 1%).
The low morbidity and mortality rates and the good morphological outcome obtained in most cases make coiling a reasonable alternative to surgical clipping in properly selected cases.
Surgical Neurology 03/2000; 53(2):150-6. · 1.67 Impact Factor
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ABSTRACT: Subarachnoid hemorrhage can lead to cerebral ischemia and irreversible brain injury. The purpose of this study was to determine whether subarachnoid hemorrhage produces changes in brain tissue oxygen pressure, carbon dioxide pressure, or pH during surgery for cerebral aneurysm clipping.
After institutional review board approval and patient consent, 30 patients undergoing craniotomy for cerebral aneurysm clipping were studied, 15 without and 15 with subarachnoid hemorrhage. Patients with subarachnoid hemorrhage were prospectively separated into groups with modest (Fisher grade 1 or 2; n = 8) and severe bleeds (Fisher grade 3; n = 7). After a craniotomy, a probe was inserted into cortex tissue supplied by the artery associated with the aneurysm. Baseline measures were made in the presence of a 4% end-tidal desflurane level. The end-tidal desflurane level was increased to 9% before clipping of the aneurysm, and a second tissue measurement was made.
The median time of surgery after subarachnoid hemorrhage was 2 days, ranging from 1 to 13 days. During baseline anesthesia, brain tissue oxygen pressure was 17+/-9 mm Hg (mean +/- SD) in control patients, 13+/-9 mm Hg in those with Fisher grade 1 or 2 hemorrhage, and 7+/-6 mm Hg in those with Fisher grade 3 hemorrhage (P<0.05 compared with control). Brain tissue pH was 7.10+/-0.10 in control patients, 7.14+/-0.13 in those with Fisher grade 1 or 2 hemorrhage, and 6.95+/-0.18 in those with with Fisher grade 3 hemorrhage (P<0.05). At a 9% end-tidal desflurane level, brain tissue oxygen pressure increased to 19+/-9 mm Hg and brain tissue pH increased to 7.11+/-0.11 in patients with Fisher grade 3 hemorrhage (P<0.05 for both increases).
These results show that subarachnoid hemorrhage can significantly decrease brain tissue oxygen pressure and pH related to the severity of the bleed. Increasing the desflurane concentration to 9% increased brain tissue oxygen pressure in all patients and brain tissue pH in patients with subarachnoid hemorrhage with baseline acidosis.
Anesthesiology 02/2000; 92(2):442-6. · 5.36 Impact Factor
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ABSTRACT: A case of traumatic, direct, carotid cavernous fistula (CCF) associated with Ehlers - Danlos syndrome (EDS) Type IV is reported along with a review of the literature. Excluding the present case, three similar cases associated with EDSTypeJV have already been reported by Gerard M. Debrun et Al(l). Despite the risks associated with endovascular manipulation, the fistula was successfully closed by intravascular embolisation but the patient expired a few days later because of underlying disease-associated vascular and visceral complications.
Interventional Neuroradiology 12/1999; 5(4):313-20. · 0.56 Impact Factor
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J Haase,
I B Magnussen,
C S Ogilvy,
R G Ojemann,
F B Meyer,
D O Quest,
M T Lawton,
C G McDougall,
R F Spetzler,
D Samson,
A Takahashi,
T Yoshimoto, J I Ausman,
F T Charbel,
G Debrun,
V Aletich,
M Dujovny
Surgical Neurology 11/1999; 52(4):386-92. · 1.67 Impact Factor
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J I Ausman
Surgical Neurology 07/1999; 51(6):584-7. · 1.67 Impact Factor
