Nabeel A Herial

University of Toledo, Toledo, Ohio, United States

Are you Nabeel A Herial?

Claim your profile

Publications (34)117.58 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The US Food and Drug Administration recently approved a detachable-tip microcatheter, the Apollo microcatheter (eV3, Inc, Irvine, California), to prevent catheter entrapment during embolization of brain arteriovenous malformations (AVMs) using liquid embolic systems. To report technical aspects and clinical results of cerebral embolizations with the Apollo microcatheter in 7 embolizations in 3 adult patients. A 62-year-old man presented with an AVM in the parieto-occipital region measuring 3.6 × 1.6 cm with major cortical feeders from the right middle cerebral artery (MCA) and minor contribution from the distal right anterior cerebral artery. Two pedicles originating from the MCA were embolized. A 48-year-old woman presented with a left frontal AVM measuring 3.3 × 1.8 cm with arterial feeders from the left MCA, left middle meningeal artery, and contralateral anterior cerebral artery. Three pedicles originating from the left MCA were embolized. A 76-year-old man presented with an arteriovenous fistula with multiple fistulous connections and feeders from both vertebral and occipital arteries and the left posterior cerebral artery draining into the left transverse, torcula, and left sigmoid sinus. Two major occipital artery feeders were embolized. Seven Apollo microcatheters were used with the Onyx 18 liquid embolic system. The length of the detachable tip was 15 mm in 2 and 30 mm in 5 embolizations. The mean microcatheter in-position time within the pedicle was 20 minutes. Detachment of tip occurred in 3 instances. No limitations in accessing target arterial feeders and safe tip disengagement were noted despite prolonged injection times. Our initial experience supports the feasibility, safety, and effectiveness of detachable-tip microcatheters in treating brain AVMs and arteriovenous fistulas. AVM, arteriovenous malformationAVF, arteriovenous fistulaDMSO, dimethyl sulfoxideMCA, middle cerebral arteryn-BCA, n-butyl cyanoacrylatePCA, posterior cerebral artery.
    Neurosurgery 06/2015; DOI:10.1227/NEU.0000000000000839 · 3.03 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Liquid embolization using Onyx® of brain arteriovenous malformations (AVMs) is sometimes limited by micro catheter retention by Onyx® cast during the disengagement process. Use of the new detachable tip micro catheter is presented in this report. Two feeding arteries of a previously ruptured brain AVM in a 62-year-old man were embolized by Onyx 18 prior to surgery using the new Apollo™ micro catheter with the detachable-tip (30 mm) was utilized. The arterial feeders were accessed without difficulty by micro catheter, guided by 0.010" microwire. Onyx reflux around the distal end of the micro catheter was necessary for effective embolization of arteriovenous fistulous components of brain AVM. The micro catheter was successfully retracted after embolization in both feeding arteries, with distal end detachment seen in one but not the other arterial embolization. No arterial thrombosis, vasospasm, dissection, or rupture was seen at respective sites of disengagement. Use of the new micro catheters with detachable-tip design allowed prolonged Onyx® injection times, safe micro catheter disengagement, without any limitations in accessing target arterial feeders.
    Journal of vascular and interventional neurology 12/2014; 7(5):64-8.
  • [Show abstract] [Hide abstract]
    ABSTRACT: High-grade stenosis of the internal carotid artery (ICA) may result in flow diversion to the external carotid artery (ECA) and its branches. Head and facial pain secondary to flow-diversion to ECA and increase in regional blood flow are under-recognized and unreported. We report a patient with high-grade ICA stenosis and recurrent ipsilateral headaches that resolved after revascularization. A 69-year-old woman presenting with right-arm weakness had neuroimaging evidence of ipsilateral high-grade ICA stenosis and left hemispheric ischemic stroke. Her history was significant for unilateral recurrent headaches that clinically resolved after left ICA angioplasty and stenting. With prior evidence supporting extracranial vasodilatation as the source of pain in migraine, and current clinical observation, we propose flow-diversion phenomenon as the connection between high-grade ICA stenosis and ipsilateral headache. Recognition of flow-diversion into the ECA as a possible mechanism for headaches may help in further understanding of ICA disease, its progression, and the effects of carotid revascularization on quality of life. Headache as a likely surrogate marker of carotid stenosis with flow-diversion warrants more research, and may be critical in the early identification of significant ICA stenosis and prevention of TIA or stroke.
    Journal of vascular and interventional neurology 12/2014; 7(5):9-11.
  • Munier Nazzal, Nabeel A Herial, Marcus W Macnealy
    [Show abstract] [Hide abstract]
    ABSTRACT: This case report presents the challenges associated with the existing screening modalities in the diagnosis of carotid artery dissection, and also reviews the diagnostic efficiency, limitations, and recent advances in imaging technology. A 54-year-old man with blunt trauma and subsequent development of ischemic stroke and no clear initial evidence of carotid dissection with noninvasive screening, including magnetic resonance imaging, magnetic resonance angiography, and computed tomography angiography. Despite emerging noninvasive imaging techniques, conventional angiography should still be considered to establish a diagnosis of carotid artery dissection, particularly when other imaging modalities are negative or inconclusive but a high degree of clinical suspicion exists based on symptoms or mechanism of injury.
    Annals of Vascular Surgery 01/2014; 28(3). DOI:10.1016/j.avsg.2013.02.031 · 1.03 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The consensus on most reliable supplemental test to predict the shunt responsiveness in patients with idiopathic normal pressure hydrocephalus (iNPH) is lacking. The aim of this study is to discuss the utility of external lumbar drain (ELD) in evaluation of shunt responsiveness for iNPH patients. A retrospective review of 66 patients with iNPH was conducted. All patients underwent 4-day ELD trial. ELD-positive patients were offered ventriculoperitoneal shunt (VPS) surgery. The primary outcome evaluation parameters were gait and mini mental status examination (MMSE) assessment. The family and patient perception of improvement was accounted for in the outcome evaluation. There were 38 male and 28 female with mean age of 74 years (range 45-88 years). ELD trial was positive in 86% (57/66) of patients. No major complications were encountered with the ELD trial. A total of 60 patients (57 ELD-positive, 3 ELD-negative) underwent VPS insertion. The negative ELD trial (P = 0.006) was associated with poor outcomes following shunt insertion. The positive ELD trial predicted shunt responsiveness in 96% patients (P < 0.0001, OR = 96.2, CI = 11.6-795.3). A receiver operating characteristic (ROC) curve analysis revealed that the ELD trial is reasonably accurate in differentiating shunt responder from non-responder in iNPH patients (area under curve = 0.8 ± 0.14, P = 0.02, CI = 0.52-1.0). The mean follow-up period was 12-months (range 0.3-3 years). The significant overall improvement after VPS was seen in 92% (55/60). The improvement was sustained in 76% of patients at mean 3-year follow-up. The number of comorbid conditions (P = 0.034, OR = 4.15, CI = 1.2-9.04), and a history of cerebrovascular accident (CVA) (P = 0.035, OR = 4.4, CI = 1.9-14.6) were the predictors of poor outcome following shunt surgery. The positive ELD test predicted shunt responsiveness in 96% of patients. With adequate technique, maximal results with minimal complications can be anticipated. The number of comorbidities, history of CVA and negative ELD test were significantly associated with poor shunt outcomes.
    Surgical Neurology International 01/2014; 5:12. DOI:10.4103/2152-7806.125860 · 1.18 Impact Factor
  • Multiple Sclerosis 09/2012; 18(9):S6-S6. · 4.86 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: This study investigated the impact of oral health on neurological disorders using the Oral Health Impact Profile (OHIP). A total of 460 subjects completed the OHIP, including 141 control subjects who did not have any neurological conditions. Of the 319 subjects with a neurological diagnosis who were enrolled in the study, 31% had multiple sclerosis (MS), 34% had epilepsy, and 34% had other neurological conditions. Compared to the control group, mean age (p = .001), education (p = .003), and household income levels (p ≤ .001) were statistically significantly lower among subjects with epilepsy than in the other two groups. The majority of the study populations were Caucasian and the percentage was highest in those with MS (87%). Patients with any neurologic diagnosis had greater physical pain and disability than controls. Adjusting for demographic variables, the impact of physical disability was statistically significantly higher in patients with any neurological diagnosis (including MS and epilepsy) (OR = 4.49). In multinomial regression, the strongest association of physical disability impact was noted in patients with epilepsy (OR = 5.17). The physical disability domain of the OHIP is more commonly associated with a neurological diagnosis, including MS, and the association is strongest in patients with diagnosis of epilepsy.
    Special Care in Dentistry 07/2012; 32(4):150-4. DOI:10.1111/j.1754-4505.2012.00259.x
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Migraine is a risk factor for stroke in young women. Biomarker studies implicate endothelial activation as a possible mechanism. Emerging relationships of childhood adversity with migraine, and with inflammation, a component of endothelial activation, suggest that it may play a role in the migraine-stroke association. Our objective is to evaluate the relationship between adverse childhood experiences (ACEs), migraine, and vascular biomarker levels in premenopausal women. Vascular and metabolic biomarkers from women 18-50 years, including 125 with migraine (interictal) and 50 without migraine, were evaluated. An ACE questionnaire was later collected by mail (response rate 80.6%, 100 migraineurs, 41 controls). Migraineurs and controls were demographically similar. Migraineurs reported adversity more commonly than controls (71% vs 46%, odds ratio [OR] = 1.53, 95% confidence interval 1.07-2.17). Average ACE scores were elevated in migraineurs as compared with controls (2.4 vs 0.76, P < .001). ACE scores correlated with headache frequency (0.37, P = .001) and younger age of headache onset (-0.22, P = .04). It also correlated with body mass index (r = 0.43, P = .0001), von Willebrand factor activity (r = 0.21, P = .009), tissue plasminogen activator antigen (r = 0.28, P = .004), prothrombin activation fragment (r = 0.36, P = .001), high-sensitivity C-reactive protein (r = 0.98, P = .0001), transforming growth factor-beta1 (r = 0.28, P = .003), tissue necrosis factor-alpha (r = 0.20, P = .03), interleukin-6 (r = 0.22, P = .03), adiponectin (r = -0.29, P = .003), and nitrate/nitrite concentration (r = -314, P = .001). Logistic regression analyses (adjusted for vascular risk factors and migraine) demonstrated an association of childhood adversity with inflammatory factors (high-sensitivity C-reactive protein, interleukin-6, and tissue necrosis factor-alpha). In young women, adverse childhood events are associated with migraine, particularly chronic and transformed migraine, and with vascular biomarkers, especially inflammatory biomarkers. These findings implicate early life stress as a link between migraine and endothelial activation.
    Headache The Journal of Head and Face Pain 04/2012; 52(6):920-9. DOI:10.1111/j.1526-4610.2012.02165.x · 3.19 Impact Factor
  • Source
    Cephalalgia 07/2011; 31(1(suppl)):11-12. · 4.12 Impact Factor
  • Headache The Journal of Head and Face Pain 06/2011; 51:39-40. · 3.19 Impact Factor
  • Headache The Journal of Head and Face Pain 06/2011; 51:27-28. · 3.19 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Antiepileptic drugs (AEDs) are commonly used for prevention of migraine headaches. Bone loss is a known complication, particularly associated with use of older AEDs. Topiramate is a newer AED, widely used for migraine prevention, but no evidence is currently available on its effect on bone metabolism. In a clinic-based pilot study, we evaluated bone health by examining biochemical and radiological markers of bone metabolism, in women with migraine. Osteopenia was noted in 53% of the patients and was associated with the duration of exposure to topiramate (P = .04).
    Headache The Journal of Head and Face Pain 03/2011; 51(4):613 - 616. DOI:10.1111/j.1526-4610.2011.01863.x · 3.19 Impact Factor
  • Headache The Journal of Head and Face Pain 08/2010; 50(S71). · 3.19 Impact Factor
  • Headache The Journal of Head and Face Pain 08/2010; 50:S41. · 3.19 Impact Factor
  • Fouzia Siddiqui, Nabeel A Herial, Imran I Ali
    [Show abstract] [Hide abstract]
    ABSTRACT: The objective of the study was to evaluate the efficacy of vagus nerve stimulator (VNS) therapy and identify factors associated with reduction of seizures. The VNS is an accepted therapeutic option for patients with refractory partial epilepsy. There are, however, limited data regarding efficacy in any specific group of patients with epilepsy. This is a retrospective review of patients with epilepsy on VNS therapy initiated between January 2000 and December 2007 at a university medical center. Information collected included demographics, epilepsy type and duration, antiepileptic drug usage, stimulation parameters, and seizure frequency at baseline, 3months, 6months, 1year, 2years, and 3years after VNS therapy initiation. Seizure frequency at different follow-up intervals was compared with baseline frequency. Patients were stratified into three subsets based on VNS response. Relationships between VNS response and factors including demographics, location of seizure focus, type or duration of epilepsy, and VNS settings were examined as a whole as well as in subsets. Fifty-four patients were implanted with VNSs over a period of 7years. Four patients were excluded. A total of 50 patients (31 men, 19 women) with mean age 39years and on VNS therapy were included in this study. Average duration of VNS therapy was 4.5years. Baseline average frequency was 10 seizures per month. Significant decreases in median seizure frequency were noted at 3months (P<0.001), 6months (P<0.001), 1year (P=0.004), 2years (P<0.001), and 3years (P<0.0001). Seventy-two percent of the patients reported a decrease in seizure frequency within the first 3months, which increased to 80% by the end of 3years. Overall, the percentage reduction in seizure frequency was 64% at 3months and increased to 86% at the end of 3years. In the subset of patients who responded to VNSs, reduction in seizure frequency improved from 80 to 89% by the end of 3years. There were no correlations between seizure frequency and specific VNS settings, epileptic focus, or duration or type of epilepsy, in the group as a whole or in its subsets. Data suggest a favorable VNS response in patients with higher baseline seizure frequency. Significant reductions in seizure frequency were noted with VNS therapy over a 3-year follow-up period with a possible cumulative effect. Lateralization or localization of epileptic focus or epilepsy subtype did not correlate with response to VNSs.
    Epilepsy & Behavior 07/2010; 18(3):299-302. DOI:10.1016/j.yebeh.2010.04.008 · 2.06 Impact Factor
  • Aijaz Sofi, Nabeel A Herial, Imran I Ali
    [Show abstract] [Hide abstract]
    ABSTRACT: Valproate-associated hyperammonemic coma in adults is a rare complication of valproate therapy and has been previously reported to occur in few days to years after initiation of therapy. We present a case of hyperammonemic coma induced within hours of initiating valproate therapy in a patient with plasma carnitine deficiency.
    American journal of therapeutics 03/2010; 20(6). DOI:10.1097/MJT.0b013e3181d56671 · 1.13 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Cutaneous allodynia (CA) in migraine is a clinical manifestation of central nervous system sensitization. Several chronic pain syndromes and mood disorders are comorbid with migraine. In this study we examine the relationship of migraine-associated CA with these comorbid conditions. We also evaluate the association of CA with factors such as demographic profiles, migraine characteristics, and smoking status that may have an influence on the relationships of CA to pain and mood. Data are from a cross-sectional multicenter study of comorbid conditions in persons seeking treatment in headache clinics. Diagnosis of migraine was determined by a physician based on the International Classification of Headache Disorders-II criteria. Participants completed a self-administered questionnaire ascertaining sociodemographics, migraine-associated allodynia, physician-diagnosed comorbid medical and psychiatric disorders, headache-related disability, current depression, and anxiety. A total of 1413 migraineurs (mean age = 42 years, 89% women) from 11 different headache treatment centers completed a survey on the prevalence of comorbid conditions. Aura was reported by 38% and chronic headache by 35% of the participants. Sixty percent of the study population reported at least one migraine-related allodynic symptom, 10% reported > or =4 symptoms. Symptoms of CA were associated with female gender, body mass index, current smoking, presence of aura, chronic headaches, transformed headaches, severe headache-related disability, and duration of migraine illness from onset. The prevalence of self-reported physician diagnosis of comorbid pain conditions (irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia) and psychiatric conditions (current depression and anxiety) was also associated with symptoms of CA. Adjusted ordinal regression indicated a significant association between number of pain conditions and severity of CA (based on symptom count). Adjusting for sociodemographics, migraine characteristics, and current depression and anxiety, the likelihood of reporting symptoms of severe allodynia was much higher in those with 3 or more pain conditions (odds ratio = 3.03, 95% confidence interval: 1.78-5.17), and 2 pain conditions (odds ratio = 2.67, 95% confidence interval: 1.78-4.01) when compared with those with no comorbid pain condition. Symptoms of CA in migraine were associated with current anxiety, depression, and several chronic pain conditions. A graded relationship was observed between number of allodynic symptoms and the number of pain conditions, even after adjusting for confounding factors. This study also presents the novel association of CA symptoms with younger age of migraine onset, and with cigarette smoking, in addition to confirming several previously reported findings.
    Headache The Journal of Head and Face Pain 10/2009; 49(9):1333-44. DOI:10.1111/j.1526-4610.2009.01521.x · 3.19 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess in a headache clinic population the relationship of childhood abuse and neglect with migraine characteristics, including type, frequency, disability, allodynia, and age of migraine onset. Childhood maltreatment is highly prevalent and has been associated with recurrent headache. Maltreatment is associated with many of the same risk factors for migraine chronification, including depression and anxiety, female sex, substance abuse, and obesity. Electronic surveys were completed by patients seeking treatment in headache clinics at 11 centers across the United States and Canada. Physician-determined data for all participants included the primary headache diagnoses based on the International Classification of Headache Disorders-2 criteria, average monthly headache frequency, whether headaches transformed from episodic to chronic, and if headaches were continuous. Analysis includes all persons with migraine with aura, and migraine without aura. Questionnaire collected information on demographics, social history, age at onset of headaches, migraine-associated allodynic symptoms, headache-related disability (The Headache Impact Test-6), current depression (The Patient Health Questionnaire-9), and current anxiety (The Beck Anxiety Inventory). History and severity of childhood (<18 years) abuse (sexual, emotional, and physical) and neglect (emotional and physical) was gathered using the Childhood Trauma Questionnaire. A total of 1348 migraineurs (88% women) were included (mean age 41 years). Diagnosis of migraine with aura was recorded in 40% and chronic headache (>or=15 days/month) was reported by 34%. Transformation from episodic to chronic was reported by 26%. Prevalence of current depression was 28% and anxiety was 56%. Childhood maltreatment was reported as follows: physical abuse 21%, sexual abuse 25%, emotional abuse 38%, physical neglect 22%, and emotional neglect 38%. In univariate analyses, physical abuse and emotional abuse and neglect were significantly associated with chronic migraine and transformed migraine. Emotional abuse was also associated with continuous daily headache, severe headache-related disability, and migraine-associated allodynia. After adjusting for sociodemographic factors and current depression and anxiety, there remained an association between emotional abuse in childhood and both chronic (odds ratio [OR] = 1.77, 95% confidence intervals [CI]: 1.19-2.62) and transformed migraine (OR = 1.89, 95% CI: 1.25-2.85). Childhood emotional abuse was also associated with younger median age of headache onset (16 years vs 19 years, P = .0002). Our findings suggest that physical abuse, emotional abuse, and emotional neglect may be risk factors for development of chronic headache, including transformed migraine. The association of maltreatment and headache frequency appears to be independent of depression and anxiety, which are related to both childhood abuse and chronic daily headache. The finding that emotional abuse was associated with an earlier age of migraine onset may have implications for the role of stress responses in migraine pathophysiology.
    Headache The Journal of Head and Face Pain 10/2009; 50(1):32-41. DOI:10.1111/j.1526-4610.2009.01557.x · 3.19 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate in a headache clinic population the relationship of childhood maltreatment on the prevalence of pain conditions comorbid with migraine. Childhood maltreatment is highly prevalent and has been frequently associated with recurrent headache. The relationship of maltreatment and pain has, however, been a subject of some debate. Cross-sectional data on self-reported physician-diagnosed pain conditions were electronically collected from persons with migraine (diagnosed according to International Classification of Headache Disorders-2), seeking treatment in headache clinics at 11 centers across the US and Canada. These included irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), fibromyalgia (FM), interstitial cystitis (IC), arthritis, endometriosis, and uterine fibroids. Other information included demographics, migraine characteristics (frequency, headache-related disability), remote and current depression (The Patient Health Questionnaire-9), and remote and current anxiety (The Beck Anxiety Inventory). Patients also completed the Childhood Trauma Questionnaire regarding sexual, emotional, and physical abuse, and emotional and physical neglect under the age of 18 years old. Statistical analyses accounted for the survey design and appropriate procedures in SAS such as surveymeans, surveyfreq, and surveylogistic were applied to the weighted data. A total of 1348 migraineurs (88% women) were included in this study (mean age 41 years). Based on physician diagnosis or validated criteria, 31% had IBS, 16% had CFS, and 10% had FM. Diagnosis of IC was reported by 6.5%, arthritis by 25%, and in women, endometriosis was reported by 15% and uterine fibroids by 14%. At least 1 comorbid pain condition was reported by 61%, 2 conditions by 18%, and 3 or more by 13%. Childhood maltreatment was reported by 58% of the patients. Emotional abuse was associated with increased prevalence of IBS, CFS, arthritis, and physical neglect with arthritis. In women, physical abuse was associated with endometriosis and physical neglect with uterine fibroids. Emotional abuse, and physical abuse and neglect (P < .0001 for all) were also associated with increased total number of comorbid conditions. In ordinal logistic regression models, adjusted for sociodemographics and current depression (prevalence 28%) and anxiety (prevalence 56%), emotional abuse (odds ratios [OR] = 1.69, 95% confidence intervals [CI]: 1.224-2.33) and physical neglect (OR = 1.73, 95% CI: 1.22-2.46) were independently associated with an increased number of pain conditions. The cohort of women, similarly, had associations of emotional abuse (OR = 1.94, 95% CI: 1.40-2.72) and physical neglect (OR = 1.90, 95% CI: 1.34-2.68) with an increased number of pain comorbidities. The association of childhood maltreatment and pain was stronger in those reporting multiple pain conditions and multiple maltreatment types. This finding suggests that in migraineurs childhood maltreatment may be a risk factor for development of comorbid pain disorders.
    Headache The Journal of Head and Face Pain 10/2009; 50(1):42-51. DOI:10.1111/j.1526-4610.2009.01558.x · 3.19 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The evaluation and diagnosis by headache specialists according to ICHD-2 criteria is a strength of this study. The geographic diversity and inclusion of both men and women allows some generalization to other headache clinic populations. In our evaluation of the associations of abuse with obesity, smoking, and substance abuse, all of which may influence migraine, we were able to control for major depression and anxiety, common confounders in this population. This study adds new insights regarding abuse prevalence in migraine, but there are certain limitations. Potential participants were informed that there were questions regarding domestic violence, and it is possible that persons not wishing to answer such questions declined participation, creating a selection bias. The overall number of invitees who declined is estimated at
    Headache The Journal of Head and Face Pain 10/2009; 50(1):20-31. DOI:10.1111/j.1526-4610.2009.01556.x · 3.19 Impact Factor