Publications (83)183.43 Total impact
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Article: History of the Department of Neurosurgery at Thomas Jefferson University Hospital.
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ABSTRACT: The Neurosurgical tradition at Jefferson Medical College began in the 19th century with Samuel Gross. In his textbook entitled A System of Surgery, Gross revealed his knowledge in the disorders of the nervous system at a time when innovations were practically inexistent. Gross's work paved the way for William Williams Keen, "America's first brain surgeon". In 1887, Keen became the first surgeon in the nation to successfully remove a primary brain tumor. In 1893, Keen operated secretly on President Grover Cleveland for removal of an intraoral sarcoma and later served as a consultant to Franklin Roosevelt after he contracted poliomyelitis. The neurosurgery division was established in 1943 by J. Rudolph Jaeger. It was Philip Gordy who created a distinct Department of Neurosurgery in 1969. Jewell L. Osterholm became Chairman of the Department of Neurosurgery in 1974. Since 2004, Robert Rosenwasser has served as chairman, and the Department of Neurosurgery at Jefferson has grown to include 26 faculty members. The residency has expanded to include three residents per academic year since 2007.Neurosurgery 04/2013; · 2.79 Impact Factor -
Article: Diagnostic Yield of Cerebral Angiography In Patients With CT-Negative, Lumbar Puncture-Positive Subarachnoid Hemorrhage.
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ABSTRACT: BACKGROUND:: Cerebral angiography is generally recommended in patients with subarachnoid hemorrhage (SAH) by positive lumbar puncture (LP) but negative CT findings. Existing data on the yield of angiography in these patients is very limited. OBJECTIVE:: To retrospectively assess the diagnostic yield of cerebral angiography in patients with CT-/LP+ SAH and to determine the clinical and laboratory predictors of a vascular abnormality on angiography. METHODS:: A total of 35 patients with CT-/LP+ SAH underwent cerebral angiography at our institution between 2008 and 2011. Patient clinical characteristics and LP findings were entered into a multivariate logistic regression analysis to identify predictors of vascular abnormalities. RESULTS:: Twenty-five patients (71.4%) were female and 10 (28.6%) were male, with a mean age of 53 years. Twenty-six patients (74.3%) had cerebrospinal fluid (CSF) xanthochromia. Sixteen patients (45.7%) were found to have an aneurysm on cerebral angiography. The median CSF red blood cell (RBC) count of both the first (7790/mm vs. 4700 mm) and last collection tubes (6800 mmvs. 3219 mm) were higher in patients with cerebral aneurysms versus those without aneurysms (p=.3). In multivariate analysis, there were no clinical or laboratory parameters that predicted the presence of aneurysm on cerebral angiography. CONCLUSION:: The diagnostic yield of cerebral angiography is high (45.7%) in patients with CT-/LP+ SAH. Higher RBC counts were noted in patients with cerebral aneurysms but no clinical or laboratory parameter can reliably predict the presence of a vascular anomaly. Thus, it is reasonable to perform cerebral angiography in all patients with CT-/LP+ SAH.Neurosurgery 04/2013; · 2.79 Impact Factor -
Article: The Pipeline Embolization Device: Learning Curve and Predictors of Complications and Aneurysm Obliteration.
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ABSTRACT: BACKGROUND:: The pipeline embolization device (PED) has emerged as a promising treatment for intracranial aneurysms. OBJECTIVE:: To assess the safety and efficacy of the PED, analyze the effect of operator experience on the complication rate, and identify predictors of complications and obliteration. METHODS:: A total of 109 patients with 120 aneurysms were treated with PED at our institution. The patient population was divided into 3 consecutive equal groups to assess whether overall and major complication rates decreased over time: Group I, patients 1-37; Group II, patients 38-73; and Group III, patients 74-109. RESULTS:: The number of PEDs used was 1.40 per aneurysm. Symptomatic and major procedure-related complications occurred in 11% and 3.7% of patients, respectively. The rate of complications decreased from 16.2% in group I to 5.6% in group III and the rate of major complications dramatically fell from 10.8% in group I to 0% in groups II and III (p<.05). Procedure time significantly decreased over time (p=0.04). In multivariate analysis, previously treated aneurysms were predictive of procedural complications (p=.02). At the latest follow-up, 65.8% of aneurysms were completely occluded, 9.6% were near-completely occluded, and 24.6% were incompletely occluded. In multivariate analysis, fusiform aneurysms (p=.05) and shorter angiographic follow-up (p=.03) were negative predictors of aneurysm obliteration. CONCLUSION:: PED therapy may have an acceptable safety-efficacy profile. The risk of complications appears to decrease dramatically with physician experience, supporting the existence of a learning curve. Patients with previously treated aneurysms have higher complication rates, whereas fusiform aneurysms achieve lower obliteration rates.Neurosurgery 04/2013; · 2.79 Impact Factor -
Article: Acrodysostosis and Spinal Canal Involvement.
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ABSTRACT: BACKGROUND: Acrodysostosis is a rare syndrome characterized by peripheral dysostosis, nasal hypoplasia and frequently mental retardation. Only two adult cases of acrodysostosis have been reported to have neurologic symptoms. CASE DESCRIPTION: We report one further adult case that presented with signs of spinal cord compression from spinal stenosis, and make the first histological description in the literature of the bony anomalies seen in acrodysostosis. The patient had a T3 to T5 laminectomy and experienced a complete recovery. CONCLUSION: Special attention should be given to these patients in order to detect signs of spinal stenosis, as early decompression can lead to neurological recovery.World Neurosurgery 03/2013; · 0.68 Impact Factor -
Article: Stent-Assisted Coiling of Intracranial Aneurysms: Predictors of Complications, Recanalization, and Outcome in 508 Cases.
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ABSTRACT: BACKGROUND AND PURPOSE: Self-expanding stents are increasingly used for treatment of complex intracranial aneurysms. We assess the safety and the efficacy of intracranial stenting and determine predictors of treatment outcomes. METHODS: A total of 508 patients with 552 aneurysms were treated with Neuroform and Enterprise stents between 2006 and 2011 at our institution. A multivariate analysis was conducted to identify predictors of complications, recanalization, and outcome. RESULTS: Of 508 patients, 461 (91%) were treated electively and 47 (9%) in the setting of subarachnoid hemorrhage. Complications occurred in 6.8% of patients. In multivariate analysis, subarachnoid hemorrhage, delivery of coils before stent placement, and carotid terminus/middle cerebral artery aneurysm locations were independent predictors of procedural complications. Angiographic follow-up was available for 87% of patients at a mean of 26 months. The rates of recanalization and retreatment were, respectively, 12% and 6.4%. Older age, previously coiled aneurysms, larger aneurysms, incompletely occluded aneurysms, Neuroform stent, and aneurysm location were predictors of recanalization. Favorable outcomes were seen in 99% of elective patients and 51% of subarachnoid hemorrhage patients. Patient age, ruptured aneurysms, and procedural complications were predictors of outcome. CONCLUSIONS: Stent-assisted coiling of intracranial aneurysms is safe, effective, and provides durable aneurysm closure. Higher complication rates and worse outcomes are associated with treatment of ruptured aneurysms. Stent delivery before coil deployment reduces the risk of procedural complications. Staging the procedure may not improve procedural safety. Closed-cell stents are associated with significantly lower recanalization rates.Stroke 03/2013; · 5.73 Impact Factor -
Article: Treatment of Large and Giant Intracranial Aneurysms: Cost Comparison of Flow Diversion and Traditional Embolization Strategies.
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ABSTRACT: OBJECTIVE: Flow diversion has emerged as a promising strategy for management of intracranial aneurysms. The purpose of this study was to determine whether treatment of large and giant aneurysms with the PED is more economical than traditional embolization strategies. METHODS: We identified 30 consecutive aneurysms larger than 10 mm that were treated with the PED at our institution. For each aneurysm treated with PED, theoretical coil embolization was performed by filling volume in a consistent, step-wise fashion until a packing density of 25% was reached. Prices of all equipment and implants were taken from price lists provided by each manufacturer. RESULTS: Median aneurysm volume was 0.90 cm3. Overall procedure cost was lower with the PED (mean, 23911$) vs. coiling (30522$, p=0.06). Above the median aneurysm volume, PED treatment was significantly less expensive than coiling even if multiple PEDs were used (p=0.006). However, below the median aneurysm volume, PED treatment was significantly more expensive than coiling (p=0.009). Treatment with multiple PEDs was not cost-beneficial compared with coiling even above the median aneurysm volume. Potential savings associated with the PED were highly dependent on the type of embolic agent used. CONCLUSION: The cost of initial treatment of large and giant aneurysms with PED is economically favorable compared to traditional embolization techniques. However, any potential cost benefit depends on aneurysm volume, coil type, and number of PEDs used. Accordingly, PED therapy is more expensive than coiling in aneurysms < 0.9 cm3 or when multiple devices are used.World Neurosurgery 03/2013; · 0.68 Impact Factor -
Article: Treatment of Ruptured Intracranial Aneurysms: Comparison of Stenting and Balloon Remodeling.
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ABSTRACT: BACKGROUND:: Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are two well-established techniques for the treatment of complex and wide-necked intracranial aneurysms. Most clinicians are reluctant to perform SAC in the setting of subarachnoid hemorrhage (SAH) because of the need for dual antiplatelet therapy. OBJECTIVE:: To compare the safety and efficacy of SAC and BAC in acutely ruptured complex and wide-necked aneurysms. METHODS:: Forty-four patients underwent SAC and 40 underwent BAC. Patients treated with SAC received antiplatelet medications. Perioperative adverse events and outcomes at follow-up (mean, 7.4 months) were retrospectively studied. RESULTS:: The two groups were statistically comparable with respect to all baseline characteristics except for older age in SAC patients (65.6 versus 56.5 years, p=.009). A higher proportion of SAC patients also had poor Hunt and Hess grades (III-V) (70.5% versus 55%, p=.l4). Hemorrhagic, thromboembolic, and overall procedural complications occurred, respectively, in 6.8%, 11.4%, and 18.2% of the SAC group versus 2.5%, 7.5%, and 10% of the BAC group (p=.5, p=.6, p=.3, respectively). Favorable outcomes (Modified Rankin Scale 0-2) at follow-up were seen in 61.0% of the SAC group versus 77% of the BAC group (p=.1). In multivariable analysis, after controlling for differences in baseline characteristics, the type of treatment was not a predictor of procedural complications or clinical outcome. CONCLUSION:: In this study, procedural complications and clinical outcomes did not differ significantly between SAC and BAC in patients with acutely ruptured aneurysms. SAC may be an acceptable alternative to BAC for complex aneurysms in the acute phase of SAH.Neurosurgery 03/2013; · 2.79 Impact Factor -
Article: Radiosurgery for dural arterio-venous fistulas: A review.
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ABSTRACT: Dural arteriovenous fistulas (dAVFs) are vascular lesions involving direct connections between intracranial dural arteries and venous sinuses. The goal of treatment of these vascular lesions is to alleviate symptoms and prevent future hemorrhage. While endovascular embolization remains the primary method of treatment and obliteration of dAVF recently, stereotactic radiosurgery (SRS) has been used as a treatment modality in select dAVF either alone or in conjunction with endovascular embolization. Considering recent studies examining dAVFs natural history and possible therapeutic interventions, the authors provide a concise review of the literature and discuss the indications, efficacy, and safety of SRS in the management of dAVFs.Clinical neurology and neurosurgery 03/2013; · 1.30 Impact Factor -
Article: Imaging aspirin effect on macrophages in the wall of human cerebral aneurysms using ferumoxytol-enhanced MRI: Preliminary results.
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ABSTRACT: BACKGROUND AND PURPOSE: Daily intake of aspirin was shown to decrease human cerebral aneurysm rupture by 60%. The feasibility of imaging macrophages in human cerebral aneurysm walls using ferumoxytol-enhanced MRI has been demonstrated. The goal of the present study is to image aspirin effect on macrophages in the wall of human cerebral aneurysm using ferumoxytol-enhanced MRI. MATERIAL AND METHODS: Five patients with known intracranial aneurysms underwent baseline imaging using T2(*) gradient-echo and T1 MRI sequences using ferumoxytol-enhanced MRI 72-hour post-ferumoxytol infusion. Patients then received 81mg aspirin per os daily. After 3months, imaging studies were repeated and analyzed by co-registration using a histogram and subtraction of follow-up images from baseline. RESULTS: In all five patients, after 3 months of treatment with aspirin, the signal intensity corresponding to the uptake of ferumoxytol by macrophages in the aneurysm wall was less intense than in the baseline images. This was confirmed by co-registration of images using histogram and subtraction of follow-up images from baseline. CONCLUSION: These preliminary results suggest the feasibility of imaging aspirin effect on macrophages localized in the wall of human cerebral aneurysm using ferumoxytol-enhanced MRI. The findings provide radiographic evidence of decreased inflammation in human cerebral aneurysms with daily intake of aspirin using macrophages as a surrogate marker for inflammation.Journal of Neuroradiology 02/2013; · 1.21 Impact Factor -
Article: Treatment of Posterior Circulation Aneurysms with the Pipeline Embolization Device.
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ABSTRACT: BACKGROUND:: Treatment of complex intracranial aneurysms with the pipeline embolization device (PED) has become common practice in neurovascular centers. Very few studies have assessed the safety and efficacy of PED treatment for posterior circulation aneurysms. OBJECTIVE:: To retrospectively present our experience with use of the PED in the posterior circulation. METHODS:: A total of 7 patients harboring 7 posterior circulation aneurysms were treated with the PED at our institution between November 2011 and July 2012. RESULTS:: Aneurysm size was 14.1 mm on average. All patients had unruptured aneurysms. Three aneurysms arose from the vertebral artery, 2 from the basilar artery, and 2 from the vertebrobasilar junction. A single stent was used in 4 patients, 2 stents in 2 patients, and 3 stents in 1 patient. Treatment was successful in all 7 patients. No procedural complications or perforator infarcts were noted in the series. No patient experienced new neurological symptoms related to PED treatment during the follow-up period. Angiographic follow-up was available for 6 patients at a mean time point of 5.5 months. Follow-up angiography showed 100% aneurysm occlusion in 3 patients, marked decrease in aneurysm size in 2 patients, and no change in 1 patient. CONCLUSION:: In our initial experience, it appears that PED treatment in select patients with vertebrobasilar aneurysms may have a reasonable safety-efficacy profile. Larger studies are needed to confirm our findings.Neurosurgery 02/2013; · 2.79 Impact Factor -
Article: Endovascular treatment of proximal and distal posterior inferior cerebellar artery aneurysms.
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ABSTRACT: Object Surgical clipping of posterior inferior cerebellar artery (PICA) aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies. The authors assess the feasibility, safety, and efficacy of endovascular therapy in the largest series of proximal and distal PICA aneurysms to date. Methods A total of 76 patients, 54 with proximal and 22 with distal PICA aneurysms, underwent endovascular treatment at Jefferson Hospital for Neuroscience between 2001 and 2011. Results Endovascular treatment was successful in 52 patients (96.3%) with proximal aneurysms and 19 patients (86.4%) with distal aneurysms. Treatment consisted of selective aneurysm coiling in 60 patients (84.5%) (including 4 with stent assistance and 4 with balloon assistance) and parent vessel trapping in 11 patients (15.5%). Specifically, a deconstructive procedure was necessary in 9.6% of proximal aneurysms (5 of 52) and 31.6% of distal aneurysms (6 of 19). There were 9 overall procedural complications (12.7%), 6 infarcts (8.5%; 4 occurring after deliberate occlusion of the PICA), and 3 intraprocedural ruptures (4.2%). The rate of procedure-related permanent morbidity was 2.8%. Complete aneurysm occlusion was achieved in 63.4% of patients (45 of 71). One patient (1.4%) treated with selective aneurysm coiling suffered a rehemorrhage on postoperative Day 15. The mean angiographic follow-up time was 17.2 months. Recurrence and re-treatment rates were, respectively, 20% and 17.1% for proximal aneurysms compared with 30.8% and 23.1% for distal aneurysms. Favorable outcomes (moderate, mild, or no disability) at follow-up were seen in 93% of patients with unruptured aneurysms and in 78.7% of those with ruptured aneurysms. Conclusions Endovascular therapy is a feasible, safe, and effective treatment in patients with proximal and distal PICA aneurysms, providing excellent patient outcomes and adequate protection against rehemorrhage. The long-term incidence of aneurysm recanalization appears to be high, especially in distal aneurysms, and requires careful angiographic follow-up.Journal of Neurosurgery 01/2013; · 2.96 Impact Factor -
Article: Treatment of recurrent intracranial aneurysms with the Pipeline Embolization Device.
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ABSTRACT: BACKGROUND: The treatment of recurrent aneurysms after previous surgery or embolization is challenging. Little is known regarding the use of the Pipeline Embolization Device (PED) for recurrent aneurysms. OBJECTIVE: To analyze the safety and results of PED therapy for recurrent aneurysms. METHODS: Fifteen patients with recurrent intracranial aneurysms after previous embolization or surgical clipping were treated with the PED at our institution between 2011 and 2012. Procedural complications and clinical and angiographic outcomes were analyzed. RESULTS: Median aneurysm size was 12 mm. Previous aneurysm treatment consisted of coiling in eight patients, stent coiling in four, a telescoping stent technique in two and surgical clipping in one. Major procedural complications (leaving significant morbidity) occurred in one patient (6.7%) and minor procedural or technical complications (no or minor morbidity) occurred in four patients (26.7%). Fourteen of the 15 patients (93.3%) had a favorable outcome (modified Rankin Scale score 0-2). Of 14 patients with angiographic follow-up, nine (64.3%) had complete aneurysm occlusion (100%), four (28.6%) had near-complete occlusion (≥90%) and only one (7.1%) had incomplete occlusion (<90%). Four of the five patients with less than 100% occlusion at follow-up had a previous stent in situ. CONCLUSIONS: Treatment of recurrent aneurysms with the PED appears to be effective, but patients with a previous stent in situ may achieve lower obliteration rates. The morbidity rate associated with PED therapy may be higher than with more standard endovascular techniques using historical data. Larger studies are needed to assess this question better.Journal of neurointerventional surgery 01/2013; · 0.92 Impact Factor -
Article: Evidence that acetylsalicylic Acid attenuates inflammation in the walls of human cerebral aneurysms: preliminary results.
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ABSTRACT: Inflammatory cells and molecules may play a critical role in formation and rupture of cerebral aneurysms. Recently, an epidemiologic study reported that acetylsalicylic acid (ASA) decreases the risk of aneurysm rupture. The goal of this study was to determine the effects of ASA on inflammatory cells and molecules in the walls of human cerebral aneurysms, using radiographic and histological techniques. Eleven prospectively enrolled patients harboring unruptured intracranial aneurysms were randomized into an ASA-treated (81 mg daily) group (n=6) and an untreated (control) group (n=5). Aneurysms were imaged at baseline using ferumoxytol-enhanced MRI to estimate uptake by macrophages. After 3 months, patients were reimaged before undergoing microsurgical clipping. Aneurysm tissues were collected for immunostaining with monoclonal antibodies for cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2), microsomal prostaglandin E2 synthase-1 (mPGES-1), and macrophages. A decrease in signal intensity on ferumoxytol-enhanced MRI was observed after 3 months of ASA treatment. Expression of COX-2 (but not COX-1), mPGES-1, and macrophages was lower in the ASA group than in the control group. This study provides preliminary radiographical and histological evidence that ASA may attenuate the inflammatory process in the walls of human cerebral aneurysms. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01710072.Journal of the American Heart Association. 01/2013; 2(1):e000019. -
Article: Infratentorial and supratentorial strokes after a cranioplasty.
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ABSTRACT: : Complications of cranioplasty are known to include infection, wound breakdown, intracerebral hemorrhage, bone resorption, and status epilepticus. Intracerebral hemorrhagic infarction after a cranioplasty is a very rare complication with only 2 reported cases to date. We present the first case in the literature of both supratentorial and infratentorial hemorrhagic infarctions after a cranioplasty. : A 64-year-old male at an outside hospital suffered a right MCA hemorrhagic infarction requiring decompressive hemicraniectomy. One year later, the patient presents to our hospital for elective right-sided cranioplasty. The procedure was uneventful. However, postoperatively, the patient suffered a generalized tonic-clonic seizure and remained comatose. Electroencephalography showed no signs of status epilepticus, but imaging did reveal diffuse cerebral edema and both infratentorial and supratentorial hemorrhagic infarcts requiring placement of a ventriculostomy, removal of the cranioplasty plate, and suboccipital craniectomy. Postoperative tests revealed only the known right M1 occlusion, with no evidence of venous thrombosis, embolic source for new strokes, or new arterial dissection or occlusion. The patient remained with only brainstem reflexes and eventually expired. : This is the first in the literature to report the complication of both supratentorial and infratentorial strokes after a cranioplasty procedure. Reperfusion, vessel injury, and venous stasis after cranioplasty as evaluated by multiple neurological imaging modalities are examined as possible mechanisms for this unique complication. These factors must be considered when evaluating the safety of the procedure for a patient.The Neurologist 01/2013; 19(1):17-21. · 1.26 Impact Factor -
Article: Surgical Treatment of Ruptured Anterior Circulation Aneurysms: Comparison of Pterional and Supra-Orbital Keyhole Approaches.
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ABSTRACT: BACKGROUND:: Recent advancements in microsurgical techniques and instrumentation have allowed the development of the keyhole approach in aneurysm surgery. OBJECTIVE:: To compare the safety, efficacy, and 1-year clinical outcome of supra-orbital keyhole and standard pterional approaches for ruptured anterior circulation aneurysms. METHODS:: A total of 87 patients underwent surgical clipping, 40 through the pterional and 47 through the supra-orbital keyhole approach. Baseline demographics, operative time, procedural complications, and 1-year patient outcome were retrospectively compared. RESULTS:: The two groups were comparable with respect to baseline characteristics with the exception of a higher proportion of small aneurysms (<7mm) in the supra-orbital group (70.2% vs. 37.5%, p=.002). Total operative time was significantly shorter in the supra-orbital group (205 minutes, p<.001) compared with the pterional group (256 minutes). The rate of procedural complications was lower in patients treated through the pterional (17.5%) versus the supra-orbital approach (23.4%, p=.4). Intra-operative aneurysm ruptures occurred more frequently in the supra-orbital group (10.6% vs. 2.5%). No patient experienced early or late rebleeding in either group. One year after treatment, 75% (30/40) of patients achieved a favorable outcome (GOS IV or V) in the pterional group versus 76.6% (36/47) in the supra-orbital group (p=.8). CONCLUSION:: The rate of procedural complications may be higher with the supra-orbital keyhole approach, but overall patient outcomes appear to be comparable. The pterional approach is a simple, reliable, and efficient procedure. The keyhole approach may be an acceptable alternative for neurosurgeons who have gained sufficient experience with the technique, especially for small non-complex aneurysms.Neurosurgery 11/2012; · 2.79 Impact Factor -
Article: In-Stent Stenosis Following Stent-Assisted Coiling: Incidence, Predictors and Clinical Outcomes of 435 Cases.
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ABSTRACT: BACKGROUND:: Neuroform and Enterprise are widely utilized self-expanding stents designed for the treatment of wide-necked intracranial aneurysms. OBJECTIVE:: To assess the incidence, clinical significance, predictors, and outcomes of in-stent stenosis (ISS). METHODS:: Angiographic studies and hospital records were retrospectively reviewed for 435 patients treated between 2005-2011 in our institution. A multivariable regression analysis was conducted to determine predictors of ISS. RESULTS:: The Neuroform stent was used in 264 (60.7%) patients and the Enterprise in 171 (39.3%). A total of 11 (2.5%) patients demonstrated some degree of ISS during the follow-up period at a mean time point of 4.2 months (range 2-12 months). The stenosis was mild (<50%) in 8 (1.8%) patients, moderate (50-75%) in 2 (0.5%), and severe (>75%) in 1 (0.2%). None were symptomatic or required further intervention. There was complete ISS resolution in 2 patients, partial resolution in 2, and no change in 5 on follow-up angiography. Patients developing ISS were significantly younger than those without ISS (40.3 vs. 54.9 yrs, p<0.001). ISS rates were 2.7% with the Neuroform and 2.3% with the Enterprise stent (p= 0.6). In multivariable analysis, younger patient age (OR=0.92; p=0.008), carotid ophthalmic aneurysm location (OR=7.7; p=0.01), and carotid terminus aneurysm location (OR=8.1; p=0.009) were strong independent predictors of ISS. The type of stent was not a predictive factor. CONCLUSION:: Neuroform and Enterprise ISS is an uncommon, often transient and clinically benign complication. Younger patients and those harboring anterior circulation aneurysms located at ophthalmic and carotid terminus locations are more likely to develop ISS.Neurosurgery 11/2012; · 2.79 Impact Factor -
Article: Delayed Migration of a Pipeline Embolization Device.
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ABSTRACT: BACKGROUND:: Giant and complex aneurysms are increasingly treated with the Pipeline Embolization Device (PED). However, clinical experience with the device remains preliminary. OBJECTIVE:: To report the first case of a delayed migration of an intracranial PED. METHODS:: A 61-year-old woman with a known large right cavernous internal carotid artery aneurysm had a 3-month history of increasing retro-orbital pain. She underwent uneventful treatment of her aneurysm with the PED. RESULTS:: Five months after the procedure, the patient's pain recurred. On the routine 6-month follow-up angiography, there was proximal PED migration, with the distal end of the device projecting directly into the aneurysm and creating a jet of contrast against the aneurysm sac. The migration distance was more than 1 cm, and there was significant foreshortening of the device. A second, overlapping PED was successfully deployed within the first PED to bridge the neck of the aneurysm and redirect the flow jet away from the aneurysm sac. Complete resolution of the patient's symptoms was noted 4 weeks later. CONCLUSION:: Delayed proximal migration may occur after placement of a PED. Accurate stent sizing and adequate apposition to the vessel wall may minimize the occurrence of this undesirable phenomenon. If there is any concern regarding the position of the PED, early imaging follow-up may be indicated.Neurosurgery 11/2012; · 2.79 Impact Factor -
Article: Early Change in Ferumoxytol-Enhanced Magnetic Resonance Imaging Signal Suggests Unstable Human Cerebral Aneurysm: A Pilot Stud.
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ABSTRACT: BACKGROUND AND PURPOSE: The clinical significance of early (ie, within the first 24 hours) uptake of ferumoxytol by macrophages in the wall of human cerebral aneurysms is not clear. The purpose of this study was to determine whether early uptake of ferumoxytol suggests unstable cerebral aneurysm. METHODS: Thirty unruptured aneurysms in 22 patients were imaged with magnetic resonance imaging 24 hours after infusion of ferumoxytol. Eighteen aneurysms were also imaged 72 hours after infusion of ferumoxytol. Aneurysm dome tissue was collected from 4 patients with early magnetic resonance imaging signal changes, 5 patients with late signal changes, and 5 other patients with ruptured aneurysms. The tissue was immunostained for expression of cyclooxygenase-1, cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages. RESULTS: In 23% (7/30) of aneurysms, there was pronounced early uptake of ferumoxytol. Four aneurysms were clipped. The remaining 3 aneurysms were managed conservatively; all 3 ruptured within 6 months. In 53% (16 of 30) of aneurysms, there was pronounced uptake of ferumoxytol at 72 hours. Eight aneurysms were surgically clipped, and 8 were managed conservatively; none ruptured or increased in size after 6 months. Expression of cyclooxygenase-2, microsomal prostaglandin E2 synthase-1, and macrophages was similar in unruptured aneurysms with early uptake of ferumoxytol and ruptured aneurysms. Expression of these inflammatory molecules was significantly higher in aneurysms with early uptake of ferumoxytol versus aneurysms with late uptake. CONCLUSIONS: Uptake of ferumoxytol in aneurysm walls within the first 24 hours strongly suggests aneurysm instability and probability of rupture within 6 months, and may warrant urgent intervention.Stroke 11/2012; · 5.73 Impact Factor -
Article: Stereotactic Radiosurgery for Cavernous Malformations: Is it Effective?
World Neurosurgery 10/2012; · 0.68 Impact Factor -
Article: Rapid and Progressive Venous Thrombosis After Occlusion of High Flow Arteriovenous Fistula.
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ABSTRACT: BACKGROUND: Cerebral venous thrombosis developing after surgical or endovascular obliteration of arterio-venous fistula (AVF) is a rare but devastating complication that has not been adequately reported. CASE DESCRIPTION: Two patients presenting with AVF (1 pial, 1 dural) and large venous pouches were successfully treated by surgical and endovascular means and were neurologically intact post-operatively. Rapid neurological deterioration was seen on post-operative day 5 in the first patient and post-operative day 2 in the second patient. Both patients had massive cerebral venous thrombosis on brain imaging and surgical exploration. One patient died and the other was severely disabled. CONCLUSION: Rapid occlusion of a high-flow AVF resulting in significant venous stasis can precipitate thrombosis of the venous system distal to the fistulous point. In the presence of large venous pouches and significant venous stasis, strict therapeutic anticoagulation may be required to prevent cerebral venous thrombosis. Therapeutic anticoagulation, while feasible following endovascular treatment, may prove particularly challenging after open surgical interventions given the risk of hemorrhagic complications.World Neurosurgery 10/2012; · 0.68 Impact Factor
Top co-authors
Top Journals
Institutions
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2010–2013
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Thomas Jefferson University Hospitals
Philadelphia, PA, USA
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2011–2012
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Wills Eye Institute
Philadelphia, PA, USA
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2004–2012
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Thomas Jefferson University
- Department of Neurological Surgery
Philadelphia, PA, USA
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2004–2005
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University of Colorado Denver
- Department of Neurosurgery
Denver, CO, USA
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