Ramesh Grandhi

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (24)71.71 Total impact

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    ABSTRACT: Introduction Impaired perioperative nutritional status has been shown to be an important predictor of surgical morbidity and is the earliest marker of nutritional deficiency. No study, however, has examined serum prealbumin as a surrogate marker of nutritional status in patients undergoing spine surgery. Methods We performed a retrospective review of all patients who developed a postoperative deep wound infection after undergoing spine surgery at the University of Pittsburgh Medical Center from January 2008 through December 2011. Demographics, preoperative diagnosis, type of surgery, perioperative serum prealbumin level, time to infection, number and type of debridement procedures, and length of hospital stay were recorded. Results A total of 83 patients had prealbumin levels available at the time of presentation of infection. Mean patient age was 56 years, and 71% were women. Surgical treatment for the infection required between 1 and 13 debridements, and 21 (25%) of the 83 patients who had instrumentation placed at the time of the initial surgery required removal of their instrumentation. Inpatient hospitalizations were extended by an average of 13 days. Prealbumin levels were below normal in 82 (99%) of the 83 patients; levels were < 7 mg/dL in 24 patients, between 7 and 11 mg/dL in 32 patients, and between 11 and 19 mg/dL in 26 patients. Conclusions All patients except one who developed postoperative deep wound infection after spine surgery had serum prealbumin levels in the malnutrition range at the time of presentation. The current study suggests serum prealbumin levels may be an inexpensive screening biomarker for nutritional status and risk stratification for postoperative infection after spine surgery. Georg Thieme Verlag KG Stuttgart · New York.
    Journal of neurological surgery. Part A, Central European neurosurgery. 01/2015;
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    ABSTRACT: Background and Purpose To assess Onyx (Covidien, Irvine, California, United States) efficacy as a preoperative embolic agent for neoplasms of the head, neck, and spine, and to compare angiographic and histologic evidence of tumor penetration as predictors of intraoperative blood loss. Materials and Methods Retrospective analysis of preoperative Onyx embolization procedures for treatment of head, neck, and spine tumors from 2009 to 2011. Patient demographics and information relating to the embolization procedure and operation were recorded. Measures of Onyx efficacy included intraoperative blood loss and length of surgery. Angiographic and histologic penetration, in addition to percentage of tumor devascularization, were assessed as predictors of efficacy. Results A total of 22 patients with 17 head or neck and 5 spinal lesions underwent trans-arterial preoperative Onyx embolization. Good angiographic penetration was reported in 41% of tumors and central histologic penetration in 59%, with mean tumor devascularization of 85.3% (standard deviation [SD]: 12.6%). There was no relationship between angiographic and histologic Onyx penetrance. Mean surgical blood loss was 1342 mL (SD: 1327 mL), and length of surgery was 289 minutes (SD: 162 minutes). Neither angiographic, nor histologic Onyx penetration predicted intraoperative blood loss (p = 0.38 and p = 0.32, respectively) or surgical length (p = 0.62 and 0.90, respectively). Devascularization was not associated with blood loss (p = 0.62), but it was a negative predictor of surgical length (p = 0.013). Conclusions Preoperative Onyx embolization of head, neck, and spine tumors is capable of deep histologic tumor penetration, even when not visualized on angiography. The lack of association between measures of procedural adequacy suggests that using angiographic devascularization as a measure of procedural efficacy may be of limited utility. Georg Thieme Verlag KG Stuttgart · New York.
    Journal of neurological surgery. Part A, Central European neurosurgery. 01/2015;
  • Case Reports 11/2014; 2014.
  • JAMA The Journal of the American Medical Association 09/2014; 312(10):1057-1058. · 30.39 Impact Factor
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    ABSTRACT: Objective Stereotactic radiosurgery (SRS) has evolved to become an established, well-studied treatment modality for intracranial pathologies traditionally treated with more invasive neurosurgical management. As the field expands, among neurosurgeons and across multiple disciplines, resident training will become increasingly crucial. Methods In this review we reflect on 25 years of SRS at the University of Pittsburgh Medical Center (UPMC) and the development of formal training in this area at our institution. We describe the formal resident rotation, fellowship opportunities, and training courses for multidisciplinary physician teams and allied health professionals. Results The number of SRS cases performed annually has significantly increased in recent years, and indeed surpassed caseloads for certain more traditional surgeries. Residents report high rates of expectation for including SRS in future practice, yet participate in only a small fraction of annual cases. The formal PGY-3 rotation established at UPMC provides a way to expose and educate residents in this growing subspecialty within the confines of duty hour regulations. In combination with extended clinical elective opportunities and post-residency fellowships, this rotation prepares residents at our institution for the use of SRS in future clinical practice. Conclusion SRS is a rapidly expanding field that requires a unique skill set and current neurosurgical resident training often does not fully prepare trainees for its use in clinical practice. Focused resident training is necessary to ensure trainees are proficient in this specialty and well equipped to become leaders in the field.
    World Neurosurgery 09/2014; · 2.42 Impact Factor
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    ABSTRACT: Hemifacial spasm (HFS) is a condition that may severely reduce patients' quality of life. We sought to determine the sensitivity and specificity of thin-slice T2 magnetic resonance imaging (MRI) for detecting vascular compression in HFS patients. Prospective information was collected on 28 patients with HFS who presented to our center between March 2011 and March 2012 with thin-slice T2 MR imaging. The sensitivity and specificity for differentiating patients from controls were calculated. Sensitivities were 78.6% and 92.9% for the blinded radiologists and 75% for the partially blinded neurosurgeon. Specificities were 42.9% and 28.6% for the blinded radiologists and 75% for the partially blinded neurosurgeon. Magnetic resonance imaging of the facial nerve can guide clinicians in selecting patients who are good surgical candidates. Thin-slice T2 MRI should be viewed as supportive rather than diagnostic. © 2014 International Parkinson and Movement Disorder Society
    Movement Disorders 07/2014; · 5.63 Impact Factor
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    ABSTRACT: ABSTRACT Fenestrations of the posterior communicating artery (PCoA) are extremely rare. Associated aneurysms have only been documented three times in the literature, and none associated with a subarachnoid hemorrhage. We describe a 52 year-old female who presented with a subarachnoid hemorrhage secondary to a ruptured saccular aneurysm at the proximal limb of a fenestrated right PCoA. The patient was also found to have bilateral middle cerebral artery (MCA) aneurysms. Surgical management included surmising the etiology of the subarachnoid hemorrhage with subsequent clipping of both the right PCoA and MCA aneurysm. The potential embryological mechanisms leading to a PCoA fenestration are discussed.
    The International journal of neuroscience 04/2014; · 1.53 Impact Factor
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    ABSTRACT: Two key discoveries in the 19th century-infection control and the development of general anesthesia-provided an impetus for the rapid advancement of surgery, especially within the field of neurosurgery. Improvements in anesthesia and perioperative care, in particular, fostered the development of meticulous surgical technique conducive to the refinement of neuroanatomical understanding and optimization of neurosurgical procedures and outcomes. Yet, even dating back to the earliest times, some form of anesthesia or perioperative pain management was used during neurosurgical procedures. Despite a few reports on anesthesia published around the time of William Morton's now-famous public demonstration of ether anesthesia in 1846, relatively little is known or written of early anesthetics in neurosurgery. In the present article the authors discuss the history of anesthesia pertaining to neurosurgical procedures and draw parallels between the refinements and developments in anesthesia care over time with some of the concomitant advances in neurosurgery.
    Neurosurgical FOCUS 04/2014; 36(4):E2. · 2.14 Impact Factor
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    ABSTRACT: External ventricular drain (EVD) placement is often a routine but lifesaving neurosurgical procedure performed throughout the world. Misadventures involving the procedure are well documented throughout the literature. However, we present a unique case of middle meningeal artery pseudoaneurysm formation after EVD placement not before described and provide a review of the literature.
    Journal of neuroimaging: official journal of the American Society of Neuroimaging 02/2014; · 1.82 Impact Factor
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    ABSTRACT: To describe procedural aspects and clinical outcomes in a consecutive series of patients in whom manual aspiration thrombectomy (MAT) was performed as the first treatment modality with other techniques used only in case MAT did not yield recanalization. A retrospective review of a prospectively acquired acute stroke intervention database was performed. Primary MAT was carried out with a preference for the largest catheter considered to be trackable into the target occlusive lesion. The catheter was wedged into the thrombus followed by manual aspiration with a 20 ml syringe. 112 consecutive patients were evaluated. The median age was 66 years and the median NIH Stroke Scale score was 17. Occlusion locations included the M1 (62%), M2 (8%), internal carotid artery terminus (19%) and the vertebrobasilar artery (11%). Patients with anterior occlusions had tandem extracranial/intracranial occlusive lesions in 18.7% Median time from symptom onset to groin puncture was 267 min, and from groin puncture to recanalization was 70 min. Successful recanalization (defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3) with primary MAT was 59% with a median of two passes. 41% of patients required the use of adjunctive therapy yielding an overall recanalization rate of TICI 2b/3 (86%) and TICI 3 (30.6%). Parenchymal hematoma of any type (PH1/PH2) was seen in 9.8% of patients, with symptomatic hemorrhage in 6%. Favorable outcomes (90-day modified Rankin Scale ≤2) were 46%. Mortality at 3 months was 31%. Primary MAT was associated with faster procedural times (mean 63 vs 97 min, p<0.0001) but not with higher rates of favorable outcomes. Primary MAT is an alternative endovascular recanalization technique with reasonable first pass efficacy that will likely improve with technology and experience.
    Journal of Neurointerventional Surgery 01/2014; · 2.50 Impact Factor
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    ABSTRACT: Angiolipomas are benign tumors that usually occur in patients during their late teens or early twenties. Most are found as multiple lesions and often located on the arm or trunk. Although predominantly subcutaneous lesions, intraosseous angiolipomas are primarily found in the mandible and ribs, with one case involving the calvarium reported in the literature.
    Surgical Neurology International 01/2014; 5:79. · 1.18 Impact Factor
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    ABSTRACT: Persistent primitive hypoglossal artery (PPHA), a remnant of embryonal circulation, is a rare variant of the posterior cerebral circulation. Seven prior cases of posterior circulation stroke in the setting of PPHA have been described in the literature, with all but one case being attributable to atherosclerotic embolization from the internal carotid artery (ICA) through the PPHA. We report a unique case of a young male with a PPHA presenting with a "top of the basilar" syndrome following the repair of his atrial septal defect who underwent emergent revascularization via endovascular mechanical aspiration thrombectomy. The patient underwent a successful aspiration thrombectomy with significant improvement in his clinical exam. Considering the rarity of this persistent fetal anastamosis, it is important to be aware of the propensity for unusual presentations in the context of stroke, understand the management of the problem, and expeditiously treat the patient.
    Surgical Neurology International 01/2014; 5:182. · 1.18 Impact Factor
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    ABSTRACT: Large vessel occlusive disease portends a poor prognosis unless recanalization is rapidly achieved. Endovascular treatment is typically performed via a transfemoral approach, but catheterization of the occluded vessel can be problematic in cases of extensive vessel tortuosity. A retrospective review of a prospectively maintained database identified 7 patients who underwent acute endovascular reperfusion therapy via transcervical approach. We identified 7 patients. Admission NIHSS ranged from 8-27 and recanalization occurred between 7-49 min of carotid access. Prior to carotid access, 20-90 min were spent attempting target vessel catheterization via the transfemoral approach. All occlusions were in the left MCA. In 87.5% of patient, TICI2b/3 recanalization was achieved. Neck hematoma formation occurred in one case requiring elective intubation. At 2 months followup, all patients had survived with mRS 0-4 except for one patient who had a large infarct despite recanalization. Transcervical access for acute ischemic stroke leads to rapid and high quality recanalization. Future studies will focus on improved hemostasis and early identification of patients who would benefit the most from direct carotid access for acute stroke.
    Journal of Neurointerventional Surgery 11/2013; · 2.50 Impact Factor
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    ABSTRACT: The complication rates of carotid artery stenting (CAS) vary from 3.0% to 4.4%, and most commonly include ischemic stroke, intracranial hemorrhage, or groin complications. We present the rare complication of a patient who underwent CAS for a symptomatic 90% left internal carotid artery stenosis and developed an expanding cervical hematoma after the procedure with imminent respiratory compromise. After intubation, an arteriogram revealed perforation of the external carotid artery trunk, proximal to the origin of the internal maxillary artery. The artery was subsequently embolized and the hematoma resolved without further intervention. We present a potential catastrophic complication and suggest potential causes and treatment options available.
    Case Reports 08/2013; 2013.
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    ABSTRACT: Percutaneous transfemoral arterial procedures rely on a variety of vascular closure methods. We studied closure success and complications after using the Mynx vascular closure device in cerebral neurovascular procedures. We prospectively analyzed patients undergoing diagnostic cerebral angiogram or neurointervention with arteriotomy closure using the Mynx device. Patient demographics and procedural factors were recorded. Statistical analyses compared groups and identified predictors of device failure and complication. A total of 766 patients, 59% women, mean age 55.5 years (SD 14.2), mean body mass index (BMI) 29.1 kg/m(2) (SD 7.4), underwent 937 neurovascular procedures in a 10 month period. Device success was achieved in 92% of patients; lower BMI, higher number of antithrombotic medications, larger sheath size, and performance of a neurointerventional procedure predicted Mynx failure. Complications occurred in 2.45% of procedures, with older age, lower BMI, higher number of antithrombotic medicines used, higher international normalized ratio, lower platelet count, and Mynx device failure conferring an increased risk of complication. The Mynx device is safe and effective for cerebral neurovascular procedures. However, specific patient populations may warrant particular attention and thorough consideration of risks and benefits prior to employing the Mynx device for femoral arteriotomy closure.
    Journal of Neurointerventional Surgery 07/2013; · 2.50 Impact Factor
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    ABSTRACT: BACKGROUND: Infectious intracranial aneurysms (IIAs) are rare and potentially devastating. First-line management involves intravenous antibiotics, with surgical or endovascular management reserved for cases of failed medical treatment or aneurysmal rupture. Endovascular therapy has become the primary approach for treating these small, distally located aneurysms. Liquid embolic agents are well suited for use because of their ability to fill the aneurysm and parent vessel. We present our experience in treating these aneurysms via Onyx embolization and review the literature. METHODS: We retrospectively reviewed the endovascular treatment of IIAs at our institution from 2010 to 2012. Eight patients with 16 IIAs ranging in size from 1 to 16 mm underwent treatment. Seven of the patients initially presented after aneurysmal rupture. Onyx was pushed until the aneurysm and parent artery were filled. Confirmation of aneurysmal occlusion was made by repeat cerebral angiography. RESULTS: One symptomatic stroke occurred after embolization. Fourteen of the 16 aneurysms have been evaluated with follow-up angiography and remain occluded. CONCLUSIONS: Treatment of IIAs using an endovascular approach with Onyx is safe and effective.
    Journal of Neurointerventional Surgery 05/2013; · 2.50 Impact Factor
  • Journal of neuroimaging: official journal of the American Society of Neuroimaging 04/2013; · 1.82 Impact Factor
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    ABSTRACT: Muir-Torre syndrome (MTS) is an autosomal dominant syndrome characterized by neoplasms of the sebaceous gland or keratoacanthomas, in addition to visceral malignancies. Cerebral neoplasms in patients with hereditary nonpolyposis colorectal cancer (HNPCC) or familial adenomatous polyposis suffer from Turcot's syndrome. Genetic mutations in MutS homolog (MSH)-2, MutL homolog (MLH)-1, and MutS homolog (MSH)-6 DNA mismatch repair genes are the most common in MTS with MSH-2 being the most predominant. In HNPCC MLH-1 and MSH-2 mutations are approximately equal in prevalence. We present the case of a 58-year-old male with a prior history of being treated for colonic adenocarcinoma and skin lesions leading to a diagnosis of MTS. The patient later developed a World Health Organization (WHO) grade 4 glioma requiring surgical resection. Pathology revealed mutations in MSH-2 and MSH-6 mismatch repair genes. This case represents the first report of Turcot's and MTS with extensive molecular testing on the cerebral neoplasm demonstrating a molecular relationship between Turcot's and MTS and only the second published report of simultaneous Turcot's and MTS.
    Surgical Neurology International 01/2013; 4:52. · 1.18 Impact Factor
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    ABSTRACT: Evolution in techniques and equipment has expanded the role, effectiveness, and safety of endovascular transarterial embolization for the treatment of severe epistaxis. Risks from this treatment approach include major ischemic complications. To date, there have been only a few reports of soft tissue necrosis following endovascular embolization for severe epistaxis; none involve the use of Onyx-18. We report the case of a 52-year-old woman who presented with epistaxis that was refractory to medical and surgical management, which lead to endovascular intervention and embolization with Onyx-18. The patient subsequently developed nasal ala and facial necrosis as a result of the procedure. We report the use of Onyx-18 for the endovascular embolization of a patient with severe epistaxis and subsequent complications. In cases of severe epistaxis that warrant intervention in the form of embolization, ischemic complications are rare; however, ischemic complications may be unavoidable and should factor into the discussion regarding procedural risks.
    Surgical Neurology International 01/2013; 4:95. · 1.18 Impact Factor
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    ABSTRACT: : As the US population ages, the number of elderly individuals on antiplatelet and anticoagulant medications at risk for traumatic injury grows. Previous studies of traumatic brain injury (TBI) outcomes in this demographic have yielded conflicting results. : We performed a retrospective analysis of elderly TBI patients ( ≥65 years) with evidence of brain hemorrhage on computed tomography (CT) scan at our institution from 2006-2010. Patient demographics, injury severity, clinical course, length of stay, and disposition were collected. Statistical analyses were performed to compare groups and identify predictors of mortality, complication, infection, neurosurgical intervention, and hemorrhage progression. : 1552 patients were identified with 543 aspirin only (AO), 97 clopidogrel only (CO), 218 warfarin only (WO), 193 clopidogrel/aspirin (CA), and 501 patients on no antithrombotic medication (NAT). Significant differences existed in abbreviated injury score (AIS) (P = 0.012), Glasgow Coma Scale (GCS) score (P = 0.013), and Marshall score (P < 0.001) at time of presentation. Blood products were administered to reverse coagulopathy in 77.3% of patients. After adjusting for covariates, including medication reversal, antithrombotic use was associated with increased mortality (P = 0.03); WO use conferred greater odds of mortality than preinjury use of antiplatelet agents (OR 2.53, P = 0.003), which did not influence mortality (P = 0.622). Rates of neurosurgical interventions (P = 0.677) did not differ between groups. Survivor subset analysis demonstrated that CT-identified hemorrhage progression was not associated with preinjury antithrombotic therapy, nor were rates of complication or infection development, hospital/ICU LOS, ventilator days, or discharge disposition. When stratifying for severe and moderate TBI only, use of antithrombotics did not affect outcomes. : Preinjury use of warfarin, but not antiplatelet medications, influences survival in elderly patients admitted with TBI. Hemorrhage progression, neurosurgical interventions, and morbidity are not affected. The importance of antithrombotic therapy seems to lie in its impact on initial injury severity, which in turn, is predictive of increased morbidity and mortality.
    Neurosurgery 08/2012; 71(2):E559-60. · 3.03 Impact Factor