Lang M.,Cerebrovascular Center |
Habboub G.,Cleveland Clinic |
Mullin J.P.,Cleveland Clinic |
Rasmussen P.A.,Cerebrovascular Center |
Rasmussen P.A.,Cleveland Clinic
Journal of Neurosurgery | Year: 2017
Carotid-cavernous fistula was one of the first intracranial vascular lesions to be recognized. This paper focuses on the historical progression of our understanding of the condition and its symptomatology-from the initial hypothesis of ophthalmic artery aneurysm as the cause of pulsating exophthalmos to the recognition and acceptance of fistulas between the carotid arterial system and cavernous sinus as the true etiology. The authors also discuss the advancements in treatment from Benjamin Travers' early common carotid ligation and wooden compression methods to today's endovascular approaches. © AANS, 2017.
Spiotta A.M.,Cerebrovascular Center |
Bartsch A.J.,Cleveland Clinic |
Benzel E.C.,Cleveland Clinic
Neurosurgery | Year: 2012
Soccer is the world's most popular sport and unique in that players use their unprotected heads to intentionally deflect, stop, or redirect the ball for both offensive and defensive strategies. Headed balls travel at high velocity pre-and postimpact. Players, coaches, parents, and physicians are justifiably concerned with soccer heading injury risk. Furthermore, risk of long-term neurocognitive and motor deficits caused by repetitively heading a soccer ball remains unknown. We review the theoretical concerns, the results of biomechanical laboratory experiments, and the available clinical data regarding the effects of chronic, subconcussive head injury during heading in soccer. Copyright © 2011 by the Congress of Neurological Surgeons.
Hui F.K.,Cleveland Clinic |
Yim J.,NASA |
Spiotta A.M.,Cleveland Clinic |
Hussain M.S.,Cerebrovascular Center |
Toth G.,Cerebrovascular Center
Journal of NeuroInterventional Surgery | Year: 2012
Objective and importance: In the setting of stroke intervention, there is typically an occlusion that limits angiographic visualization of patent vasculature distal to the embolus. Certain mechanical thrombectomy paradigms include angiography of the vasculature distal to the point of occlusion in preparation for thrombectomy, typically using a microcatheter. Injections using an intermediate catheter allows for higher volume of injection at a faster rate, resulting in radically different pressure gradients. Clinical presentations: Two patients presenting with acute ischemic stroke were treated via mechanical thrombectomy using the Penumbra 054 system. The first was a tandem occlusion with a high grade narrowing and occlusion of the internal carotid artery (ICA) origin and an ICA terminus thrombus. The second was a long segment, high volume thrombus extending from the cavernous segment to the ICA terminus. Intervention: Conventional access techniques were utilized to position the Penumbra 054 catheter in the ICA in both cases. Intraprocedurally, angiography through the 054 catheter within the closed segment resulted in contrast extravasation adjacent to the tentorium, originating from the communicating segment of the ICA, both of which cleared within 48 h. Due to the extravasation, the interventions were both terminated, and the infarcts went on to complete. Conclusion: During an acute stroke, flow within large vessels is abnormal, and rapid changes in volume may result in drastic changes in pressure which may lead to extravasation. The authors recommend never performing a contrast injection through a large lumen catheter when flow may be impeded proximally and distally. Closed segment injections of large volumes at a high rate are probably at high risk for vessel injury.
Tsivgoulis G.,University of Tennessee Health Science Center |
Tsivgoulis G.,National and Kapodistrian University of Athens |
Zand R.,University of Tennessee Health Science Center |
Katsanos A.H.,National and Kapodistrian University of Athens |
And 9 more authors.
Stroke | Year: 2015
Background and Purpose - Shortening door-to-needle time may lead to inadvertent intravenous thrombolysis (IVT) administration in stroke mimics (SMs). We sought to determine the safety of IVT in SMs using prospective, single-center data and by conducting a comprehensive meta-analysis of reported case-series. Methods - We prospectively analyzed consecutive IVT-treated patients during a 5-year period at a tertiary care stroke center. A systematic review and meta-analysis of case-series reporting safety of IVT in SMs and confirmed acute ischemic stroke were conducted. Symptomatic intracerebral hemorrhage was defined as imaging evidence of ICH with an National Institutes of Health Stroke scale increase of ≥4 points. Favorable functional outcome at hospital discharge was defined as a modified Rankin Scale score of 0 to 1. Results - Of 516 consecutive IVT patients at our tertiary care center (50% men; mean age, 60±14 years; median National Institutes of Health Stroke scale, 11; range, 3-22), SMs comprised 75 cases. Symptomatic intracerebral hemorrhage occurred in 1 patient, whereas we documented no cases of orolingual edema or major extracranial hemorrhagic complications. In meta-analysis of 9 studies (8942 IVT-treated patients), the pooled rates of symptomatic intracerebral hemorrhage and orolingual edema among 392 patients with SM treated with IVT were 0.5% (95% confidence interval, 0%-2%) and 0.3% (95% confidence interval, 0%-2%), respectively. Patients with SM were found to have a significantly lower risk for symptomatic intracerebral hemorrhage compared with patients with acute ischemic stroke (risk ratio=0.33; 95% confidence interval, 0.14-0.77; P=0.010), with no evidence of heterogeneity or publication bias. Favorable functional outcome was almost 3-fold higher in patients with SM in comparison with patients with acute ischemic stroke (risk ratio=2.78; 95% confidence interval, 2.07-3.73; P<0.00001). Conclusions - Our prospective, single-center experience coupled with the findings of the comprehensive meta-analysis underscores the safety of IVT in SM. © 2015 American Heart Association, Inc.
McTaggart R.A.,Cleveland Clinic |
McTaggart R.A.,Cerebrovascular Center |
Jovin T.G.,University of Pittsburgh |
Lansberg M.G.,Stanford University |
And 6 more authors.
Stroke | Year: 2015
BACKGROUND AND PURPOSE - : In this study, we compare the performance of pretreatment Alberta Stroke Program Early Computed Tomographic scoring (ASPECTS) using noncontrast CT (NCCT) and MRI in a large endovascular therapy cohort. METHODS - : Prospectively enrolled patients underwent baseline NCCT and MRI and started endovascular therapy within 12 hours of stroke onset. Inclusion criteria for this analysis were evaluable pretreatment NCCT, diffusion-weighted MRI (DWI), and 90-day modified Rankin Scale scores. Two expert readers graded ischemic change on NCCT and DWI using the ASPECTS. ASPECTS scores were analyzed with the full scale or were trichotomized (0-4 versus 5-7 versus 8-10) or dichotomized (0-7 versus 8-10). Good functional outcome was defined as a 90-day modified Rankin Scale score of 0 to 2. RESULTS - : Seventy-four patients fulfilled our study criteria. The full-scale inter-rater agreement for CT-ASPECTS and DWI-ASPECTS was 0.579 and 0.867, respectively. DWI-ASPECTS correlated with functional outcome (P=0.004), whereas CT-ASPECTS did not (P=0.534). Both DWI-ASPECTS and CT-ASPECTS correlated with DWI volume. The receiver operating characteristic analysis revealed that DWI-ASPECTS outperformed both CT-ASPECTS and the time interval between symptom onset and start of the procedure for predicting good functional outcome (modified Rankin Scale score, ≤2) and DWI volume ≥70 mL. CONCLUSION - : Inter-rater agreement for DWI-ASPECTS was superior to that for CT-ASPECTS. DWI-ASPECTS outperformed NCCT ASPECTS for predicting functional outcome at 90 days. © 2015 American Heart Association, Inc.
PubMed | Cerebrovascular Center and Shanghai University
Type: Journal Article | Journal: Journal of neurosurgery | Year: 2016
OBJECT Unruptured posterior communicating artery (PCoA) aneurysms with oculomotor nerve palsy (ONP) have a very high risk of rupture. This study investigated the hemodynamic and morphological characteristics of intracranial aneurysms with high rupture risk by analyzing PCoA aneurysms with ONP. METHODS Fourteen unruptured PCoA aneurysms with ONP, 33 ruptured PCoA aneurysms, and 21 asymptomatic unruptured PCoA aneurysms were included in this study. The clinical, morphological, and hemodynamic characteristics were compared among the different groups. RESULTS The clinical characteristics did not differ among the 3 groups (p > 0.05), whereas the morphological and hemodynamic analyses showed that size, aspect ratio, size ratio, undulation index, nonsphericity index, ellipticity index, normalized wall shear stress (WSS), and percentage of low WSS area differed significantly (p < 0.05) among the 3 groups. Furthermore, multiple comparisons revealed that these parameters differed significantly between the ONP group and the asymptomatic unruptured group and between the ruptured group and the asymptomatic unruptured group, except for size, which differed significantly only between the ONP group and the asymptomatic unruptured group (p = 0.0005). No morphological or hemodynamic parameters differed between the ONP group and the ruptured group. CONCLUSIONS Unruptured PCoA aneurysms with ONP demonstrated a distinctive morphological-hemodynamic pattern that was significantly different compared with asymptomatic unruptured PCoA aneurysms and was similar to ruptured PCoA aneurysms. The larger size, more irregular shape, and lower WSS might be related to the high rupture risk of PCoA aneurysms.
PubMed | Cerebrovascular Center and Shanghai University
Type: Journal Article | Journal: PloS one | Year: 2016
The conflicting findings of previous morphological and hemodynamic studies on intracranial aneurysm rupture may be caused by the relatively small sample sizes and the variation in location of the patient-specific aneurysm models. We aimed to determine the discriminators for aneurysm rupture status by focusing on only posterior communicating artery (PCoA) aneurysms.In 129 PCoA aneurysms (85 ruptured, 44 unruptured), clinical, morphological and hemodynamic characteristics were compared between the ruptured and unruptured cases. Multivariate logistic regression analysis was performed to determine the discriminators for rupture status of PCoA aneurysms.While univariate analyses showed that the size of aneurysm dome, aspect ratio (AR), size ratio (SR), dome-to-neck ratio (DN), inflow angle (IA), normalized wall shear stress (NWSS) and percentage of low wall shear stress area (LSA) were significantly associated with PCoA aneurysm rupture status. With multivariate analyses, significance was only retained for higher IA (OR = 1.539, p < 0.001) and LSA (OR = 1.393, p = 0.041).Hemodynamics and morphology were related to rupture status of intracranial aneurysms. Higher IA and LSA were identified as discriminators for rupture status of PCoA aneurysms.
PubMed | Cerebrovascular Center and Shanghai University
Type: | Journal: World neurosurgery | Year: 2016
The management of small, unruptured intracranial aneurysms is still controversial. Given the distinctive natural history of aneurysm at different locations, location-specific analysis might be a reasonable approach. This study aimed to investigate morphological discriminators for rupture status by focusing on only posterior communicating artery (PcomA) aneurysms smaller than 7 mm.In 108 small PcomA aneurysms (68 ruptured, 40 unruptured), clinical and morphological characteristics were compared between the ruptured and unruptured groups. Multivariate logistic regression analysis was performed to determine the independent predictors for the rupture status of small PcomA aneurysms.None of the clinical characteristics were significantly different between the ruptured and unruptured groups (P > 0.05). The ruptured group revealed a significantly larger size (P = 0.009), aspect ratio (P = 0.009), size ratio (P = 0.002), dome-to-neck ratio (P = 0.002), inflow angle (P < 0.001), and proportion of bleb formation (P = 0.039). Bottleneck factor (P = 0.154), diameter of PcomA (P = 0.302), and fetal-type PcomA (P = 0.832) showed no significance. With multivariate analyses, size ratio (P = 0.012) and inflow angle (P = 0.001) were shown to be independently associated with the rupture status of small PcomA aneurysms.Morphological characteristics were closely related with the rupture status of small PcomA aneurysms. Size ratio and inflow angle were independent risk factors for rupture and might be useful in clinical risk stratification of small PcomA aneurysms.
PubMed | Cerebrovascular Center and Kyushu University
Type: | Journal: Case reports in emergency medicine | Year: 2015
Communication is a serious problem for patients with ventilator-dependent tetraplegia. A 73-year-old man was presented at the emergency room in cardiopulmonary arrest after falling from a height of 2m. After successful resuscitation, fractures of the cervical spine and cervical spinal cord injury were found. Due to paralysis of the respiratory muscles, a mechanical ventilator with a tracheostomy tube was required. First, a cuffed tracheostomy tube and a speaking tracheostomy tube were inserted, and humidified oxygen was introduced via the suction line. Using these tubes, the patient could produce speech sounds, but use was limited to 10min due to discomfort. Second, a mouthstick stylus, fixed on a mouthpiece that fits over the maxillary teeth, was used. The patient used both a communication board and a touch screen device with this mouthstick stylus. The speaking tracheostomy tube and mouthstick stylus greatly improved his ability to communicate.
News Article | February 22, 2017
A cylindrical “pipeline” used for treating large brain aneurysms is just as effective on smaller and sometimes harder to reach ones, according to the results of a clinical trial announced Wednesday. The study’s findings were presented at the International Stroke Conference in Houston by Ricardo A. Hanel, MD, PhD, neurovascular surgeon with Baptist Health and Lyerly Neurosurgery and director of the Baptist Neurological Institute. Eric Sauvageau, MD, neurovascular surgeon and director of the Baptist Stroke & Cerebrovascular Center, was also a co-author and co-investigator on the study. “This study shows the benefit of this breakthrough technology for smaller aneurysms. It demonstrates that the Pipeline ™ Embolization Device is a safe and effective way of dealing with under 12 millimeter aneurysms,” Dr. Hanel said. “The good thing about the pipeline device is once the aneurysm is closed off and treated, the patient is cured, which is very empowering. “The Pipeline is likely more durable and, in the hands of experienced operators like the ones in the study, has low complication rates,” he added. A cerebral aneurysm (also known as an intracranial aneurysm) is a weak or thin spot on a blood vessel in the brain that balloons out and fills with blood. The Pipeline, a braided cylindrical mesh known as a flow diverter, is inserted through a microcatheter into an artery in the groin. The device is then threaded through the body to the brain to slow the flow of blood into the aneurysm and allow the diseased vessel to heal. The Pipeline is currently approved by the U.S. Food and Drug Administration for adults with large aneurysms (which are greater than 12 mm). The results of the clinical trial could open up the procedure for use on patients with small- and medium-sized, wide-necked, unruptured aneurysms, which make up the majority of the cases. "This study confirms that flow diversion is a valid alternative to complement our existing techniques to fix brain aneurysms,” Dr. Sauvageau said. Twenty-two sites in the United States and one in Canada participated in the PREMIER study and 141 patients, including 21 from Baptist Medical Center Jacksonville, which had the highest number enrolled. The study found that a high rate of aneurysms were completely healed at the one-year follow up, with no cases of recurrence. There were also no incidents of aneurysms rupturing one year after the procedure. These results will be submitted to the FDA for review. Dana Bean, of Fernandina Beach, was one of the first to participate in the study; Kristine Meyer, from Mandarin, was the last. Both had successful treatment and surgery at the Baptist Neurological Institute and the Stroke & Cerebrovascular Center at Baptist Medical Center Jacksonville and Lyerly Neurosurgery. Bean, now 54, had lived with a small, hard-to-reach brain aneurysm for six years. It was in the exact spot as the aneurysm that took her mother’s life when Bean was just 6. Her mother collapsed on the playground, as Bean and her brothers played nearby. An ambulance came and she never saw her mother again. She used to wake up in the middle of the night worrying that her aneurysm would burst. In 2014, she became just the second person in the world to be part of the Pipeline clinical trial. At her two-year follow up this past fall, Bean described life without the aneurysm. “Before I worried about dying or being a burden to other people,” she said. “I wanted to be here for graduations, weddings and new babies and the future. Now that I’m cured, I know to seize every day. I live every day to the fullest and I’m excited about the future.” The 42-year-old Meyer worried that her brain aneurysm would burst while driving in her car, with her young children in the back seat. She had the Pipeline procedure in November 2015. Last October, she learned that her aneurysm was gone after shrinking over time. “That was the best Thanksgiving gift I could have received. I don’t have to live with that fear anymore of what could go wrong,” Meyer said. More than a year earlier, she had been experiencing numbness in her arm, dizziness and headaches, which led to the discovery of her aneurysm. “My equilibrium was off, which wasn’t the norm for me. I felt like something was wrong,” Meyer said. The aneurysm was in a difficult location behind her eye and nose, and Meyer said she didn’t want to risk any complications from other more invasive brain surgeries. Using the Pipeline, Dr. Hanel was able to reach the aneurysm and redirect the blood flow away from the aneurysm. The commercial real estate broker was home the next day and was back to work in just two weeks. “Dr. Hanel really took time explaining the procedure and answering questions with not only me, but my husband and mother. We never felt rushed,” Meyer said. “I was excited I had the opportunity to participate [in the study], otherwise I would have had to live with it and not know if and/or when it was going to rupture.” For more information on Baptist Health and Lyerly Neurosurgery, go to lyerlyneuro.com. ### About Baptist Health Baptist Health is a faith-based, mission-driven system in Northeast Florida comprised of Baptist Medical Center Jacksonville; Baptist Medical Center Beaches; Baptist Medical Center Nassau; Baptist Medical Center South; Baptist Clay Medical Campus and Wolfson Children’s Hospital – the region’s only children’s hospital. All Baptist Health hospitals, along with Baptist Home Health Care, have achieved Magnet™ status for excellence in patient care. Baptist Health is part of Coastal Community Health, a regional affiliation between Baptist Health, Flagler Hospital and Southeast Georgia Health System forming a highly integrated hospital network focused on significant initiatives designed to enhance the quality and value of care provided to our contiguous communities. Baptist Health has the area’s only dedicated heart hospital; orthopedic institute; women’s services; neurological institute, including comprehensive neurosurgical services, a comprehensive stroke center and three primary stroke centers; a Bariatric Center of Excellence; a full range of psychology and psychiatry services; urgent care services; and primary and specialty care physicians’ offices throughout Northeast Florida. Baptist MD Anderson Cancer Center is a regional destination for multidisciplinary cancer care which is clinically integrated with MD Anderson Cancer Center, the internationally renowned cancer treatment and research institution in Houston. For more details, visit baptistjax.com.