Mario Zanaty - Academia.edu (original) (raw)

Papers by Mario Zanaty

Journal of Clinical Neuroscience, 2020

Determining which patients will benefit from reoperation for recurrent glioblastoma remains diffi... more Determining which patients will benefit from reoperation for recurrent glioblastoma remains difficult and the impact of the volume of FLAIR signal hyperintensity is not well known. The primary purpose of this study is to analyze the impact of preoperative volume of FLAIR hyperintensity on prognosis. 37 patients who underwent a reoperation for recurrent glioblastoma after initial gross total resection followed by standard chemoradiation were retrospectively reviewed. Volumetric analysis of preoperative MR images from the initial and second surgery was performed and correlated with clinical data. Survival probabilities were estimated using the Kaplan-Meier method and Cox regression to assess the effect of risk factors on time to reoperation (TTR), progression-free survival (PFS) after reoperation, and overall survival (OS). The volumes of FLAIR signal hyperintensity prior to the initial surgery and reoperation were not associated with prognosis. TTR and OS were significantly affected by the preoperative enhancement volume at the initial surgery, with increasing volumes yielding poorer prognosis. Patients with tumor in critical/eloquent areas were found to have a worse prognosis. Median TTR was 11 months, median PFS after reoperation was 3 months, and OS in patients undergoing a reoperation was 21 months. The results suggest FLAIR signal change seen in patients with glioblastoma does not influence time to reoperation, progression-free survival, or overall survival. These findings suggest the amount of FLAIR signal change should not greatly influence a surgeon's decision to perform a second surgical resection compare to other factors, and when appropriate, aggressive surgical intervention should be considered.

Radiology, 2002

PURPOSE: To evaluate the endovascular treatment (EVT) of mycotic aneurysms (MAs). MATERIALS AND M... more PURPOSE: To evaluate the endovascular treatment (EVT) of mycotic aneurysms (MAs). MATERIALS AND METHODS: Clinical and radiologic data of 18 MAs treated with EVT were retrospectively reviewed. There were 14 patients (11 men, three women), ranging in age from 28 to 64 (mean age, 44 years). All patients had endocarditis and positive blood culture. The aneurysms were located within the distal cerebral circulation (n ϭ 13) or in the circle of Willis (n ϭ 5). There were 12 ruptured aneurysms and six unruptured aneurysms. Distal or fusiform aneurysms were treated by means of parent vessel occlusion. Proximal saccular aneurysms were selectively treated. * SAH ϭ subarachnoid hemorrhage, ICH ϭ intracranial hemorrhage. † PCA ϭ posterior cerebral artery, MCA ϭ middle cerebral artery. ‡ GDC ϭ Guglielmi detachable coil, PVA ϭ polyvinyl alcohol. Volume 222 ⅐ Number 2 Endovascular Treatment of Cerebral Mycotic Aneurysms ⅐ 391

British Journal of Radiology, 2008

The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 c... more The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery. Methods. One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27-87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome-indicated by mRS scores of 0 to 2 after at least 6 months-was achieved in 71% of patients. Conclusions. Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination.

Acta Neurologica Scandinavica, 1998

Stroke, 2015

Introduction: Flow diverters have emerged as an important tool in the management of intracranial ... more Introduction: Flow diverters have emerged as an important tool in the management of intracranial aneurysms. This study aims to assess the visual outcomes, the obliteration rate and the need for retreatment of ophthalmic segment aneurysms (OSA) treated by the pipeline embolization device (PED). The study also systematically assesses a crucial issue with the use of flow diverters namely the patency of the ophthalmic artery (OA). Methods: Forty-one patients harboring 44 OSA treated by flow-diversion and 95 patients with internal carotid artery (ICA) aneurysms who had one or more PEDs covering the OA and in whom angiographic follow-up was available were identified. Complication rates, the need for re-treatment, aneurysm occlusion rates, the evolution of visual symptoms, and the evolution of headache/retro-orbital pain were registered. The patency of the OA at follow-up was systematically evaluated by two investigators. Results: The technical success rate was 100% for OSA. The complicati...

Stroke, 2020

Background: High-resolution vessel wall imaging (HR-VWI) has emerged as a useful tool for charact... more Background: High-resolution vessel wall imaging (HR-VWI) has emerged as a useful tool for characterization of intracranial vasculopathic processes. HR-VWI allows better characterization of the arterial wall and may aid in the identification of atherosclerotic plaques, intra-arterial hemorrhages such as in the case of dissections and/or increased contrast enhancement such as in vasculitis. 7T HR-VWI may provide additional information in the identification of stroke mechanism in patients with cryptogenic stroke. Methods: Patients with cryptogenic stroke were prospectively imaged with a 7T scan. Strokes were determined to be cryptogenic after an extensive diagnostic work-up was completed. T1-weighted (pre- and post-contrast), T2-weighted, TOF and SWAN sequences were obtained. Demographic and clinical information was gathered from electronic medical charts. Results: Seventeen patients were included. Mean age was 57.8 ± 16.3 years-old, and 10 (58.8%) were women. HR-VWI determined the eti...

Stroke, 2018

Background: Aspirin is a promising medical therapy for the prevention of intracranial aneurysm (I... more Background: Aspirin is a promising medical therapy for the prevention of intracranial aneurysm (IA) rupture. Recently, we found that men have a better response to aspirin than women. The purpose of this study was to determine whether a sex differential exists in the level of 15-hydroxyprostaglandin dehydrogenase (15-PGDH) in the lumen of human IAs. Methods and Results: Consecutive patients undergoing coiling or stent-assisted coiling for a saccular IA at our institution were enrolled. Two samples (A and B) were collected from IA lumens and the plasma level of 15-PGDH was measured using an ELISA-based method. The study included 38 patients, with 20 women and 18 men. Women and men were comparable with respect to baseline characteristics. In samples A, the mean plasma concentration of 15-PGDH in IA lumens was significantly higher in men (75.8±13.8 ng/ml) than women (51.2±6.4 ng/ml, p<0.0001). Similarly, in samples B, the mean plasma concentration of 15-PGDH in IA lumens was signific...

Stroke, 2019

Unruptured intracranial aneurysms (IAs) are present in ≈3% of people living in the western world.... more Unruptured intracranial aneurysms (IAs) are present in ≈3% of people living in the western world. When ruptured, these aneurysms commonly cause devastating neurological morbidity and mortality. In the unfortunate case of spontaneous aneurysm rupture, it is estimated that nearly 12% of patients die before receiving medical attention. Nearly 30% of the subsequently hospitalized patients die within 1 month after the initial bleed. Of those who survive, another 30% suffer from persistent neurological deficits. In many clinical scenarios, these lesions are prophylactically treated with either open or endovascular surgery, but both carry procedural risk. Incidentally discovered small (<7 mm) IAs are often observed clinically because of a low but nonnegligible rate of growth. Given the increasing number of incidentally detected observed IAs, there is a significant global need for a noninvasive pharmaceutical treatment capable of decreasing the risk of aneurysm rupture. There has been an accumulation of basic science evidence suggesting inflammation plays a critical role in the structural deterioration of the IA wall and its subsequent rupture. These vessel wall changes include but are not limited to high concentrations of proinflammatory cytokines and chemotactic molecules, high levels of macrophage and inflammatory cell infiltration, and phenotypic and apoptotic changes in the vascular smooth muscle cells themselves. In this review, we provide the most comprehensive summary to date of the basic science and clinical evidence suggesting that acetylsalicylic acid (ASA) beneficially modulates the aberrant inflammatory microenvironment within the IA vessel wall, ultimately preventing rupture.

World Neurosurgery, 2019

The Woven EndoBridge (WEB) device, an intrasaccular flow-diverter that does not require long-term... more The Woven EndoBridge (WEB) device, an intrasaccular flow-diverter that does not require long-term antiplatelet use, has recently emerged as an alternative to embolize complex intracranial aneurysms; however, there are limitations to the WEB device. First, it does not immediately secure the aneurysm in most subarachnoid hemorrhage cases. Second, it may not be suitable for embolization of wide-neck aneurysms with an unfavorable aspect ratio. To overcome these limitations, we have used the WEB device in conjunction with stenting and/or coiling. Here, we present a technical note with an illustrated case series and provide a detailed step-by-step description on how the WEB device can be used in adjunct to coiling and/or stenting to achieve successful angiographic results. Accurate sizing of the WEB device before deployment is critical. Larger case series are required to further assess the safety and success of these combined techniques.

Journal of Neurosurgery, 2019

OBJECTIVERevascularization of a symptomatic, medically refractory, cervical chronically occluded ... more OBJECTIVERevascularization of a symptomatic, medically refractory, cervical chronically occluded internal carotid artery (COICA) using endovascular techniques (ETs) has surfaced as a viable alternative to extracranial-intracranial bypass. The authors aimed to assess the safety, success, and neurocognitive outcomes of recanalization of COICA using ETs or hybrid treatment (ET plus carotid endarterectomy) and to identify candidate radiological markers that could predict success.METHODSThe authors performed a retrospective analysis of their prospectively collected institutional database and used their previously published COICA classification to assess the potential benefits of ETs or hybrid surgery to revascularize symptomatic patients with COICA. Subjects who had undergone CT perfusion (CTP) imaging and Montreal Cognitive Assessment (MoCA) testing, both pre- and postprocedure, were included. The authors then performed a review of the literature on patients with COICA to further evalua...

Stroke and Vascular Neurology, 2019

BackgroundEndovascular treatment of intracranial aneurysms usually involves stent-assisted coilin... more BackgroundEndovascular treatment of intracranial aneurysms usually involves stent-assisted coiling (SAC) and flow diverters. Glycoprotein IIb/IIIa inhibitors such as tirofiban and dual antiplatelet therapy (DAPT) are required to prevent thromboembolic complications afterwards. We sought to determine the safety of tirofiban and DAPT in these cases.MethodsWe conducted a retrospective analysis of our database for patients with intracranial aneurysms who underwent SAC or flow diversion. The tirofiban-DAPT protocol used is described. Data regarding duration of infusion, placement of external ventricular devices (EVDs), complications, haemoglobin levels and platelet count before and 24 hours after antiplatelet therapy were collected and analysed.ResultsOne-hundred and forty-one patients with 148 aneurysms/procedures were included. 110 aneurysms were treated acutely and 38 electively. Minor and major haemorrhagic events were recognised in 20% (30/148) aneurysms. Only 5 (3.4%) intracerebral...

Case reports in vascular medicine, 2017

We think that these publications were developed simultaneously. In addition, we think that more s... more We think that these publications were developed simultaneously. In addition, we think that more series would be reported in the future regarding the failure of the pipeline in the treatment of posterior communicating artery aneurysms associated with a fetal posterior cerebral artery. We also congratulate Srinivasan et al. [3] and Kan et al. [4] on their work on this topic and we agree that the most likely explanation of the pipeline failure is the high flow demand in this type of circulation. This can also explain why parent artery occlusion can lead to cerebellar infarction in this subset of patients [5]. We are also working on reporting other aneurysm geometrical factors that contribute to failure of flow-diversion; however this work is still in its early stages.

World neurosurgery, Jan 12, 2016

Studies that showed endovascular coiling of ruptured intracranial aneurysms (RAs) to be superior ... more Studies that showed endovascular coiling of ruptured intracranial aneurysms (RAs) to be superior to microsurgical clipping were comparing dedicated endovascular interventionalists vs. open cerebrovascular surgeons. This is the first study to evaluate outcomes of coiling vs. clipping of RAs treated by a dual trained cerebrovascular surgeon using a specific intervention protocol. The prospectively maintained database was reviewed for all patients with RAs undergoing endovascular coiling (+/- stenting) or clipping by the senior author (dual trained vascular neurosurgeon) between July 2010 and April 2015. In 252 identified patients, 70 underwent clipping and 182 underwent endovascular treatment. The mean and median time to last follow-up were 179.6 and 176.5 days in the endovascular cohort, 203.9 and 154.0 days in the surgical cohort. There was no difference in age, gender, WFNS and Fisher grade, mean aneurysm size and LOS in the hospital/ICU. Clipping had a higher proportion of MCA ane...

Journal of neurosurgery, Jan 3, 2015

OBJECT Endovascular interventions have become an essential part of a neurosurgeon's practice.... more OBJECT Endovascular interventions have become an essential part of a neurosurgeon's practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship. METHODS A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship. RESULTS The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, ...

TheScientificWorldJournal, 2014

Endosaccular coiling, vessel occlusion, stenting, stent-assisted coiling, and flow diversion are ... more Endosaccular coiling, vessel occlusion, stenting, stent-assisted coiling, and flow diversion are all endovascular treatment options for pseudoaneurysms (PAs) of the head and neck. We explore different clinical situations in which these were selected for PA management at a single institution. Over a period of ten years, 33 patients presented to our hospital with PAs of the head and neck. Their outcomes and procedural complications are discussed. We observed a complication rate of 18.2% (6 of 33), consisting predominantly of infarcts following vessel occlusion. As measured by the modified Rankin Scale, 25 (75.8%) patients had achieved favorable outcomes on discharge. A single patient who was treated with stent-assisted coiling expired following procedural complications. In our series, most patients with traumatic/iatrogenic PAs were successfully treated with parent vessel sacrifice. When parent vessel occlusion is not an option, stenting with or without coiling, or flow diversion, may...

Stroke; a journal of cerebral circulation, 2014

Several endovascular treatment options are available for cavernous carotid aneurysms. We compared... more Several endovascular treatment options are available for cavernous carotid aneurysms. We compared pipeline embolization device (PED) versus conventional endovascular treatment in terms of evolution of mass effect, complications, recurrence, and retreatment rate. One hundred fifty-seven patients harboring 167 cavernous carotid aneurysms were treated using PED placement, coiling, stent-assisted coiling, and carotid vessel destruction. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. There were no difference in age, sex, and mean aneurysm size between those treated with PED and those treated with conventional endovascular procedures. The patients treated with PED had a significantly lower proportion of small-size aneurysms (<10 mm) and a shorter follow-up duration. Multivariate analysis revealed treatment other than PED (PED: odds ratio [OR], 0.03; P=0.002) and size >15 mm (OR, 4.27; P=0.003) to be predictors of no improvement in s...

The Scientific World Journal, 2014

The tools for managing retinoblastoma have been increasing in the past decade. While globe-salvag... more The tools for managing retinoblastoma have been increasing in the past decade. While globe-salvage still relies heavily on intravenous chemotherapy, tumors in advanced stage that failed chemotherapy are now referred for intra-arterial chemotherapy (IAC) to avoid enucleation. However, IAC still has many obstacles to overcome. We present an update on the indications, complications, limitations, success, and technical aspects of IAC. Given its safety and high efficacy, it is expected that IAC will replace conventional strategies and will become a first-line option even for tumors that are amenable for other strategies.

The Scientific World Journal, 2014

Introduction.The variables that predispose to postcranioplasty infections are poorly described in... more Introduction.The variables that predispose to postcranioplasty infections are poorly described in the literature. We formulated a multivariate model that predicts the risk of infection in patients undergoing cranioplasty.Method.Retrospective review of all patients who underwent cranioplasty following craniectomy from January, 2000, to December, 2011. Tested predictors were age, sex, diabetic status, hypertensive status, reason for craniectomy, urgency status of craniectomy, location of cranioplasty, reoperation for hematoma, hydrocephalus postcranioplasty, and material type. A multivariate logistic regression analysis was performed.Results.Three hundred forty-eight patients met the study criteria. Infection rate was 26.43% (92/348). Of these cases with infection, 56.52% (52/92) were superficial (supragaleal), 43.48% (40/92) were deep (subgaleal), and 31.52% (29/92) were present in both the supragaleal and subgaleal spaces. The predominant pathogen was coagulase-negative staphylococc...

Journal of Clinical Neuroscience, 2020

Determining which patients will benefit from reoperation for recurrent glioblastoma remains diffi... more Determining which patients will benefit from reoperation for recurrent glioblastoma remains difficult and the impact of the volume of FLAIR signal hyperintensity is not well known. The primary purpose of this study is to analyze the impact of preoperative volume of FLAIR hyperintensity on prognosis. 37 patients who underwent a reoperation for recurrent glioblastoma after initial gross total resection followed by standard chemoradiation were retrospectively reviewed. Volumetric analysis of preoperative MR images from the initial and second surgery was performed and correlated with clinical data. Survival probabilities were estimated using the Kaplan-Meier method and Cox regression to assess the effect of risk factors on time to reoperation (TTR), progression-free survival (PFS) after reoperation, and overall survival (OS). The volumes of FLAIR signal hyperintensity prior to the initial surgery and reoperation were not associated with prognosis. TTR and OS were significantly affected by the preoperative enhancement volume at the initial surgery, with increasing volumes yielding poorer prognosis. Patients with tumor in critical/eloquent areas were found to have a worse prognosis. Median TTR was 11 months, median PFS after reoperation was 3 months, and OS in patients undergoing a reoperation was 21 months. The results suggest FLAIR signal change seen in patients with glioblastoma does not influence time to reoperation, progression-free survival, or overall survival. These findings suggest the amount of FLAIR signal change should not greatly influence a surgeon's decision to perform a second surgical resection compare to other factors, and when appropriate, aggressive surgical intervention should be considered.

Radiology, 2002

PURPOSE: To evaluate the endovascular treatment (EVT) of mycotic aneurysms (MAs). MATERIALS AND M... more PURPOSE: To evaluate the endovascular treatment (EVT) of mycotic aneurysms (MAs). MATERIALS AND METHODS: Clinical and radiologic data of 18 MAs treated with EVT were retrospectively reviewed. There were 14 patients (11 men, three women), ranging in age from 28 to 64 (mean age, 44 years). All patients had endocarditis and positive blood culture. The aneurysms were located within the distal cerebral circulation (n ϭ 13) or in the circle of Willis (n ϭ 5). There were 12 ruptured aneurysms and six unruptured aneurysms. Distal or fusiform aneurysms were treated by means of parent vessel occlusion. Proximal saccular aneurysms were selectively treated. * SAH ϭ subarachnoid hemorrhage, ICH ϭ intracranial hemorrhage. † PCA ϭ posterior cerebral artery, MCA ϭ middle cerebral artery. ‡ GDC ϭ Guglielmi detachable coil, PVA ϭ polyvinyl alcohol. Volume 222 ⅐ Number 2 Endovascular Treatment of Cerebral Mycotic Aneurysms ⅐ 391

British Journal of Radiology, 2008

The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 c... more The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery. Methods. One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27-87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome-indicated by mRS scores of 0 to 2 after at least 6 months-was achieved in 71% of patients. Conclusions. Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination.

Acta Neurologica Scandinavica, 1998

Stroke, 2015

Introduction: Flow diverters have emerged as an important tool in the management of intracranial ... more Introduction: Flow diverters have emerged as an important tool in the management of intracranial aneurysms. This study aims to assess the visual outcomes, the obliteration rate and the need for retreatment of ophthalmic segment aneurysms (OSA) treated by the pipeline embolization device (PED). The study also systematically assesses a crucial issue with the use of flow diverters namely the patency of the ophthalmic artery (OA). Methods: Forty-one patients harboring 44 OSA treated by flow-diversion and 95 patients with internal carotid artery (ICA) aneurysms who had one or more PEDs covering the OA and in whom angiographic follow-up was available were identified. Complication rates, the need for re-treatment, aneurysm occlusion rates, the evolution of visual symptoms, and the evolution of headache/retro-orbital pain were registered. The patency of the OA at follow-up was systematically evaluated by two investigators. Results: The technical success rate was 100% for OSA. The complicati...

Stroke, 2020

Background: High-resolution vessel wall imaging (HR-VWI) has emerged as a useful tool for charact... more Background: High-resolution vessel wall imaging (HR-VWI) has emerged as a useful tool for characterization of intracranial vasculopathic processes. HR-VWI allows better characterization of the arterial wall and may aid in the identification of atherosclerotic plaques, intra-arterial hemorrhages such as in the case of dissections and/or increased contrast enhancement such as in vasculitis. 7T HR-VWI may provide additional information in the identification of stroke mechanism in patients with cryptogenic stroke. Methods: Patients with cryptogenic stroke were prospectively imaged with a 7T scan. Strokes were determined to be cryptogenic after an extensive diagnostic work-up was completed. T1-weighted (pre- and post-contrast), T2-weighted, TOF and SWAN sequences were obtained. Demographic and clinical information was gathered from electronic medical charts. Results: Seventeen patients were included. Mean age was 57.8 ± 16.3 years-old, and 10 (58.8%) were women. HR-VWI determined the eti...

Stroke, 2018

Background: Aspirin is a promising medical therapy for the prevention of intracranial aneurysm (I... more Background: Aspirin is a promising medical therapy for the prevention of intracranial aneurysm (IA) rupture. Recently, we found that men have a better response to aspirin than women. The purpose of this study was to determine whether a sex differential exists in the level of 15-hydroxyprostaglandin dehydrogenase (15-PGDH) in the lumen of human IAs. Methods and Results: Consecutive patients undergoing coiling or stent-assisted coiling for a saccular IA at our institution were enrolled. Two samples (A and B) were collected from IA lumens and the plasma level of 15-PGDH was measured using an ELISA-based method. The study included 38 patients, with 20 women and 18 men. Women and men were comparable with respect to baseline characteristics. In samples A, the mean plasma concentration of 15-PGDH in IA lumens was significantly higher in men (75.8±13.8 ng/ml) than women (51.2±6.4 ng/ml, p<0.0001). Similarly, in samples B, the mean plasma concentration of 15-PGDH in IA lumens was signific...

Stroke, 2019

Unruptured intracranial aneurysms (IAs) are present in ≈3% of people living in the western world.... more Unruptured intracranial aneurysms (IAs) are present in ≈3% of people living in the western world. When ruptured, these aneurysms commonly cause devastating neurological morbidity and mortality. In the unfortunate case of spontaneous aneurysm rupture, it is estimated that nearly 12% of patients die before receiving medical attention. Nearly 30% of the subsequently hospitalized patients die within 1 month after the initial bleed. Of those who survive, another 30% suffer from persistent neurological deficits. In many clinical scenarios, these lesions are prophylactically treated with either open or endovascular surgery, but both carry procedural risk. Incidentally discovered small (<7 mm) IAs are often observed clinically because of a low but nonnegligible rate of growth. Given the increasing number of incidentally detected observed IAs, there is a significant global need for a noninvasive pharmaceutical treatment capable of decreasing the risk of aneurysm rupture. There has been an accumulation of basic science evidence suggesting inflammation plays a critical role in the structural deterioration of the IA wall and its subsequent rupture. These vessel wall changes include but are not limited to high concentrations of proinflammatory cytokines and chemotactic molecules, high levels of macrophage and inflammatory cell infiltration, and phenotypic and apoptotic changes in the vascular smooth muscle cells themselves. In this review, we provide the most comprehensive summary to date of the basic science and clinical evidence suggesting that acetylsalicylic acid (ASA) beneficially modulates the aberrant inflammatory microenvironment within the IA vessel wall, ultimately preventing rupture.

World Neurosurgery, 2019

The Woven EndoBridge (WEB) device, an intrasaccular flow-diverter that does not require long-term... more The Woven EndoBridge (WEB) device, an intrasaccular flow-diverter that does not require long-term antiplatelet use, has recently emerged as an alternative to embolize complex intracranial aneurysms; however, there are limitations to the WEB device. First, it does not immediately secure the aneurysm in most subarachnoid hemorrhage cases. Second, it may not be suitable for embolization of wide-neck aneurysms with an unfavorable aspect ratio. To overcome these limitations, we have used the WEB device in conjunction with stenting and/or coiling. Here, we present a technical note with an illustrated case series and provide a detailed step-by-step description on how the WEB device can be used in adjunct to coiling and/or stenting to achieve successful angiographic results. Accurate sizing of the WEB device before deployment is critical. Larger case series are required to further assess the safety and success of these combined techniques.

Journal of Neurosurgery, 2019

OBJECTIVERevascularization of a symptomatic, medically refractory, cervical chronically occluded ... more OBJECTIVERevascularization of a symptomatic, medically refractory, cervical chronically occluded internal carotid artery (COICA) using endovascular techniques (ETs) has surfaced as a viable alternative to extracranial-intracranial bypass. The authors aimed to assess the safety, success, and neurocognitive outcomes of recanalization of COICA using ETs or hybrid treatment (ET plus carotid endarterectomy) and to identify candidate radiological markers that could predict success.METHODSThe authors performed a retrospective analysis of their prospectively collected institutional database and used their previously published COICA classification to assess the potential benefits of ETs or hybrid surgery to revascularize symptomatic patients with COICA. Subjects who had undergone CT perfusion (CTP) imaging and Montreal Cognitive Assessment (MoCA) testing, both pre- and postprocedure, were included. The authors then performed a review of the literature on patients with COICA to further evalua...

Stroke and Vascular Neurology, 2019

BackgroundEndovascular treatment of intracranial aneurysms usually involves stent-assisted coilin... more BackgroundEndovascular treatment of intracranial aneurysms usually involves stent-assisted coiling (SAC) and flow diverters. Glycoprotein IIb/IIIa inhibitors such as tirofiban and dual antiplatelet therapy (DAPT) are required to prevent thromboembolic complications afterwards. We sought to determine the safety of tirofiban and DAPT in these cases.MethodsWe conducted a retrospective analysis of our database for patients with intracranial aneurysms who underwent SAC or flow diversion. The tirofiban-DAPT protocol used is described. Data regarding duration of infusion, placement of external ventricular devices (EVDs), complications, haemoglobin levels and platelet count before and 24 hours after antiplatelet therapy were collected and analysed.ResultsOne-hundred and forty-one patients with 148 aneurysms/procedures were included. 110 aneurysms were treated acutely and 38 electively. Minor and major haemorrhagic events were recognised in 20% (30/148) aneurysms. Only 5 (3.4%) intracerebral...

Case reports in vascular medicine, 2017

We think that these publications were developed simultaneously. In addition, we think that more s... more We think that these publications were developed simultaneously. In addition, we think that more series would be reported in the future regarding the failure of the pipeline in the treatment of posterior communicating artery aneurysms associated with a fetal posterior cerebral artery. We also congratulate Srinivasan et al. [3] and Kan et al. [4] on their work on this topic and we agree that the most likely explanation of the pipeline failure is the high flow demand in this type of circulation. This can also explain why parent artery occlusion can lead to cerebellar infarction in this subset of patients [5]. We are also working on reporting other aneurysm geometrical factors that contribute to failure of flow-diversion; however this work is still in its early stages.

World neurosurgery, Jan 12, 2016

Studies that showed endovascular coiling of ruptured intracranial aneurysms (RAs) to be superior ... more Studies that showed endovascular coiling of ruptured intracranial aneurysms (RAs) to be superior to microsurgical clipping were comparing dedicated endovascular interventionalists vs. open cerebrovascular surgeons. This is the first study to evaluate outcomes of coiling vs. clipping of RAs treated by a dual trained cerebrovascular surgeon using a specific intervention protocol. The prospectively maintained database was reviewed for all patients with RAs undergoing endovascular coiling (+/- stenting) or clipping by the senior author (dual trained vascular neurosurgeon) between July 2010 and April 2015. In 252 identified patients, 70 underwent clipping and 182 underwent endovascular treatment. The mean and median time to last follow-up were 179.6 and 176.5 days in the endovascular cohort, 203.9 and 154.0 days in the surgical cohort. There was no difference in age, gender, WFNS and Fisher grade, mean aneurysm size and LOS in the hospital/ICU. Clipping had a higher proportion of MCA ane...

Journal of neurosurgery, Jan 3, 2015

OBJECT Endovascular interventions have become an essential part of a neurosurgeon's practice.... more OBJECT Endovascular interventions have become an essential part of a neurosurgeon's practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship. METHODS A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship. RESULTS The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, ...

TheScientificWorldJournal, 2014

Endosaccular coiling, vessel occlusion, stenting, stent-assisted coiling, and flow diversion are ... more Endosaccular coiling, vessel occlusion, stenting, stent-assisted coiling, and flow diversion are all endovascular treatment options for pseudoaneurysms (PAs) of the head and neck. We explore different clinical situations in which these were selected for PA management at a single institution. Over a period of ten years, 33 patients presented to our hospital with PAs of the head and neck. Their outcomes and procedural complications are discussed. We observed a complication rate of 18.2% (6 of 33), consisting predominantly of infarcts following vessel occlusion. As measured by the modified Rankin Scale, 25 (75.8%) patients had achieved favorable outcomes on discharge. A single patient who was treated with stent-assisted coiling expired following procedural complications. In our series, most patients with traumatic/iatrogenic PAs were successfully treated with parent vessel sacrifice. When parent vessel occlusion is not an option, stenting with or without coiling, or flow diversion, may...

Stroke; a journal of cerebral circulation, 2014

Several endovascular treatment options are available for cavernous carotid aneurysms. We compared... more Several endovascular treatment options are available for cavernous carotid aneurysms. We compared pipeline embolization device (PED) versus conventional endovascular treatment in terms of evolution of mass effect, complications, recurrence, and retreatment rate. One hundred fifty-seven patients harboring 167 cavernous carotid aneurysms were treated using PED placement, coiling, stent-assisted coiling, and carotid vessel destruction. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. There were no difference in age, sex, and mean aneurysm size between those treated with PED and those treated with conventional endovascular procedures. The patients treated with PED had a significantly lower proportion of small-size aneurysms (<10 mm) and a shorter follow-up duration. Multivariate analysis revealed treatment other than PED (PED: odds ratio [OR], 0.03; P=0.002) and size >15 mm (OR, 4.27; P=0.003) to be predictors of no improvement in s...

The Scientific World Journal, 2014

The tools for managing retinoblastoma have been increasing in the past decade. While globe-salvag... more The tools for managing retinoblastoma have been increasing in the past decade. While globe-salvage still relies heavily on intravenous chemotherapy, tumors in advanced stage that failed chemotherapy are now referred for intra-arterial chemotherapy (IAC) to avoid enucleation. However, IAC still has many obstacles to overcome. We present an update on the indications, complications, limitations, success, and technical aspects of IAC. Given its safety and high efficacy, it is expected that IAC will replace conventional strategies and will become a first-line option even for tumors that are amenable for other strategies.

The Scientific World Journal, 2014

Introduction.The variables that predispose to postcranioplasty infections are poorly described in... more Introduction.The variables that predispose to postcranioplasty infections are poorly described in the literature. We formulated a multivariate model that predicts the risk of infection in patients undergoing cranioplasty.Method.Retrospective review of all patients who underwent cranioplasty following craniectomy from January, 2000, to December, 2011. Tested predictors were age, sex, diabetic status, hypertensive status, reason for craniectomy, urgency status of craniectomy, location of cranioplasty, reoperation for hematoma, hydrocephalus postcranioplasty, and material type. A multivariate logistic regression analysis was performed.Results.Three hundred forty-eight patients met the study criteria. Infection rate was 26.43% (92/348). Of these cases with infection, 56.52% (52/92) were superficial (supragaleal), 43.48% (40/92) were deep (subgaleal), and 31.52% (29/92) were present in both the supragaleal and subgaleal spaces. The predominant pathogen was coagulase-negative staphylococc...