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Central Retinal Artery Visualization with Cone-Beam CT Angiography

Raz, Eytan; Shapiro, Maksim; Shepherd, Timothy M; Nossek, Erez; Yaghi, Shadi; Gold, Doria M; Ishida, Koto; Rucker, Janet C; Belinsky, Irina; Kim, Eleanore; Grory, Brian Mac; Mir, Osman; Hagiwara, Mari; Agarwal, Shashank; Young, Matthew G; Galetta, Steven L; Nelson, Peter Kim
Background There are multiple tools available to visualize the retinal and choroidal vasculature of the posterior globe. However, there are currently no reliable in vivo imaging techniques that can visualize the entire retrobulbar course of the retinal and ciliary vessels. Purpose To identify and characterize the central retinal artery (CRA) using cone-beam CT (CBCT) images obtained as part of diagnostic cerebral angiography. Materials and Methods In this retrospective study, patients with catheter DSA performed between October 2019 and October 2020 were included if CBCT angiography included the orbit in the field of view. The CBCT angiography data sets were postprocessed with a small field-of-view volume centered in the posterior globe to a maximum resolution of 0.2 mm. The following were evaluated: CRA origin, CRA course, CRA point of penetration into the optic nerve sheath, bifurcation of the CRA at the papilla, visualization of anatomic variants, and visualization of the central retinal vein. Descriptive statistical analysis was performed. Results Twenty-one patients with 24 visualized orbits were included in the analysis (mean age, 55 years ± 15; 14 women). Indications for angiography were as follows: diagnostic angiography (n = 8), aneurysm treatment (n = 6), or other (n = 7). The CRA was identified in all orbits; the origin, course, point of penetration of the CRA into the optic nerve sheath, and termination in the papilla were visualized in all orbits. The average length of the intraneural segment was 10.6 mm (range, 7-18 mm). The central retinal vein was identified in six of 24 orbits. Conclusion Cone-beam CT, performed during diagnostic angiography, consistently demonstrated the in vivo central retinal artery, demonstrating excellent potential for multiple diagnostic and therapeutic applications. © RSNA, 2021 Online supplemental material is available for this article.
PMID: 34783593
ISSN: 1527-1315
CID: 5049072

Neuroanatomy of the middle cerebral artery: implications for thrombectomy

Shapiro, Maksim; Raz, Eytan; Nossek, Erez; Chancellor, Breehan; Ishida, Koto; Nelson, Peter Kim
Our perspective on anatomy frequently depends on how this anatomy is utilized in clinical practice, and by which methods knowledge is acquired. The thrombectomy revolution, of which the middle cerebral artery (MCA) is the most common target, is an example of a clinical paradigm shift with a unique perspective on cerebrovascular anatomy. This article reviews important features of MCA anatomy in the context of thrombectomy. Recognizing that variation, frequently explained by evolutionary concepts, is the rule when it comes to branching pattern, vessel morphology, territory, or collateral potential is key to successful thrombectomy strategy.
PMID: 32107286
ISSN: 1759-8486
CID: 4323662

Arterial and Venous 3D Fusion AV-3D-DSA: A Novel Approach to Cerebrovascular Neuroimaging

Raz, E; Shapiro, M; Mir, O; Nossek, E; Nelson, P K
DSA is the standard imaging technique for evaluation of cerebrovascular conditions. However, One drawback is its limitation in depicting a single angiographic phase at a time. We describe a new 3D-DSA algorithm, which we call arterial and venous-3D-DSA, which allows the concurrent yet distinct display of the arterial and venous structures, which may be useful for different clinical and educational purposes.
PMID: 33832953
ISSN: 1936-959x
CID: 4840952

Dual Layer vs Single Layer Woven EndoBridge Device in the Treatment of Intracranial Aneurysms: A Propensity Score-Matched Analysis

Dmytriw, Adam A; Salim, Hamza; Musmar, Basel; Aslan, Assala; Cancelliere, Nicole M; McLellan, Rachel M; Algin, Oktay; Ghozy, Sherief; Dibas, Mahmoud; Lay, Sovann V; Guenego, Adrien; Renieri, Leonardo; Carnevale, Joseph; Saliou, Guillaume; Mastorakos, Panagiotis; Naamani, Kareem El; Shotar, Eimad; Premat, Kevin; Möhlenbruch, Markus; Kral, Michael; Doron, Omer; Chung, Charlotte; Salem, Mohamed M; Lylyk, Ivan; Foreman, Paul M; Vachhani, Jay A; Shaikh, Hamza; Župančić, Vedran; Hafeez, Muhammad U; Catapano, Joshua; Waqas, Muhammad; Tutino, Vincent M; Ibrahim, Mohamed K; Mohammed, Marwa A; Imamoglu, Cetin; Bayrak, Ahmet; Rabinov, James D; Ren, Yifan; Schirmer, Clemens M; Piano, Mariangela; Kühn, Anna L; Michelozzi, Caterina; Elens, Stéphanie; Starke, Robert M; Hassan, Ameer E; Ogilvie, Mark; Sporns, Peter; Jones, Jesse; Brinjikji, Waleed; Nawka, Marie T; Psychogios, Marios; Ulfert, Christian; Diestro, Jose Danilo Bengzon; Pukenas, Bryan; Burkhardt, Jan-Karl; Huynh, Thien; Martinez-Gutierrez, Juan Carlos; Essibayi, Muhammed Amir; Sheth, Sunil A; Spiegel, Gary; Tawk, Rabih; Lubicz, Boris; Panni, Pietro; Puri, Ajit S; Pero, Guglielmo; Nossek, Erez; Raz, Eytan; Killer-Oberfalzer, Monika; Griessenauer, Christoph J; Asadi, Hamed; Siddiqui, Adnan; Brook, Allan L; Altschul, David; Ducruet, Andrew F; Albuquerque, Felipe C; Regenhardt, Robert W; Stapleton, Christopher J; Kan, Peter; Kalousek, Vladimir; Lylyk, Pedro; Boddu, Srikanth; Knopman, Jared; Aziz-Sultan, Mohammad A; Tjoumakaris, Stavropoula I; Clarençon, Frédéric; Limbucci, Nicola; Cuellar-Saenz, Hugo H; Jabbour, Pascal M; Pereira, Vitor Mendes; Patel, Aman B; Adeeb, Nimer
BACKGROUND:The Woven EndoBridge (WEB) devices have been used for treating wide neck bifurcation aneurysms (WNBAs) with several generational enhancements to improve clinical outcomes. The original device dual-layer (WEB DL) was replaced by a single-layer (WEB SL) device in 2013. This study aimed to compare the effectiveness and safety of these devices in managing intracranial aneurysms. METHODS:A multicenter cohort study was conducted, and data from 1,289 patients with intracranial aneurysms treated with either the WEB SL or WEB DL devices were retrospectively analyzed. Propensity score matching was utilized to balance the baseline characteristics between the two groups. Outcomes assessed included immediate occlusion rate, complete occlusion at last follow-up, retreatment rate, device compaction, and aneurysmal rupture. RESULTS:Before propensity score matching, patients treated with the WEB SL had a significantly higher rate of complete occlusion at the last follow-up and a lower rate of retreatment. After matching, there was no significant difference in immediate occlusion rate, retreatment rate, or device compaction between the WEB SL and DL groups. However, the SL group maintained a higher rate of complete occlusion at the final follow-up. Regression analysis showed that SL was associated with higher rates of complete occlusion (OR: 0.19; CI: 0.04 to 0.8, p = 0.029) and lower rates of retreatment (OR: 0.12; CI: 0 to 4.12, p = 0.23). CONCLUSION/CONCLUSIONS:The WEB SL and DL devices demonstrated similar performances in immediate occlusion rates and retreatment requirements for intracranial aneurysms. The SL device showed a higher rate of complete occlusion at the final follow-up.
PMID: 38483647
ISSN: 1437-2320
CID: 5639822

Endoscopic Endonasal Approach for Direct Puncture Embolization of Cavernous Dural Arteriovenous Fistula: 2-Dimensional Operative Video

Sangwon, Karl L; Esparza, Rogelio; Sharashidze, Vera; Dastagirzada, Yosef; Shapiro, Maksim; Riina, Howard A; Lieberman, Seth; Pacione, Donato; Raz, Eytan; Nossek, Erez
PMID: 37831980
ISSN: 2332-4260
CID: 5604252

Transpalpebral/Blepharoplasty Incision and Supraorbital Craniotomy for the Treatment of Ethmoidal Dural Arteriovenous Fistulas: A Case Series

Hagstrom, Rory; Nossek, Erez; Rutledge, Caleb W; Ponchione, Elizabeth; Suryadevara, Carter; Kremer, Caroline; Alcon, Andre; Sharashidze, Vera; Shapiro, Maksim; Raz, Eytan; Nelson, Peter K; Staffenberg, David A; Riina, Howard A
BACKGROUND AND OBJECTIVES/OBJECTIVE:Inherent complex angioarchitecture associated with ethmoidal dural arteriovenous fistulas (dAVFs) can make endovascular treatment methods challenging. Many surgical approaches are accompanied by unfavorable cosmetic results such as facial scarring. Blepharoplasty incision of the eyelid offers a minimal, well-hidden scar compared with other incision sites while offering the surgeon optimal visualization of pathogenic structures. This case series aims to report an initial assessment of the safety and efficacy of supraorbital craniotomy by blepharoplasty transpalpebral (eyelid) incision for surgical disconnection of ethmoidal dAVFs. METHODS:Retrospective chart review was conducted for all patients who underwent blepharoplasty incision and craniotomy for disconnection of ethmoidal dAVFs at our institution between October 2011 and February 2023. Patient charts and follow-up imaging were reviewed to report clinical and angiographic outcomes as well as periprocedural and follow-up complications. RESULTS:Complete obliteration and disconnection of ethmoidal dAVF was achieved in all 6 (100%) patients as confirmed by intraoperative angiogram with no resulting morbidity or mortality. Periprocedural complications included one case of transient nasal cerebrospinal fluid leak that was self-limiting and resolved before discharge without intervention. CONCLUSION/CONCLUSIONS:Surgical treatment for ethmoidal dAVFs, specifically by transpalpebral incision and supraorbital craniotomy, is a safe and effective treatment option and affords the surgeon greater access to the floor of the anterior fossa when necessary. In addition, blepharoplasty incision addressed patient concerns for facial scarring compared with other incision sites by creating a more well-hidden, minimal scar in the natural folds of the eyelid for patients with an eyelid crease.
PMID: 38376155
ISSN: 2332-4260
CID: 5634152

Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery

Meyer, Lukas; Stracke, Christian Paul; Broocks, Gabriel; Wallocha, Marta; Elsharkawy, Mohamed; Sporns, Peter B; Piechowiak, Eike I; Kaesmacher, Johannes; Maegerlein, Christian; Hernandez Petzsche, Moritz Roman; Zimmermann, Hanna; Naziri, Weis; Abdullayev, Nuran; Kabbasch, Christoph; Behme, Daniel; Thormann, Maximilian; Maus, Volker; Fischer, Sebastian; Möhlenbruch, Markus A; Weyland, Charlotte Sabine; Langner, Soenke; Ernst, Marielle; Jamous, Ala; Meila, Dan; Miszczuk, Milena; Siebert, Eberhard; Lowens, Stephan; Krause, Lars Udo; Yeo, Leonard Ll; Tan, Benjamin Y Q; Gopinathan, Anil; Gory, Benjamin; Galvan Fernandez, Jorge; Schüller Arteaga, Miguel; Navia, Pedro; Raz, Eytan; Shapiro, Maksim; Arnberg, Fabian; Zeleňák, Kamil; Martínez-Galdámez, Mario; Alexandrou, Maria; Kastrup, Andreas; Papanagiotou, Panagiotis; Dorn, Franziska; Kemmling, André; Psychogios, Marios-Nikos; Andersson, Tommy; Chapot, René; Fiehler, Jens; Hanning, Uta
BACKGROUND:Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs). METHODS:Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality. RESULTS:Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups. CONCLUSION/CONCLUSIONS:LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.
PMID: 37142393
ISSN: 1759-8486
CID: 5509162

Thrombectomy With the pRESET vs Solitaire Stent Retrievers as First-Line Large Vessel Occlusion Stroke Treatment: A Randomized Clinical Trial

Nogueira, Raul G; Lobsien, Donald; Klisch, Joachim; Pielenz, Daniel; Lobsien, Elmar; Sauvageau, Eric; Aghaebrahim, Nima; Möhlenbruch, Markus; Vollherbst, Dominik; Ulfert, Christian; Bozorgchami, Hormozd; Clark, Wayne; Priest, Ryan; Samaniego, Edgar A; Ortega-Gutierrez, Santiago; Ghannam, Malik; Lopes, Demetrius; Billingsley, Joshua; Keigher, Kiffon; Haussen, Diogo C; Al-Bayati, Alhamza R; Siddiqui, Adnan; Levy, Elad; Chen, Michael; Munich, Stephan; Schramm, Peter; Boppel, Tobias; Narayanan, Sandra; Gross, Bradley A; Roth, Christian; Boeckh-Behrens, Tobias; Hassan, Ameer; Fifi, Johanna; Budzik, Ron F; Tarpley, Jason; Starke, Robert M; Raz, Eytan; Brogan, Gary; Liebeskind, David S; Hanel, Ricardo A
IMPORTANCE/UNASSIGNED:Stent retriever-based thrombectomy is highly beneficial in large vessel occlusion (LVO) strokes. Many stent retriever designs are currently available, but comparison of these technologies in well-conducted studies is lacking. OBJECTIVE/UNASSIGNED:To determine whether thrombectomy for LVO stroke with the pRESET stent retriever is noninferior to treatment with the Solitaire stent retriever. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This study was a multicenter, prospective, randomized, controlled, open-label, adaptive, noninferiority trial with blinded primary end point evaluation. Between October 2019 and February 2022, multicenter participation occurred across 19 research hospitals and/or universities in the US and 5 in Germany. Patients with LVO stroke were enrolled and included up to 8 hours after symptom onset. INTERVENTIONS/UNASSIGNED:Patients underwent 1:1 randomization to thrombectomy with the pRESET or Solitaire stent retriever. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the difference in the rate of 90-day functional independence across the 2 devices, using a -12.5% noninferiority margin for the lower bound of the 1-sided 95% CI of the difference between pRESET and Solitaire retrievers. RESULTS/UNASSIGNED:Of 340 randomized patients, 170 (50.0%) were female, and the median (IQR) age was 73.0 (64.0-82.0) years. The study procedure was completed in 322 of the 340 randomized patients. The primary end point of 90-day functional independence was achieved by 95 patients (54.9%; 95% CI, 48.7-61.1) in the pRESET group and in 96 (57.5%; 95% CI, 51.2-63.8) in the Solitaire group (absolute difference, -2.57%; 95% CI, -11.42 to 6.28). As the lower bound of the 95% CI was greater than -12.5%, the pRESET retriever was deemed noninferior to the Solitaire retriever. The noninferiority of pRESET over Solitaire was also observed in the secondary clinical end point (90-day shift in modified Rankin Scale score) and in both angiographic end points (Expanded Treatment in Cerebral Infarction [eTICI] score of 2b50 or greater within 3 passes: 146 of 173 [84.4%] vs 149 of 167 [89.2%]; absolute difference, -4.83%; 95% CI, -10.84 to 1.19; eTICI of 2c or greater following the first pass: 76 of 173 [43.7%] vs 74 of 167 [44.3%]; absolute difference, -0.63%; 95% CI, -9.48 to 8.21). Symptomatic intracranial hemorrhage occurred in 0 patients in the pRESET group and 2 (1.2%) in the Solitaire group. Mortality occurred in 25 (14.5%) in the pRESET group and in 24 (14.4%) in the Solitaire group at 90 days. Findings of the per-protocol and as-treated analyses were in concordance with findings of the intention-to-treat analysis. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this study, among patients with LVO stroke, thrombectomy with the pRESET stent retriever was noninferior to thrombectomy with the Solitaire stent retriever. Findings suggest that pRESET offers a safe and effective option for flow restoration and disability reduction in patients with LVO stroke.
PMID: 38165690
ISSN: 2168-6157
CID: 5635182

Use of Carotid Web Angioarchitecture for Stroke Risk Assessment

von Oiste, Grace G; Sangwon, Karl L; Chung, Charlotte; Narayan, Vinayak; Raz, Eytan; Shapiro, Maksim; Rutledge, Caleb; Nelson, Peter Kim; Ishida, Koto; Torres, Jose L; Rostanski, Sara K; Zhang, Cen; Yaghi, Shadi; Riina, Howard; Oermann, Eric K; Nossek, Erez
OBJECTIVE:To examine the usefulness of carotid web (CW), carotid bifurcation and their combined angioarchitectural measurements in assessing stroke risk. METHODS:Anatomic data on the internal carotid artery (ICA), common carotid artery (CCA), and the CW were gathered as part of a retrospective study from symptomatic (stroke) and asymptomatic (nonstroke) patients with CW. We built a model of stroke risk using principal-component analysis, Firth regression trained with 5-fold cross-validation, and heuristic binary cutoffs based on the Minimal Description Length principle. RESULTS:The study included 22 patients, with a mean age of 55.9 ± 12.8 years; 72.9% were female. Eleven patients experienced an ischemic stroke. The first 2 principal components distinguished between patients with stroke and patients without stroke. The model showed that ICA-pouch tip angle (P = 0.036), CCA-pouch tip angle (P = 0.036), ICA web-pouch angle (P = 0.036), and CCA web-pouch angle (P = 0.036) are the most important features associated with stroke risk. Conversely, CCA and ICA anatomy (diameter and angle) were not found to be risk factors. CONCLUSIONS:This pilot study shows that using data from computed tomography angiography, carotid bifurcation, and CW angioarchitecture may be used to assess stroke risk, allowing physicians to tailor care for each patient according to risk stratification.
PMID: 38006939
ISSN: 1878-8769
CID: 5617512

Endovascular intervention for the treatment of epistaxis: cone beam CT review of anatomy, collateral, and treatment implications/efficacy

Hoover, Madeline; Berwanger, Robert; Scott, John A; DeNardo, Andrew; Amuluru, Krishna; Payner, Troy; Kulwin, Charles; Raz, Eytan; Gibson, Daniel; Sahlein, Daniel H
Epistaxis is common, impacting more than half the population, and can require procedural intervention in approximately 10% of cases. With an aging population and increasing use of antiplatelets and anticoagulants, severe epistaxis is likely to increase in frequency significantly over the next two decades. Sphenopalatine artery embolization is rapidly becoming the most common type of procedural intervention. The efficacy of endovascular embolization is dependent on a refined understanding of the anatomy and collateral physiology of this circulation as well as the impact of temporizing measures such as nasal packing and inflation of a nasal balloon. Likewise, safety is dependent on a detailed appreciation of collateralization with the internal carotid artery and ophthalmic artery. Cone beam CT imaging has the resolution to enable a clear visualization of the anatomy and collateral circulation associated with the arterial supply to the nasal cavity, in addition to assisting with hemorrhage localization. We present a review of epistaxis treatment, a detailed description of anatomic and physiologic considerations informed by cone beam CT imaging, and a proposed protocol for sphenopalatine embolization for which there is currently no standard.
PMID: 37019626
ISSN: 1759-8486
CID: 5626302