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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

A Call About Arms [Comment]

Riina, Howard A
PMID: 38231076
ISSN: 1524-4040
CID: 5628802

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

Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes

Chen, Huanwen; Salem, Mohamed M; Colasurdo, Marco; Sioutas, Georgios S; Khalife, Jane; Kuybu, Okkes; Carroll, Kate T; Hoang, Alex Nguyen; Baig, Ammad A; Salih, Mira; Khorasanizadeh, Mirhojjat; Baker, Cordell; Mendez Ruiz, Aldo; Cortez, Gustavo M; Abecassis, Zack; Ruiz Rodríguez, Juan Francisco; Davies, Jason M; Narayanan, Sandra; Cawley, C Michael; Riina, Howard; Moore, Justin; Spiotta, Alejandro M; Khalessi, Alexander; Howard, Brian M; Hanel, Ricardo A; Tanweer, Omar; Tonetti, Daniel; Siddiqui, Adnan H; Lang, Michael; Levy, Elad I; Jovin, Tudor G; Grandhi, Ramesh; Srinivasan, Visish M; Levitt, Michael R; Ogilvy, Christopher S; Jankowitz, Brian; Thomas, Ajith J; Gross, Bradley A; Burkhardt, Jan Karl; Kan, Peter
BACKGROUND:Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown. METHODS:cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness. RESULTS:722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations. CONCLUSIONS:Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.
PMID: 37932033
ISSN: 1759-8486
CID: 5620292

Quantitative Analysis of Parenchymal Effects and Flow of Large Arteriovenous Malformations Managed With Stereotactic Radiosurgery

Alzate, Juan Diego; Mashiach, Elad; Bernstein, Kenneth; De Nigris Vasconcellos, Fernando; Qu, Tanxia; Silverman, Joshua S; Shapiro, Maksim; Nelson, Peter K; Raz, Eytan; Riina, Howard A; Kondziolka, Douglas
BACKGROUND AND OBJECTIVES/OBJECTIVE:Stereotactic radiosurgery (SRS) of larger arteriovenous malformations (AVM) is associated with an elevated incidence of adverse radiation effects (ARE). To date, volume-response and dose-response models have been used to predict such effects. To understand radiological outcomes and their hemodynamic effects on the regional brain. METHODS:A retrospective analysis was conducted at our institution using a prospective registry of patients managed between 2014 and 2020. We included patients with AVM with a nidus larger than 5 cc who received either single-session or volume-staged Gamma Knife radiosurgery. AVM volume changes, volumes of parenchymal response, and obliteration were analyzed and correlated with transit times and diameters of feeding arteries and draining veins. RESULTS:Sixteen patients underwent single-session SRS, and 9 patients underwent volume-staged SRS. The average AVM volume was 12.6 cc (5.5-23). The AVM locations were predominantly lobar (80%) and 17 (68%) were in critical locations. The mean margin dose was 17.2 Gy (15-21), and the median V12Gy was 25.5 cc. Fourteen (56%) AVMs had a transit time shorter than 1 second. The median vein-artery ratio (sum diameter of the veins/sum diameter of feeding arteries) was 1.63 (range, 0.60-4.19). Asymptomatic parenchymal effects were detected in 13 (52%) patients and were symptomatic in 4 (16%) patients. The median time to ARE was 12 months (95% CI 7.6-16.4). On univariate analysis, significant predictors of ARE were lower vein-artery ratio (P = .024), longer transit time (P = .05), higher mean dose (P = .028), and higher D95 (P = .036). CONCLUSION/CONCLUSIONS:Transit times and vessel diameters are valuable predictors of the subsequent parenchymal response after SRS. A more quantitative understanding of blood flow is critical for predicting the effects on the regional brain after AVM radiosurgery.
PMID: 37235978
ISSN: 1524-4040
CID: 5508662

Superior hypophyseal arteries: angiographic re-discovery, comprehensive assessment, and embryologic implications

Shapiro, Maksim; Sharashidze, Vera; Nossek, Erez; Sen, Chandra; Rutledge, Caleb; Chung, Charlotte; Khawaja, Ayaz; Kvint, Svetlana; Riina, Howard; Nelson, Peter Kim; Raz, Eytan
UNLABELLED:The superior hypophyseal arteries (SHAs) are well known in anatomical and surgical literature, with a well-established role in supply of the anterior hypophysis and superjacent optic apparatus. However, due to small size and overlap with other vessels, in vivo imaging by any modality has been essentially non-existent. Advances in high resolution cone beam CT angiography (CBCTA) now enables this deficiency to be addressed. This paper presents, to the best of our knowledge, the first comprehensive in vivo imaging evaluation of the SHAs. METHODS:Twenty-five CBCTA studies of common or internal carotid arteries were obtained for a variety of clinical reasons. Dedicated secondary reconstructions of the siphon were performed, recording the presence, number, and supply territory of SHAs. A spectrum approach, emphasizing balance with adjacent territories (inferior hypophyseal, ophthalmic, posterior and communicating region arteries) was investigated. RESULTS:The SHAs were present in all cases. Supply of the anterior pituitary was nearly universal (96%) and almost half (44%) originated from the 'cave' region, in excellent agreement with surgical literature. Optic apparatus supply was more difficult to adjudicate, but appeared present in most cases. The relationship with superior hypophyseal aneurysms was consistent. Patency following flow diverter placement was typical, despite a presumably rich collateral network. Embryologic implications with respect to the ophthalmic artery and infraoptic course of the anterior cerebral artery are intriguing. CONCLUSIONS:SHAs are consistently seen with CBCTA, allowing for correlation with existing anatomical and surgical literature, laying the groundwork for future in vivo investigation.
PMID: 37875341
ISSN: 1759-8486
CID: 5614322

Advances in Radiosurgical Planning: High-Resolution Imaging and Objective Hemodynamic Measurements for Arteriovenous Malformations [Letter]

Alzate, Juan Diego; Mashiach, Elad; Raz, Eytan; Shapiro, Maksim; Riina, Howard; Kondziolka, Douglas
PMID: 37573234
ISSN: 1878-8769
CID: 5605062

Health system-scale language models are all-purpose prediction engines

Jiang, Lavender Yao; Liu, Xujin Chris; Nejatian, Nima Pour; Nasir-Moin, Mustafa; Wang, Duo; Abidin, Anas; Eaton, Kevin; Riina, Howard Antony; Laufer, Ilya; Punjabi, Paawan; Miceli, Madeline; Kim, Nora C; Orillac, Cordelia; Schnurman, Zane; Livia, Christopher; Weiss, Hannah; Kurland, David; Neifert, Sean; Dastagirzada, Yosef; Kondziolka, Douglas; Cheung, Alexander T M; Yang, Grace; Cao, Ming; Flores, Mona; Costa, Anthony B; Aphinyanaphongs, Yindalon; Cho, Kyunghyun; Oermann, Eric Karl
Physicians make critical time-constrained decisions every day. Clinical predictive models can help physicians and administrators make decisions by forecasting clinical and operational events. Existing structured data-based clinical predictive models have limited use in everyday practice owing to complexity in data processing, as well as model development and deployment1-3. Here we show that unstructured clinical notes from the electronic health record can enable the training of clinical language models, which can be used as all-purpose clinical predictive engines with low-resistance development and deployment. Our approach leverages recent advances in natural language processing4,5 to train a large language model for medical language (NYUTron) and subsequently fine-tune it across a wide range of clinical and operational predictive tasks. We evaluated our approach within our health system for five such tasks: 30-day all-cause readmission prediction, in-hospital mortality prediction, comorbidity index prediction, length of stay prediction, and insurance denial prediction. We show that NYUTron has an area under the curve (AUC) of 78.7-94.9%, with an improvement of 5.36-14.7% in the AUC compared with traditional models. We additionally demonstrate the benefits of pretraining with clinical text, the potential for increasing generalizability to different sites through fine-tuning and the full deployment of our system in a prospective, single-arm trial. These results show the potential for using clinical language models in medicine to read alongside physicians and provide guidance at the point of care.
PMCID:10338337
PMID: 37286606
ISSN: 1476-4687
CID: 5536672

Early Experience of Surgical Planning for STA-MCA Bypass Using Virtual Reality

Kim, Nora C; Sangwon, Karl L; Raz, Eytan; Shapiro, Maksim; Rutledge, Caleb; Nelson, Peter K; Riina, Howard A; Nossek, Erez
BACKGROUND:The superficial temporal artery (STA)-to-middle cerebral artery (MCA) bypass requires precise preoperative planning, and 3-dimensional virtual reality (VR) models have recently been used to optimize planning of STA-MCA bypass. In the present report, we have described our experience with VR-based preoperative planning of STA-MCA bypass. METHODS:Patients from August 2020 to February 2022 were analyzed. For the VR group, using 3-dimensional models from the patients' preoperative computed tomography angiograms, VR was used to locate the donor vessels, potential recipient, and anastomosis sites and plan the craniotomy, which were referenced throughout surgery. Computed tomography angiograms or digital subtraction angiograms were used to plan the craniotomy for the control group. The procedure time, bypass patency, craniotomy size, and postoperative complication rates were assessed. RESULTS:The VR group included 17 patients (13 women; age, 49 ± 14 years) with Moyamoya disease (76.5%) and/or ischemic stroke (29.4%). The control group included 13 patients (8 women; age, 49 ± 12 years) with Moyamoya disease (92.3%) and/or ischemic stroke (7.3%). For all 30 patients, the preoperatively planned donor and recipient branches were effectively translated intraoperatively. No significant difference were found in the procedure time or craniotomy size between the 2 groups. Bypass patency was 94.1% for the VR group (16 of 17) and 84.6% for the control group (11 of 13). No permanent neurological deficits occurred in either group. CONCLUSIONS:Our early experience has shown that VR can serve as a useful, interactive preoperative planning tool by enhancing visualization of the spatial relationship between the STA and MCA without compromising the surgical results.
PMID: 36906090
ISSN: 1878-8769
CID: 5462442