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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
Comprehensive Analysis of Post-Pipeline Endothelialization and Remodeling
Sharashidze, Vera; Raz, Eytan; Nossek, Erez; Kvint, Svetlana; Riina, Howard; Rutledge, Caleb; Baranoski, Jacob; Khawaja, Ayaz; Chung, Charlotte; Nelson, Peter Kim; Shapiro, Maksim
BACKGROUND AND PURPOSE/OBJECTIVE:Successful post-flow-diverter endoluminal reconstruction is widely believed to require endothelial overgrowth of the aneurysmal inflow zone. However, endothelialization/neointimal overgrowth is a complex process, over which we currently have very limited influence. Less emphasized is vascular remodeling of the target arterial segment, the dynamic response of the vessel to flow-diverter implantation. This process is distinct from flow modifications in covered branches. It appears that basic angiographic methods allow simple and useful observations. The purpose of this article was to quantitatively evaluate observable postimplantation changes in target vessels following deployment of Pipeline endoluminal constructs. MATERIALS AND METHODS/METHODS:One hundred consecutive adults with unruptured, previously untreated, nondissecting aneurysms treated with the Pipeline Embolization Device with Shield Technology and the availability of follow-up conventional angiography were studied with 2D DSA imaging. Target vessel size; Pipeline Embolization Device diameter; endothelial thickness; and various demographic, antiplatelet, and device-related parameters were recorded and analyzed. RESULTS:The thickness of neointimal overgrowth (mean, 0.3 [SD, 0.1] mm; range, 0.1-0.7 mm) is inversely correlated with age and is independent of vessel size, smoking status, sex, and degree of platelet inhibition. The decrease in lumen diameter caused by neointimal overgrowth, however, appears counteracted by outward remodeling (dilation) of the target arterial segment. This leads to an increase in the diameter with a corresponding decrease in length (foreshortening) of the implanted Pipeline Embolization Device. This physiologic remodeling process affects optimally implanted devices and is not a consequence of stretching, device migration, vasospasm, and so forth. A direct, linear, statistically significant relationship exists between the degree of observed outward remodeling and the diameter of the implanted Pipeline Embolization Device relative to the target vessel. Overall, remodeled arterial diameters were reduced by 15% (SD, 10%) relative to baseline and followed a normal distribution. Clinically relevant stenosis was not observed. CONCLUSIONS:Vessel healing involves both outward remodeling and neointimal overgrowth. Judicial oversizing could be useful in specific settings to counter the reduction in lumen diameter due to postimplant neointimal overgrowth; however, this overszing needs to be balanced against the decrease in metal coverage accompanying the use of oversized devices. Similar analysis for other devices is essential.
PMCID:11286005
PMID: 38663989
ISSN: 1936-959x
CID: 5697632
Spinal dural and epidural fistulas: role of cone beam CT in diagnosis and treatment
Shapiro, Maksim; Nossek, Erez; Sharashidze, Vera; Tanaka, Michihiro; Rutledge, Caleb; Chung, Charlotte; Khawaja, Ayaz; Riina, Howard; Nelson, Peter Kim; Raz, Eytan
Understanding normal spinal arterial and venous anatomy, and spinal vascular disease, is impossible without flow-based methods. Development of practical spinal angiography led to site-specific categorization of spinal vascular conditions, defined by the 'seat of disease' in relation to the cord and its covers. This enabled identification of targets for highly successful surgical and endovascular treatments, and guided interpretation of later cross-sectional imaging.Spinal dural and epidural arteriovenous fistulas represent the most common types of spinal shunts. Although etiology is debated, anatomy provides excellent pathophysiologic correlation. A spectrum of fistulas, from foramen magnum to the sacrum, is now well-characterized.Most recently, use of cone beam CT angiography has yielded new insights into normal and pathologic anatomy, including venous outflow. It provides unrivaled visualization of the fistula and its relationship with spinal cord vessels, and is the first practical method to study normal and pathologic spinal veins in vivo-with multiple implications for both safety and efficacy of treatments. We advocate consistent use of cone beam CT imaging in modern spinal fistula evaluation.The role of open surgery is likely to remain undiminished, with increasing availability and use of hybrid operating rooms for practical intraoperative angiography enhancing safety and efficacy of complex surgery.
PMID: 37673678
ISSN: 1759-8486
CID: 5653862
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
Poor Accuracy of Manually Derived Head Computed Tomography Parameters in Predicting Intracranial Hypertension After Nontraumatic Intracranial Hemorrhage
Frontera, Jennifer A; Fang, Taolin; Grayson, Kammi; Lalchan, Rebecca; Dickstein, Leah; Hussain, M Shazam; Kahn, D Ethan; Lord, Aaron S; Mazzuchin, Daniel; Melmed, Kara R; Rutledge, Caleb; Zhou, Ting; Lewis, Ariane
BACKGROUND:The utility of head computed tomography (CT) in predicting elevated intracranial pressure (ICP) is known to be limited in traumatic brain injury; however, few data exist in patients with spontaneous intracranial hemorrhage. METHODS:We conducted a retrospective review of prospectively collected data in patients with nontraumatic intracranial hemorrhage (subarachnoid hemorrhage [SAH] or intraparenchymal hemorrhage [IPH]) who underwent external ventricular drain (EVD) placement. Head CT scans performed immediately prior to EVD placement were quantitatively reviewed for features suggestive of elevated ICP, including temporal horn diameter, bicaudate index, basal cistern effacement, midline shift, and global cerebral edema. The modified Fisher score (mFS), intraventricular hemorrhage score, and IPH volume were also measured, as applicable. We calculated the accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these radiographic features for the coprimary outcomes of elevated ICP (> 20 mm Hg) at the time of EVD placement and at any time during the hospital stay. Multivariable backward stepwise logistic regression analysis was performed to identify significant radiographic factors associated with elevated ICP. RESULTS:Of 608 patients with intracranial hemorrhages enrolled during the study time frame, 243 (40%) received an EVD and 165 (n = 107 SAH, n = 58 IPH) had a preplacement head CT scan available for rating. Elevated opening pressure and elevated ICP during hospitalization were recorded in 48 of 152 (29%) and 103 of 165 (62%), respectively. The presence of ≥ 1 radiographic feature had only 32% accuracy for identifying elevated opening pressure (PPV 30%, NPV 58%, area under the curve [AUC] 0.537, 95% asymptotic confidence interval [CI] 0.436-0.637, P = 0.466) and 59% accuracy for predicting elevated ICP during hospitalization (PPV 63%, NPV 40%, AUC 0.514, 95% asymptotic CI 0.391-0.638, P = 0.820). There was no significant association between the number of radiographic features and ICP elevation. Head CT scans without any features suggestive of elevated ICP occurred in 25 of 165 (15%) patients. However, 10 of 25 (40%) of these patients had elevated opening pressure, and 15 of 25 (60%) had elevated ICP during their hospital stay. In multivariable models, mFS (adjusted odds ratio [aOR] 1.36, 95% CI 1.10-1.68) and global cerebral edema (aOR 2.93, 95% CI 1.27-6.75) were significantly associated with elevated ICP; however, their accuracies were only 69% and 60%, respectively. All other individual radiographic features had accuracies between 38 and 58% for identifying intracranial hypertension. CONCLUSIONS:More than 50% of patients with spontaneous intracranial hemorrhage without radiographic features suggestive of elevated ICP actually had ICP > 20 mm Hg during EVD placement or their hospital stay. Morphological head CT findings were only 32% and 59% accurate in identifying elevated opening pressure and ICP elevation during hospitalization, respectively.
PMID: 36577900
ISSN: 1556-0961
CID: 5409662
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
Direct puncture of the superior ophthalmic vein for carotid cavernous fistulas: a 21-year experience
Catapano, Joshua S; Srinivasan, Visish M; De La Peña, Nicole M; Singh, Rohin; Cole, Tyler S; Wilkinson, D Andrew; Baranoski, Jacob F; Rutledge, Caleb; Pacult, Mark A; Winkler, Ethan A; Jadhav, Ashutosh P; Ducruet, Andrew F; Albuquerque, Felipe C
BACKGROUND:Direct puncture of the superior ophthalmic vein (SOV) is an alternative approach to traversing the inferior petrosal sinus for embolization of carotid cavernous fistulas (CCFs). OBJECTIVE:To analyze direct SOV puncture for the treatment of CCFs and review the literature. METHODS:All patients at a single center, treated for a CCF with direct SOV cannulation between January 1, 2000, and December 31, 2020, were retrospectively analyzed. An additional review of the literature for all case series for direct puncture of the SOV for treatment of CCF was performed. RESULTS:During the 21-year study period, direct cannulation of the SOV for treatment of a CCF was attempted for 19 patients, with the procedure aborted for one patient because of an inability to navigate the wire into the distal aspect of the cavernous sinus. In 18 patients with direct SOV CCF treatment, 1 experienced a minor complication with an asymptomatic postoperative hemorrhage. Angiographic cure and improvement of symptoms were achieved in 17 patients with a mean (SD) follow-up of 6 (5.2) months. In the review of the literature, an additional 45 patients were reported to have direct cannulation of the SOV for CCF treatment, with angiographic cure in 43 (96%) and decreased objective visual acuity in 1 (2%). CONCLUSION/CONCLUSIONS:Direct SOV cannulation to treat CCFs is safe and effective. Although it is typically used after other endovascular approaches have failed, SOV access for CCF treatment may be warranted as a first-line treatment for select patients.
PMID: 36261279
ISSN: 1759-8486
CID: 5473332
Retained radial catheters associated with variant radial anatomy in neurointerventional procedures
Catapano, Joshua S; Winkler, Ethan A; Srinivasan, Visish M; Dishion, Evan L; Rutledge, Caleb; Baranoski, Jacob F; Cole, Tyler S; Rudy, Robert F; Rumalla, Kavelin; Zomaya, Martin P; Jadhav, Ashutosh P; Ducruet, Andrew F; Albuquerque, Felipe C
BACKGROUND:Transradial artery access (TRA) for neurointerventional procedures is gaining widespread acceptance. However, complications that were previously rare may arise as TRA procedures increase. Here we report a series of retained catheter cases with a literature review. METHODS:All patients who underwent a neurointerventional procedure during a 23-month period at a single institution were retrospectively reviewed for a retained catheter in TRA cases. In cases of retained catheters, imaging was reviewed for anatomical variances in the radial artery, and clinical and demographic case details were analyzed. RESULTS:A total of 1386 nondiagnostic neurointerventional procedures were performed during the study period, 631 (46%) initially via TRA. The 631 TRA cases were performed for aneurysm embolization (n=221, 35%), mechanical thrombectomy (n=116, 18%), carotid stent/angioplasty (n=40, 6%), arteriovenous malformation embolization (n=38, 6%), and other reasons (n=216, 34%). Thirty-nine (6%) TRA procedures crossed over to femoral access, most commonly because the artery of interest could not be catheterized (26/39, 67%). A retained catheter was identified in five cases (1%), and one (0.2%) patient had an entrapped catheter that was recovered. All six patients with a retained or entrapped catheter had aberrant radial anatomy. CONCLUSION/CONCLUSIONS:Retained catheters for neurointerventional procedures performed via TRA are rare. However, this complication may be associated with variant radial anatomy. With the increased use of TRA for neurointerventional procedures, awareness of anatomical abnormalities that may lead to a retained catheter is necessary. We propose a simple protocol to avoid catheter entrapment, including in emergent situations such as TRA for stroke thrombectomy.
PMID: 36190952
ISSN: 1759-8486
CID: 5473312
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
Republished: Resolution of an enlarging subdural haematoma after contralateral middle meningeal artery embolisation
Rutledge, Caleb; Baranoski, Jacob F; Catapano, Joshua S; Jadhav, Ashutosh P; Albuquerque, Felipe C; Ducruet, Andrew F
A man in his 50s presented 1 month after an automobile accident with worsening headaches and an enlarging chronic left subdural haematoma (SDH). He underwent left middle meningeal artery (MMA) embolisation. Due to tortuosity at its origin, we were unable to catheterise the MMA distally. Only proximal coil occlusion at the origin was performed. Follow-up interval head CT showed an increase in the size of the SDH with new haemorrhage, worsening mass effect and midline shift. However, he remained neurologically intact. Contralateral embolisation of the right MMA was performed with a liquid embolic agent. His headaches improved, and a follow-up head CT 3 months later showed near-complete resolution of the SDH.
PMID: 33986110
ISSN: 1759-8486
CID: 5473032