Publications by authors named "Erez Nossek"

72 Publications

Early Experience with Comaneci, a Newly FDA-Approved Controllable Assist Device for Wide-Necked Intracranial Aneurysm Coiling.

Cerebrovasc Dis 2021 May 10:1-8. Epub 2021 May 10.

Department of Neurosurgery, NYU Langone Health, New York, New York, USA.

Background: Comaneci (Rapid Medical) is a compliant, adjustable mesh that provides temporary scaffolding during coiling of wide-necked intracranial aneurysms (WNAs) that preserves antegrade flow. We report our early multi-institutional experience with the Comaneci device in the USA.

Method: We reviewed all patients with WNAs that were treated using the Comaneci device for coil remodeling of ruptured and unruptured aneurysms at 4 institutions between July 2019 and May 2020. Clinical characteristics, angiographic variables, and endovascular results were assessed.

Results: A total of 26 patients were included (18 women). The mean age was 62.7 years (range 44-81). Fifteen patients presented with ruptured aneurysms and 11 with unruptured aneurysms. The mean aneurysm neck width was 3.91 mm (range 1.9-6.5) with a mean dome-to-neck ratio of 1.57 (range 0.59-3.39). The mean maximum width was 5.80 mm (range 3.0-9.9) and the mean maximum height was 5.61 mm (range 2.0-11.8). Successful aneurysm occlusion was achieved in 25 of 26 patients. Complete occlusion was achieved in 16 patients, near-complete occlusion was observed in 9 patients, and 1 patient demonstrated residual filling. The mean time of device exposure was 24 min (range 8-76). No vasospasm was observed at the device location. Clot formation on the device was noted in 2 separate cases, but there were no clinical sequelae. There was 1 intraprocedural complication in a case that involved the simultaneous use of 2 Comaneci devices.

Conclusions: Our initial experience shows that the Comaneci device is a promising and reliable tool that can safely support coil remodeling of WNAs.
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http://dx.doi.org/10.1159/000514371DOI Listing
May 2021

Pipeline embolization of cerebral aneurysms in pediatric patients: combined systematic review of patient-level data and multicenter retrospective review.

J Neurosurg Pediatr 2021 Apr 23:1-9. Epub 2021 Apr 23.

Departments of1Neurological Surgery and.

Objective: Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience.

Methods: A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included.

Results: Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death.

Conclusions: Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.
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http://dx.doi.org/10.3171/2020.10.PEDS20324DOI Listing
April 2021

How I do it: endarterectomy for carotid web.

Acta Neurochir (Wien) 2021 06 19;163(6):1763-1766. Epub 2021 Apr 19.

Department of Neurosurgery, NYU Langone Health, 550 1st Ave, New York, NY, 10016, USA.

Background: The carotid web is an important and under recognized etiology for recurrent cryptogenic strokes. A management option for a symptomatic carotid web is a carotid endarterectomy (CEA) with surgical microdissection and removal of the intimal luminal defect.

Methods: We describe some of the technical nuances involved in successfully performing a carotid endarterectomy for resection of a carotid web.

Conclusion: Utilizing a familiar approach to an understudied pathology, this procedure can be safely performed and provides the patient with lasting protection against recurrent infarcts through removal of the thromboembolic nidus.
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http://dx.doi.org/10.1007/s00701-021-04841-zDOI Listing
June 2021

Dural venous system: angiographic technique and correlation with ex vivo investigations.

J Neurointerv Surg 2021 Mar 16. Epub 2021 Mar 16.

Department of Radiology, New York University Langone Medical Center, New York, New York, USA.

Background: The dural vasculature plays a key role in several important conditions, including dural fistulas and subdural collections. While in vivo investigations of intrinsic dural arterial angioarchitecture are rare, no angiographic studies of dural venous drainage exist to our knowledge.

Objective: To describe methods by which dural venous drainage might be visualized with current angiographic equipment and technique, and to correlate our results with existing ex vivo literature.

Methods: Digital subtraction angiography and 3D angiography (rotational and Dyna CT) of dural neurovasculature were acquired in the context of subdural hematoma embolization and normal dura. Protocols for visualization of dural venous drainage were established, and findings correlated with ex vivo studies.

Results: Meningeal arteries supply both the skull and dura. Normal dural enhancement is accentuated by the presence of hypervascular membranes. Intrinsic meningeal veins/sinuses parallel outer layer arteries with well-known tram-tracking appearance. Dura adjacent to main arterial trunks drains via skull base foramina into the pterygopalatine venous plexus, or via emissary veins into the temporalis venous plexus. Dura near the sinuses drains into venous pouches adjacent to the sinus, before emptying into the sinus proper-possibly the same pouches implicated in the angioarchitecture of dural fistulas. Finally, posterior temporoparietal convexity dura, situated in a watershed-like region between middle and posterior meningeal territories, frequently empties into diploic and emissary veins of the skull. Wide variation in balance is expected between these three routes. Drainage patterns appear to correlate with venous embryologic investigations of Padget and ex vivo studies in adults.

Conclusions: Continued attention to dural venous drainage may prove useful in the diagnosis and management of dural-based vascular diseases.
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http://dx.doi.org/10.1136/neurintsurg-2020-017237DOI Listing
March 2021

Percutaneous transorbital direct puncture to obliterate a cavernous sinus dural arteriovenous fistula.

J Neurointerv Surg 2021 Mar 8. Epub 2021 Mar 8.

Radiology, New York University Langone Health, New York, New York, USA.

Cavernous sinus dural arteriovenous fistulas (CS-DAVF) can have an indolent course, with insidious onset, but still showing a high likelihood of spontaneous resolution.1 Nevertheless, symptoms in a subset of patients evolve more rapidly, with malignant signs on imaging, warranting intervention.2 We report on a patient in his 40s presenting with redness and proptosis of the right eye, intermittent blurred vision and diplopia. Once ophthalmological examination revealed increased intraocular pressure and imaging showed cortical venous congestion, the decision was made to obliterate a CS-DAVF involving the posteromedial right cavernous sinus.Multiple arteries including branches of the ascending pharyngeal artery, occipital artery and bilateral meningohypophyseal trunks supplied the fistula. Once transarterial embolization was deemed unsafe and both inferior petrosal sinuses did not grant access to the right cavernous sinus, a direct puncture to the cavernous sinus was performed to successfully coil the involved compartments.3-5 The aid of DynaCT imaging and needle guidance software is emphasized (video 1).neurintsurg;neurintsurg-2020-017118v2/V1F1V1Video 1.
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http://dx.doi.org/10.1136/neurintsurg-2020-017118DOI Listing
March 2021

Neuroanatomy of cranial dural vessels: implications for subdural hematoma embolization.

J Neurointerv Surg 2021 May 25;13(5):471-477. Epub 2021 Feb 25.

Radiology, Neurosurgery, NYU School of Medicine, New York, New York, USA.

Adoption of middle meningeal artery embolization in the management of chronic subdural hematomas has led to a renewed interest in dural vascular anatomy. The readily identifiable major dural arteries and potential hazards associated with their embolization are well described. Less emphasized are several levels of intrinsic dural angioarchitecture, despite their more direct relationship to dural based diseases, such as subdural hematoma and dural fistula. Fortunately, microvascular aspects of dural anatomy, previously limited to ex vivo investigations, are becoming increasingly accessible to in vivo visualization, setting the stage for synthesis of the old and the new, and providing a rationale for the endovascular approach to subdural collections in particular. In contrast with traditional anatomical didactics, where descriptions advance from larger trunks to smaller pedicles, we present a strategic approach that proceeds from a fundamental understanding of the dural microvasculature and its relationship to larger vessels.
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http://dx.doi.org/10.1136/neurintsurg-2020-016798DOI Listing
May 2021

Endovascular Treatment of Aneurysms Using Flow-Diversion Embolization: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 03;20(4):E284-E285

Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York.

Initially developed for large and giant wide-necked aneurysms of the internal carotid artery, flow diverter devices are now used in almost every location safely and with effectiveness.1-5 This video demonstrates a unique case of a giant aneurysm of the right petrous internal carotid artery in a 20-yr-old patient. This is an extremely rare location, and most of patients are asymptomatic.3-6 Signs of compression of the seventh and eight cranial nerves can be present and even Horner syndrome and lower cranial nerves neuropathies. Nevertheless, rupture can lead to epistaxis and otorrhagia, and ultimately to hemorrhagic shock. The patient in the current report was otherwise healthy but presented with lightheadedness and dizziness for 10 d. The patient consented to the procedure. There was no history of major trauma or head and neck infection. A transradial endovascular flow diversion embolization of a giant aneurysm of the petrous internal carotid artery is herein demonstrated in a stepwise manner. A triaxial system was used to deploy 3 overlapping devices. Concepts of J-wire technique, multiple coverage,1 and the so-called weld technique are emphasized. The role of adjunctive coiling and main reasons for failure are also discussed.7,8 Brief cases of flow diversion embolization of aneurysms of different morphologies at different locations are used to highlight the importance of assessing vessel wall apposition and follow-up imaging.
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http://dx.doi.org/10.1093/ons/opaa462DOI Listing
March 2021

Superficial Temporal Artery to Middle Cerebral Artery Cranial Bypass for Nonmoyamoya Steno-Occlusive Disease in Patients Who Failed Optimal Medical Treatment: A Case Series.

Oper Neurosurg (Hagerstown) 2021 04;20(5):444-455

Department of Neurosurgery, NYU Langone Health, New York, New York.

Background: In the post-Carotid Occlusion Surgery Study (COSS) era, multiple reviews suggested subset groups of patients as potential candidates for superficial temporal artery to middle cerebral artery (STA-MCA) bypass. Among them are patients with recurrent strokes despite optimal medical therapy. There is a paucity of data on the outcome of bypass in these specific patients.

Objective: To examine the safety and efficacy of direct STA-MCA bypass in patients with nonmoyamoya, symptomatic steno-occlusive disease with impaired distal perfusion, who failed optimal medical management or endovascular treatment.

Methods: A retrospective review was performed to identify patients with cerebrovascular steno-occlusive disease who underwent bypass after symptomatic recurrent or rapidly progressive strokes, despite optimal conservative or endovascular treatment.

Results: A total of 8 patients (mean age 60 ± 6 yr) underwent direct or combined direct/indirect STA-MCA bypass between 2016 and 2019. All anastomoses were patent. One bypass carried slow flow. There were no procedure-related permanent deficits. One patient developed seizures which were controlled by medications. A total of 7 out of 8 patients were stable or improved clinically at last follow-up (mean 27.3 ± 13.8 mo) without recurrent strokes. One patient did not recover from their presenting stroke, experienced severe bilateral strokes 4 mo postoperatively, and subsequently expired. Modified Rankin Scale (mRS) improved in 6 patients (75%), remained stable in 1 patient (12.5%), and deteriorated in 1 (12.5%). Good long-term functional outcome was achieved in 5 patients (63%, mRS ≤ 2).

Conclusion: Patients with symptomatic, hypoperfused steno-occlusive disease who fail optimal medical or endovascular treatment may benefit from cerebral revascularization. Direct or combined STA-MCA bypass was safe and provided favorable outcomes in this small series.
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http://dx.doi.org/10.1093/ons/opaa458DOI Listing
April 2021

Intra-arterial thrombolytic therapy for acute anterior spinal artery stroke.

J Clin Neurosci 2021 Feb 24;84:102-105. Epub 2020 Dec 24.

Department of Neurosurgery, NYU Langone Health, New York, NY, USA. Electronic address:

Background And Importance: Spinal cord infarction is rare but can be extremely disabling. Prompt diagnosis and treatment of these infarcts is important for patient outcomes. While intravenous thrombolytic therapy is a well-established form of treatment in circumstances of cerebral stroke, it has only recently been successfully used in a few incidents of spinal cord ischemia. We present a case of anterior spinal artery (ASA) territory ischemia treated with ASA intra-arterial thrombolytic therapy.

Clinical Presentation: A 52-year-old male presented with acute onset of severe lumbar pain, rapidly progressing paraplegia and loss of pain and temperature sensation, with preservation of proprioception and vibratory sensation at the L1 level and below on the right and at the L3 level and below on the left. MRI showed restricted diffusion involving the cord at and below L1 level, with normal cord T2 signal. Digital subtraction spinal angiography showed ASA cutoff in the descending limb at the level of L1. Intra-arterial tissue plasminogen activator (t-PA) combined with verapamil and eptifibatide was administered within the ASA and the patient had significant neurological improvement immediately postoperatively and at 8-month clinical follow-up.

Conclusion: Direct ASA intra-arterial thrombolysis is feasible, and this drug combination might be an effective therapy for spinal stroke.
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http://dx.doi.org/10.1016/j.jocn.2020.11.035DOI Listing
February 2021

Acquisition of Basic Microsurgical Skills Using Low-Cost, Readily Available Models: The Orange Model.

World Neurosurg 2021 02 18;146:189-196. Epub 2020 Nov 18.

Department of Neurosurgery, New York University Langone Health, New York, New York, USA.

Background: Attainment of basic microsurgical skills in neurosurgery presents a departmental challenge worldwide. Models for teaching are either not readily available or expensive and are incompatible with a resident's busy schedule, requiring lengthy and proper setup. We present a model and a set of measurable tasks, based on a fruit (orange) that is cheap, easy to set up instantly when desired, and useful for training of basic microsurgical skills.

Methods: Basic microsurgical skills were identified, necessitating hand-eye coordination working with the microscope. The goal was to dissect an orange segment while preserving adjacent segments. Assessment was based on the number of side tears and task completion duration. The task was repeated in a sequential manner (n = 10), for validation purposes, for 3 operators at different seniority levels.

Results: An improvement in the number of side tears (mean of 12.66 ± 9.01 in the first trial vs. 4 ± 4.35 in the 10th trial, P < 0.01), as well as duration of time required for task completion (mean initial duration of 28:16 ± 19:00 minutes to a duration of 16:33 ± 10:50 minutes in the last attempt, P < 0.01), was observed. Daily practice scores and time gradually improved, and the seniority level of operators was correlated with scoring between individuals.

Conclusions: The orange model is an easily accessible, cheap model that enables the acquisition of basic microneurosurgical skills. In this work, we validated and defined reproducible tasks that can be scored and tracked, correlated with operator's proficiency and experience. This model can be incorporated into a resident's workflow environment and provides a platform for attainment of elementary microsurgical skills for neurosurgical residents.
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http://dx.doi.org/10.1016/j.wneu.2020.11.060DOI Listing
February 2021

Carotid web: an occult mechanism of embolic stroke.

J Neurol Neurosurg Psychiatry 2020 12 1;91(12):1283-1289. Epub 2020 Oct 1.

Department of Neurosurgery, New York University School of Medicine, New York, New York, USA.

The carotid web is a proposed stroke mechanism that may underlie cryptogenic stroke, particularly in younger patients without vascular risk factors. The web appears as a shelf-like projection into the lumen of the proximal cervical internal carotid artery without evidence of calcification. It is pathologically defined as intimal fibromuscular dysplasia. Altered haemodynamics distal to the web cause flow stagnation and remote embolisation of fibrin-based clots. It is best demonstrated and diagnosed on CT angiography (CTA) of the neck because of its ability to resolve calcium and create multiplanar reconstructions. Although they can be readily visualised on CTA, carotid webs may be missed or misinterpreted because they do not typically cause haemodynamically significant stenosis and can mimic arterial dissection, non-calcified atherosclerotic plaque and intraluminal thrombus. Options for management include antiplatelet therapy, carotid endarterectomy and carotid artery stenting. Modern management strategies for cryptogenic stroke include long-term cardiac monitoring, further investigation for structural cardiac disease and a diagnostic workup for arterial hypercoagulability, however, these strategies are not likely to capture the possibility of a carotid web. Carotid webs should be suspected in a young patient presenting with recurrent unihemispheric strokes particularly when conventional vascular risk factors are not present.
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http://dx.doi.org/10.1136/jnnp-2020-323938DOI Listing
December 2020

Endarterectomy for symptomatic internal carotid artery web.

J Neurosurg 2020 Aug 28:1-8. Epub 2020 Aug 28.

3Department of Neurosurgery.

Objective: The carotid web (CW) is an underrecognized source of cryptogenic, embolic stroke in patients younger than 55 years of age, with up to 37% of these patients found to have CW on angiography. Currently, there are little data detailing the best treatment practices to reduce the risk of recurrent stroke in these patients. The authors describe their institutional surgical experience with patients treated via carotid endarterectomy (CEA) for a symptomatic internal carotid artery web.

Methods: A retrospective, observational cohort study was performed including all patients presenting to the authors' institution with CW. All patients who were screened underwent either carotid artery stenting (CAS) or CEA after presentation with ischemic stroke from January 2019 to February 2020. From this sample, patients with suggestive radiological features and pathologically confirmed CW who underwent CEA were identified. Patient demographics, medical histories, radiological images, surgical results, and clinical outcomes were collected and described using descriptive statistics.

Results: A total of 45 patients with symptomatic carotid lesions were treated at the authors' institution during the time period. Twenty patients underwent CAS, 1 of them for a CW. Twenty-five patients were treated via CEA, and of these, 6 presented with ischemic strokes ipsilateral to CWs, including 3 patients who presented with recurrent strokes. The mean patient age was 55 ± 12.6 years and 5 of 6 were women. CT angiography or digital subtraction angiography demonstrated the presence of CWs ipsilateral to the stroke in all patients. All patients underwent resection of CWs using CEA. There were no permanent procedural complications and no patients had stroke recurrence following intervention at the latest follow-up (mean 6.1 ± 4 months). One patient developed mild tongue deviation most likely related to retraction, with complete recovery at follow-up.

Conclusions: CEA is a safe and feasible treatment for symptomatic carotid webs and should be considered a viable alternative to CAS in this patient population.
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http://dx.doi.org/10.3171/2020.5.JNS201107DOI Listing
August 2020

Anticoagulation use and Hemorrhagic Stroke in SARS-CoV-2 Patients Treated at a New York Healthcare System.

Neurocrit Care 2021 06 24;34(3):748-759. Epub 2020 Aug 24.

Department of Neurology, NYU Langone Medical Center, New York, NY, 10016, USA.

Background And Purpose: While the thrombotic complications of COVID-19 have been well described, there are limited data on clinically significant bleeding complications including hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this particular subset of patients are especially salient as therapeutic anticoagulation becomes increasingly common in the treatment and prevention of thrombotic complications of COVID-19.

Methods: We conducted a retrospective cohort study of patients with hemorrhagic stroke (both non-traumatic intracerebral hemorrhage and spontaneous non-aneurysmal subarachnoid hemorrhage) who were hospitalized between March 1, 2020, and May 15, 2020, within a major healthcare system in New York, during the coronavirus pandemic. Patients with hemorrhagic stroke on admission and who developed hemorrhage during hospitalization were both included. We compared the clinical characteristics of patients with hemorrhagic stroke and COVID-19 to those without COVID-19 admitted to our hospital system between March 1, 2020, and May 15, 2020 (contemporary controls), and March 1, 2019, and May 15, 2019 (historical controls). Demographic variables and clinical characteristics between the individual groups were compared using Fischer's exact test for categorical variables and nonparametric test for continuous variables. We adjusted for multiple comparisons using the Bonferroni method.

Results: During the study period in 2020, out of 4071 patients who were hospitalized with COVID-19, we identified 19 (0.5%) with hemorrhagic stroke. Of all COVID-19 with hemorrhagic stroke, only three had isolated non-aneurysmal SAH with no associated intraparenchymal hemorrhage. Among hemorrhagic stroke in patients with COVID-19, coagulopathy was the most common etiology (73.7%); empiric anticoagulation was started in 89.5% of these patients versus 4.2% in contemporary controls (p ≤ .001) and 10.0% in historical controls (p ≤ .001). Compared to contemporary and historical controls, patients with COVID-19 had higher initial NIHSS scores, INR, PTT, and fibrinogen levels. Patients with COVID-19 also had higher rates of in-hospital mortality (84.6% vs. 4.6%, p ≤ 0.001). Sensitivity analyses excluding patients with strictly subarachnoid hemorrhage yielded similar results.

Conclusion: We observed an overall low rate of imaging-confirmed hemorrhagic stroke among patients hospitalized with COVID-19. Most hemorrhages in patients with COVID-19 infection occurred in the setting of therapeutic anticoagulation and were associated with increased mortality. Further studies are needed to evaluate the safety and efficacy of therapeutic anticoagulation in patients with COVID-19.
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http://dx.doi.org/10.1007/s12028-020-01077-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444897PMC
June 2021

Acute stroke care in a New York City comprehensive stroke center during the COVID-19 pandemic.

J Stroke Cerebrovasc Dis 2020 Sep 20;29(9):105068. Epub 2020 Jun 20.

Department of Neurology, New York Langone Health, New York, NY, United States. Electronic address:

Background And Purpose: The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented demand and burden on emergency health care services in New York City. We aim to describe our experience providing acute stroke care at a comprehensive stroke center (CSC) and the impact of the pandemic on the quality of care for patients presenting with acute ischemic stroke (AIS).

Methods: We retrospectively analyzed data from a quality improvement registry of consecutive AIS patients at New York University Langone Health's CSC between 06/01/2019-05/15/2020. During the early stages of the pandemic, the acute stroke process was modified to incorporate COVID-19 screening, testing, and other precautionary measures. We compared stroke quality metrics including treatment times and discharge outcomes of AIS patients during the pandemic (03/012020-05/152020) compared with a historical pre-pandemic group (6/1/2019-2/29/2020).

Results: A total of 754 patients (pandemic-120; pre-pandemic-634) were admitted with a principal diagnosis of AIS; 198 (26.3%) received alteplase and/or mechanical thrombectomy. Despite longer median door to head CT times (16 vs 12 minutes; p = 0.05) and a trend towards longer door to groin puncture times (79.5 vs. 71 min, p = 0.06), the time to alteplase administration (36 vs 35 min; p = 0.83), door to reperfusion times (103 vs 97 min, p = 0.18) and defect-free care (95.2% vs 94.7%; p = 0.84) were similar in the pandemic and pre-pandemic groups. Successful recanalization rates (TICI≥2b) were also similar (82.6% vs. 86.7%, p = 0.48). After adjusting for stroke severity, age and a prior history of transient ischemic attack/stroke, pandemic patients had increased discharge mortality (adjusted OR 2.90 95% CI 1.77 - 7.17, p = 0.021) CONCLUSION: Despite unprecedented demands on emergency healthcare services, early multidisciplinary efforts to adapt the acute stroke treatment process resulted in keeping the stroke quality time metrics close to pre-pandemic levels. Future studies will be needed with a larger cohort comparing discharge and long-term outcomes between pre-pandemic and pandemic AIS patients.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305900PMC
September 2020

Stroke Treatment Delay Limits Outcome After Mechanical Thrombectomy: Stratification by Arrival Time and ASPECTS.

J Neuroimaging 2020 09 27;30(5):625-630. Epub 2020 Jun 27.

Department of Neurology, New York Langone Medical Center, New York, NY.

Background And Purpose: Mechanical thrombectomy (MT) has helped many patients achieve functional independence. The effect of time-to-treatment based in specific epochs and as related to Alberta Stroke Program Early CT Score (ASPECTS) has not been established. The goal of the study was to evaluate the association between last known normal (LKN)-to-puncture time and good functional outcome.

Methods: We conducted a retrospective cohort study of prospectively collected acute ischemic stroke patients undergoing MT for large vessel occlusion. We used binary logistic regression models adjusted for age, Modified Treatment in Cerebral Ischemia score, initial National Institutes of Health Stroke Scale, and noncontrast CT ASPECTS to assess the association between LKN-to-puncture time and favorable outcome defined as Modified Rankin Score 0-2 on discharge.

Results: Among 421 patients, 328 were included in analysis. Increased LKN-to-puncture time was associated with decreased probability of good functional outcome (adjusted odds ratio [aOR] ratio per 15-minute delay = .98; 95% confidence interval [CI], .97-.99; P = .001). This was especially true when LKN-puncture time was 0-6 hours (aOR per 15-minute delay = .94; 95% CI, .89-.99; P = .05) or ASPECTS 8-10 (aOR = .98; 95% CI, .97-.99; P = .002) as opposed to when LKN-puncture time was 6-24 hours (aOR per 15-minute delay = .99; 95% CI, .97-1.00; P = .16) and ASPECTS <8 (aOR = .98; 95% CI, .93-1.03; P = .37).

Conclusion: Decreased LKN-groin puncture time improves outcome particularly in those with good ASPECTS presenting within 6 hours. Strategies to decrease reperfusion times should be investigated, particularly in those in the early time window and with good ASPECTS.
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http://dx.doi.org/10.1111/jon.12729DOI Listing
September 2020

Cardiac-gated intracranial elastance in a swine model of raised intracranial pressure: a novel method to assess intracranial pressure-volume dynamics.

J Neurosurg 2020 Jun 5:1-8. Epub 2020 Jun 5.

1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem.

Objective: Previous studies have demonstrated the importance of intracranial elastance; however, methodological difficulties have limited widespread clinical use. Measuring elastance may offer potential benefit in helping to identify patients at risk for untoward intracranial pressure (ICP) elevation from small rises in intracranial volume. The authors sought to develop an easily used method that accounts for the changing ICP that occurs over a cardiac cycle and to assess this method in a large-animal model over a broad range of ICPs.

Methods: The authors used their previously described cardiac-gated intracranial balloon pump and swine model of cerebral edema. In the present experiment they measured elastance at 4 points along the cardiac cycle-early systole, peak systole, mid-diastole, and end diastole-by using rapid balloon inflation to 1 ml over an ICP range of 10-30 mm Hg.

Results: The authors studied 7 swine with increasing cerebral edema. Intracranial elastance rose progressively with increasing ICP. Peak-systolic and end-diastolic elastance demonstrated the most consistent rise in elastance as ICP increased. Cardiac-gated elastance measurements had markedly lower variance within swine compared with non-cardiac-gated measures. The slope of the ICP-elastance curve differed between swine. At ICP between 20 and 25 mm Hg, elastance varied between 8.7 and 15.8 mm Hg/ml, indicating that ICP alone cannot accurately predict intracranial elastance.

Conclusions: Measuring intracranial elastance in a cardiac-gated manner is feasible and may offer an improved precision of measure. The authors' preliminary data suggest that because elastance values may vary at similar ICP levels, ICP alone may not necessarily best reflect the state of intracranial volume reserve capacity. Paired ICP-elastance measurements may offer benefit as an adjunct "early warning monitor" alerting to the risk of untoward ICP elevation in brain-injured patients that is induced by small increases in intracranial volume.
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http://dx.doi.org/10.3171/2020.3.JNS193262DOI Listing
June 2020

DynaCT Enhancement of Subdural Membranes After Middle Meningeal Artery Embolization: Insights into Pathophysiology.

World Neurosurg 2020 07 13;139:e265-e270. Epub 2020 Apr 13.

Department of Neurosurgery, New York University School of Medicine, New York, New York, USA. Electronic address:

Objective: Middle meningeal artery (MMA) embolization could be an effective method of inhibiting neovascularization of the subdural capsular membrane and preventing hematoma maintenance. We sought to better understand how the MMA might affect subdural hematoma physiology and how this process might be modified by embolization.

Methods: We performed a retrospective review of 27 patients with 29 subdural hematomas (SDHs) who had undergone MMA embolization from July 2018 to May 2019. Of the 27 patients, 8 had undergone postembolization DynaCT imaging studies and were included in the present study.

Results: The average patient age was 75 years. The baseline noncontrast-enhanced cranial computed tomography (CT) scans showed the presence of a hematoma membrane in all 8 patients. The postembolization DynaCT scans of all patients demonstrated enhancement of all 4 components (i.e., dura, capsular membrane, septations, and subdural hematoma fluid). All patients had a minimum of 60-day imaging and clinical follow-up data available. The average decrease in SDH volume at the last follow-up examination was 87% compared with that at baseline. A significant difference was found between the average baseline and average last follow-up SDH volume (P < 0.0001, paired t test) in all 8 patients. The average interval from the date of the procedure to the last follow-up scan was 89 days (range, 61-122 days). No patient experienced postembolization complications, subsequent SDH drainage, or mortality.

Conclusions: Our data lend support to the theory of contiguous vascular networks between the MMA and SDH membranes. Targeting these leaky vascular networks might remove the source of hematoma accumulation. These data add to the pathophysiological understanding of the disease and suggests potential insights into the mechanism of action of MMA embolization.
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http://dx.doi.org/10.1016/j.wneu.2020.03.188DOI Listing
July 2020

Neuroanatomy of the middle cerebral artery: implications for thrombectomy.

J Neurointerv Surg 2020 Aug 27;12(8):768-773. Epub 2020 Feb 27.

Radiology and Neurology, New York University Langone Medical Center, New York, New York, USA.

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.
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http://dx.doi.org/10.1136/neurintsurg-2019-015782DOI Listing
August 2020

Radial Arterial Access for Thoracic Intraoperative Spinal Angiography in the Prone Position.

World Neurosurg 2020 05 4;137:e358-e365. Epub 2020 Feb 4.

Section of Neurointerventional Radiology, Department of Radiology, New York University School of Medicine, New York, New York, USA. Electronic address:

Background: Verification of complete occlusion or resection of neurovascular lesions is often performed using intraoperative angiography. Surgery for spinal vascular lesions such as arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) is typically performed with the patient in the prone position, making intraoperative angiography difficult. No standardized protocol is available for intraoperative angiography during spinal surgery with the patient in the prone position. We have described our experience using radial artery access for intraoperative angiography in thoracic spinal neurovascular procedures performed with the patient in the prone position.

Methods: We reviewed the data from all patients who had undergone surgical resection of spinal vascular lesions in the prone position with radial artery vascular access for intraoperative angiography. The patients were treated in a hybrid endovascular operating room.

Results: A total of 4 patients were treated in the prone position using transradial artery access intraoperative angiography for confirmation of complete resection of the vascular lesions. Of the 4 patients, 2 had undergone surgery for a dural AVF, 1 for a pial AVF, and 1 for an AVM of the filum terminale. None of the patients had experienced any procedural complications.

Conclusion: Radial artery access for intraoperative angiography during spinal neurovascular procedures in which selective catheterization of a thoracic branch is necessary is feasible, safe, and practical.
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http://dx.doi.org/10.1016/j.wneu.2020.01.208DOI Listing
May 2020

Flow Diversion for Intracranial Aneurysm Treatment: Trials Involving Flow Diverters and Long-Term Outcomes.

Neurosurgery 2020 01;86(Suppl 1):S36-S45

The Bernard and Irene Schwartz Neurointerventional Radiology Section, Center for Stroke and Cerebrovascular Diseases, New York University Langone Medical Center, New York, New York.

Flow diverters (FDs) have changed the management of brain aneurysms; not only for complex aneurysms (giant, fusiform and blister) refractory to conventional therapies, but also for unruptured lesions previously managed by traditional surgical or coil-based endovascular methods. Since 2011 when the PipelineTM Embolization Device (Medtronic) was cleared by the Food and Drug Administration for adults with large or giant wide-neck intracranial aneurysms of the internal carotid artery proximal to the posterior communicating segment, the role of flow diversion for aneurysm treatment has expanded-supported by favorably low complication and high cure rates compared with alternative treatments. Here we review the key clinical trials and the long term outcomes that have demonstrated safety and efficacy of minimized porosity endoluminal devices in the treatment of cerebral aneurysms.
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http://dx.doi.org/10.1093/neuros/nyz345DOI Listing
January 2020

Microsurgical Resection of a Spinal Cord Pial Arteriovenous Fistula: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 08;19(2):E152

Department of Neurosurgery, New York University School of Medicine, New York, New York.

We present a patient who was diagnosed 20 yr prior to current presentation with a spinal arteriovenous malformation. This patient had a 10-yr history of worsening back pain (and underwent lumbar fusion), urinary dysfunction leading to 3-yr dependence on intermittent catheterization, lower extremity paresthesias and pain, and progressive weakness with multiple falls, leading to walker then wheelchair dependence for mobility. Magnetic resonance studies showed extensive thoracic cord expansion and edema with enlarged spinal cord surface veins and flow voids extending from spinal levels T6 to the conus medullaris. Partial embolization at an outside institution elicited transient symptom improvement. Repeated spinal angiogram demonstrated persistent T10 pial arteriovenous fistula (AVF) supplied by the posterior spinal artery arising from the right T11 segmental artery as well as by the anterior spinal artery from the left T10 segmental artery. Because additional embolization carried significant risk, we planned open surgery with fistula resection. Informed consent for the surgery and video recording was obtained. The patient was placed in the prone position, and a radial artery access was obtained for intraoperative angiogram. Following a posterior T9-T11 laminectomy and dural opening, a pial dissection was performed to expose the AVF. Intraoperative indocyanine green angiography was used to assist in identifying the feeders and major drainage of the AVF. Post-AVF resection, a formal intraoperative radial access spinal angiogram demonstrated complete resection of the lesion with no residual shunt or early venous drainage. The patient improved significantly and, on last follow-up, is ambulating without any assistive devices.
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http://dx.doi.org/10.1093/ons/opz388DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594179PMC
August 2020

Possible Empirical Evidence of Glymphatic System on Computed Tomography After Endovascular Perforations.

World Neurosurg 2020 Feb 23;134:e400-e404. Epub 2019 Oct 23.

Department of Radiology, NYU Langone Health, New York, New York, USA; Department of Neurosurgery, NYU Langone Health, New York, New York, USA.

Background: The glial-lymphatic pathway is a fluid-clearance pathway consisting of a para-arterial route for the flow of cerebrospinal fluid along perivascular spaces and subsequently toward the brain interstitium. In this case series, we aim to investigate an empirical demonstration of glymphatic clearance of extravasated iodine following perforation incurred during endovascular therapy on serial computed tomography.

Methods: Six consecutive cases of endovascular perforation during thrombectomy performed between 2005 and 2018 were retrospectively collected by searching our internal database of total 446 thrombectomies. Two cases were excluded because care was withdrawn shortly following the procedure and no follow-up imaging was available. One case was excluded because a ventricular drain was placed. Three cases were hence included in this analysis.

Results: All 3 cases demonstrated progressive absorption of contrast by the brain parenchyma with eventual contrast disappearance.

Conclusions: We described a likely in vivo computed tomography correlate of the glymphatic system in a cohort of patients who sustained intraprocedural extravasation during thrombectomy for acute ischemic stroke.
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http://dx.doi.org/10.1016/j.wneu.2019.10.089DOI Listing
February 2020

Unilateral Venous Approach to Contralateral or Bilateral Carotid Cavernous Shunts.

World Neurosurg 2020 Jan 18;133:e479-e486. Epub 2019 Sep 18.

Department of Neurosurgery, North-Shore Hospital, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA; Department of Radiology, North-Shore Hospital, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA.

Background: Cavernous carotid fistulas (CCF) are anatomically complex vascular lesions. Treatment via the venous approach has been previously described and is highly dependent on the patency of the drainage pathways. The use of a unilateral approach to contralateral or bilateral shunts is technically challenging and not commonly described. We present our experience with the unilateral across-the-midline approach to both cavernous sinuses to treat shunts according to anatomic compartments to achieve anatomic cure.

Methods: Patients included in this study presented with either bilateral or unilateral shunts with unilateral venous drainage. We used a transarterial guiding catheter for road mapping and control angiography. A venous triaxial system was used to achieve support for distal navigation across the midline via the coronary sinus to the contralateral cavernous sinus. Coils were favored for embolization, with occasional complementary liquid embolic material.

Results: Five patients underwent complete occlusion in a single session. One patient required additional complementary transarterial embolization. Despite a successful unilateral approach to bilateral cavernous sinuses, 1 patient needed an additional ipsilateral transophthalmic venous approach to obliterate the anterior compartment of the cavernous sinus. No complications were encountered. Complete angiographic cure was observed in all patients by the end of the final procedures, with persistent occlusion in their follow-up imaging.

Conclusions: Careful inspection of the venous anatomy and fistulization sites is critical when treating unilateral or bilateral carotid cavernous shunts. The contralateral venous route can serve as a safe approach when visualized. Crossing the midline via the anterior or posterior coronary sinuses is feasible and efficacious.
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http://dx.doi.org/10.1016/j.wneu.2019.09.054DOI Listing
January 2020

A canine model of mechanical thrombectomy in stroke.

J Neurointerv Surg 2019 Dec 18;11(12):1243-1248. Epub 2019 May 18.

New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

Purpose: To develop a preclinical model of stroke with a large vessel occlusion treated with mechanical thrombectomy.

Materials And Methods: An ischemic stroke model was created in dogs by the introduction of an autologous clot into the middle cerebral artery (MCA). A microcatheter was navigated to the clot and a stent retriever thrombectomy was performed with the goal to achieve Thrombolysis in Cerebral Ischemia (TICI) 2b/3 reperfusion. Perfusion and diffusion MRI was acquired after clot placement and following thrombectomy to monitor the progression of restricted diffusion as well as changes in ischemia as a result of mechanical thrombectomy. Post-mortem histology was done to confirm MCA territory infarct volume.

Results: Initial MCA occlusion with TICI 0 flow was documented in all six hound-cross dogs entered into the study. TICI 2b/3 revascularization was achieved with one thrombectomy pass in four of six animals (67%). Intra-procedural events including clot autolysis leading to spontaneous revascularization (n=1) and unresolved vasospasm (n=1) accounted for thrombectomy failure. In one case, iatrogenic trauma during microcatheter navigation resulted in a direct arteriovenous fistula at the level of the cavernous carotid. Analysis of MRI indicated that a volume of tissue from the initial perfusion deficit was spared with reperfusion following thrombectomy, and there was also a volume of tissue that infarcted between MRI and ultimate recanalization.

Conclusion: We describe a large animal stroke model in which mechanical thrombectomy can be performed. This model may facilitate, in a preclinical setting, optimization of complex multimodal stroke treatment paradigms for clinical translation.
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http://dx.doi.org/10.1136/neurintsurg-2019-014969DOI Listing
December 2019

The Impact of Colloid Cyst Treatment on Neurocognition.

World Neurosurg 2019 05 29;125:e372-e377. Epub 2019 Jan 29.

Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.

Background: Colloid cysts (CC) have been associated with neurocognitive function (NCF) decline, both preoperatively and after resection. Factors such as local pressure on the fornix and hydrocephalus are thought to contribute to preoperative NCF decline. The potential cause of postoperative decline is thought to be forniceal injury during surgery. In the current series, we describe NCF outcomes amongst patients with CC, both nonoperated and operated.

Methods: A total of 36 patients (23 operated, 13 nonoperated) were included in this retrospective study. All patients underwent at least 1 NCF evaluation battery. Of the 13 nonoperated cases, 5 had follow-up tests too. Of the 23 operated, 14 had both pre- and postoperative tests, and 8 had early and late postoperative tests.

Results: There was no significant difference in baseline NCF between nonoperated and operated cases (as evaluated preoperatively). Nonoperated patients had a stable NCF test over time. Patients who were operated showed a significant improvement after surgery in several NCF variables. There was no significant change in NCF between early and late postoperative evaluation. None of the operated patients had a postoperative NCF decline.

Conclusions: Patients with CC should undergo routine NCF testing with a standardized protocol, whether they are operated or followed. Surgery has a positive impact on NCF; however, it remains to be determined if the improvement is solely secondary to treatment of hydrocephalus, or to a reduction of local pressure on the fornices. It remains to be determined whether the surgical technique, that is, endoscopic, interhemispheric, or transcortical, has an impact on NCF outcome.
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http://dx.doi.org/10.1016/j.wneu.2019.01.079DOI Listing
May 2019

Radial Artery Access for Treatment of Posterior Circulation Aneurysms Using the Pipeline Embolization Device: Case Series.

Oper Neurosurg (Hagerstown) 2019 10;17(4):340-347

Department of Neurosurgery, NYU Langone Medical Center, New York, New York.

Background: The treatment of selected wide-neck and fusiform posterior circulation aneurysms is challenging for clipping as well as for endovascular route.

Objective: To describe an endovascular approach for vertebral artery aneurysm treatment using transradial access (TRA) instead of the conventional transfemoral access.

Methods: We collected cases from two institutions in which TRA was used for posterior circulation Pipeline Embolization Device (Medtronic, Dublin, Ireland) deployment.

Results: A total of four patients were treated. TRA was useful in the setting of extreme vessel tortuosity. We utilized 5F Terumo Glidesheath (Terumo Medical, Somerset, New Jersey), intermediate catheter, and a 027 microcatheter for Pipeline deployment. TRA was not associated with any access or deployment difficulties.

Conclusions: Early experience suggests that TRA for Pipeline Embolization Device placement for posterior circulation aneurysm is a safe and efficient alternative to standard transfemoral access. While this approach was initially applied to patients with vascular anatomy that may not allow for safe femoral access or navigation, experience so far argues for considering a radial approach towards some posterior circulation aneurysm treatment.
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http://dx.doi.org/10.1093/ons/opy378DOI Listing
October 2019

Technical Aspects and Operative Nuances Using a High-Definition 3-Dimensional Exoscope for Cerebral Bypass Surgery.

Oper Neurosurg (Hagerstown) 2019 08;17(2):157-163

Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hosfstra/Northwell, New York, New York.

Background: Cerebral bypass operation is a technically challenging operation that requires excellent surgical visibility and efficient ergonomics to minimize complications and maximize successful revascularization. Despite the operative microscope's utilization for the past two generations, there remains a need for continued improvement in operative visualization and surgical ergonomics.

Objective: To report the positives and negatives of our initial experience using a novel 4 K high-definition (4K-HD) 3-dimensional (3D) exoscope (EX) for cranial bypass surgery.

Methods: A retrospective review over 6 mo was performed of all patients who have undergone cerebral bypass surgery at a single institution using the 4K-HD 3D EX. Advantages and disadvantages of the EX and clinical outcome of the patients were assessed.

Results: A total of 5 patients underwent cerebral EC-IC bypass surgery with no EX-related complications and successful revascularization. The lightweight design of the EX allowed for easy instrument maneuverability as well as uncomplicated surgical set up in the operating room. The assistance of the cosurgeon was significantly more efficient compared to that of the operating microscope. The large monitor allowed for an immersive, collaborative, and valuable educational surgical experience.

Conclusion: Using the EX for cerebral bypass surgery, with 3D ultra-high-definition optics, enhancements of ergonomics, and improved training, we believe that the 3D 4K-HD EX may represent the next generation of operative scopes in microneurosurgery.
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http://dx.doi.org/10.1093/ons/opy342DOI Listing
August 2019

Intracranial Aneurysm: Diagnostic Monitoring, Current Interventional Practices, and Advances.

Curr Treat Options Cardiovasc Med 2018 Oct 24;20(12):94. Epub 2018 Oct 24.

Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, 130 E 77th Street, 3rd Floor, New York, NY, 10075, USA.

Purpose Of Review: Cerebral aneurysms are commonly diagnosed incidentally with non-invasive neuro-imaging modalities (i.e., brain MRA and/or head CTA). The first decision to be made in the management of patients with unruptured cerebral aneurysms is to determine if the aneurysm should undergo treatment as any intervention carries a risk of morbidity and mortality.

Recent Findings: The multiple risk factors that are associated with increased risk of aneurysm rupture should be evaluated (size, shape, and location of aneurysm; history of hypertension and cigarette smoking and family history of cerebral aneurysms). With the advent and rapid evolution of less traumatic neuro-endovascular surgery techniques in the past two decades, many more patients are undergoing treatment of cerebral aneurysms. The neuro-endovascular surgeon has multiple options for the treatment of aneurysms including coiling, with or without balloon/stent assistance, and flow diversion. A number of intrasaccular devices for the neuro-endovascular treatment of cerebral aneurysms are being evaluated. The percentage of patients with cerebral aneurysms treated with craniotomy and clip ligation is decreasing. This is controversial as it has direct impact in neurosurgical training and the aneurysms that are usually recommended for microsurgical clipping are the ones with challenging anatomy that cannot be treated safely with endovascular approaches. The best outcomes are achieved with management by experienced, high-volume practitioners at specialized cerebrovascular treatment centers that consist of individuals with dedicated training in neuro-endovascular surgery as well as individuals trained in open cerebrovascular neurosurgery.
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http://dx.doi.org/10.1007/s11936-018-0695-yDOI Listing
October 2018

Keyhole approaches for surgical treatment of intracranial aneurysms: a short review.

Neurol Res 2019 Jan 12;41(1):68-76. Epub 2018 Oct 12.

a Department of Neurosurgery , Basel University Hospital, University of Basel , Basel , Switzerland.

: To clarify the reported experience with keyhole approaches for the treatment of intracranial aneurysms. : The PubMed and Embase databases were searched up to December 2017 for full-text publications that report the treatment of aneurysms with the eyebrow variant of the supraorbital craniotomy (SOC), the minipterional craniotomy, or the eyelid variant of the SOC. The anatomical distribution of aneurysms, the postoperative aneurysm occlusion rate, and the type and rate of complications were examined using univariate analysis. : Sixty-seven publications covering treatment of 5770 aneurysms met the eligibility criteria. The reported experience was the largest for the eyebrow variant of the SOC (69.4% of aneurysms), followed by the minipterional approach (28.2%), and the eyelid variant of the SOC (2.4%). The anterior communicating artery (ACoA) was the most frequent aneurysm location for the SOC (eyebrow variant: 33.2%; eyelid variant: 31.2%). The middle cerebral artery (MCA) was the most frequent aneurysm location in the minipterional cohort (55.2%). In the eyelid variant of the SOC cohort, the rate of complete aneurysm occlusion was the lowest (eyelid variant: 90.8%; eyebrow variant: 97.8%,  < 0.001; minipterional approach: 97.9%,  < 0.001), and the postoperative infarction rate was the highest (eyelid variant: 7.2%; eyebrow variant: 3.5%,  = 0.025; minipterional approach: 2.6%,  = 0.003). : Each approach has a specific safety and efficacy profile. Surgeons selected the eyebrow variant of the SOC for many aneurysm locations including in particular the ACoA. There is a recent tendency however to opt for the minipterional approach above all for MCA aneurysms. : SOC: Supraorbital Craniotomy; MPT: Minipterional; MCA: Middle Cerebral Artery; ACoA: Anterior Communicating Artery; PCoA: Posterior Communicating Artery; aSAH: Aneurysmal Subarachnoid Hemorrhage; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; MINORS: Methodological Index For Non-Randomized Studies.
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http://dx.doi.org/10.1080/01616412.2018.1531202DOI Listing
January 2019