Publications by authors named "Jan-Karl Burkhardt"

203 Publications

Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort.

J Neurointerv Surg 2021 Nov 3. Epub 2021 Nov 3.

Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA

Background: Data regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches.

Methods: Prospectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011-2018). The pertinent clinical and radiographic data were collected and analyzed.

Results: 87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90-99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0-2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019).

Conclusion: FDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.
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http://dx.doi.org/10.1136/neurintsurg-2021-018224DOI Listing
November 2021

Adoption of Advanced Microneurosurgical Technologies: An International Survey.

World Neurosurg 2021 Oct 20. Epub 2021 Oct 20.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address:

Background: Operating microscopes and adjunctive technologies are continually refined to advance microneurosurgical care. How frequently these advances are used is unknown. In the present study, we assessed the international adoption of microneurosurgical technologies and discussed their value.

Methods: A 27-question electronic survey was distributed to cerebrovascular neurosurgeon members of U.S., European, and North American neurosurgical societies and social media networks of cerebrovascular and skull base neurosurgeons. The survey encompassed the surgeons' training background, surgical preferences, and standard microneurosurgical practices.

Results: Of the respondents, 56% (53 of 95) were attendings, 74% (70 of 95) were in their first 10 years of practice, and 67% (63 of 94) practiced at an academic teaching hospital. Vascular, endovascular, and skull base fellowships had been completed by 38% (36 of 95), 27% (26 of 95), and 32% (30 of 95) of the respondents, respectively. Most respondents did not use an exoscope (78%; 73 of 94), a mouthpiece (61%; 58 of 95), or foot pedals (56%; 55 of 94). All 95 respondents used a microscope, and 71 (75%) used Zeiss microscopes. Overall, 57 neurosurgeons (60%) used indocyanine green for aneurysms (n = 54), arteriovenous malformations (n = 43), and dural arteriovenous fistulas (n = 42). Most (80%; 75 of 94) did not use fluorescence. The respondents with a vascular-focused practice more commonly used indocyanine green, Yellow 560 fluorescence, and intraoperative 2-dimensional digital subtraction angiography. The respondents with a skull base-focused practice more commonly used foot pedals and an endoscope-assist device.

Conclusions: The results from the present survey have characterized the current adoption of operative microscopes and adjunctive technologies in microneurosurgery. Despite numerous innovations to improve the symbiosis between neurosurgeon and microscope, their adoption has been underwhelming. Future advances are essential to improve surgical outcomes.
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http://dx.doi.org/10.1016/j.wneu.2021.10.128DOI Listing
October 2021

Carotid artery revascularization using the Walrus balloon guide catheter: safety and feasibility from a US multicenter experience.

J Neurointerv Surg 2021 Oct 22. Epub 2021 Oct 22.

Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

Introduction: The Walrus balloon guide catheter (BGC) is a new generation of BGC, designed to eliminate conventional limitations during mechanical thrombectomy.

Objective: To report a multi-institutional experience using this BGC for proximal flow control (PFC) in the setting of carotid artery angioplasty/stenting (CAS) in elective (eCAS) and tandem strokes (tCAS).

Methods: Prospectively maintained databases at 8 North American centers were queried to identify patients with cervical carotid disease undergoing eCAS/tCAS with a Walrus BGC.

Results: 110 patients (median age 68, 64.6% male), 80 (72.7%) undergoing eCAS and 30 (27.3%) tCAS procedures, were included (median cervical carotid stenosis 90%; 46 (41.8%) with contralateral stenosis). Using a proximal flow-arrest technique in 95 (87.2%) and flow-reversal in 14 (12.8%) procedures, the Walrus was navigated into the common carotid artery successfully in all cases despite challenging arch anatomy (31, 28.2%), with preferred femoral access (103, 93.6%) and in monitored anesthesia care (90, 81.8%). Angioplasty and distal embolic protection devices (EPDs) were used in 91 (83.7%) and 58 (52.7%) procedures, respectively. tCAS led to a modified Thrombolysis in Cerebral Infarction 2b/3 in all cases. Periprocedural ischemic stroke (up to 30 days postoperatively) rate was 0.9% (n=1) and remote complications occurred in 2 (1.8%) cases. Last follow-up modified Rankin Scale score of 0-2 was seen in 95.3% of eCAS cohort, with no differences in complications in the eCAS subgroup between PFC only versus PFC and distal EPD (median follow-up 4.1 months).

Conclusion: Walrus BGC for proximal flow control is safe and effective during eCAS and tCAS. Procedural success was achieved in all cases, with favorable safety and functional outcomes on short-term follow-up.
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http://dx.doi.org/10.1136/neurintsurg-2021-018126DOI Listing
October 2021

Middle meningeal artery embolization for chronic subdural hematoma in cancer patients with refractory thrombocytopenia.

J Neurosurg 2021 Oct 8:1-5. Epub 2021 Oct 8.

5Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas.

Objective: Surgical evacuation of chronic subdural hematoma (SDH) in cancer patients is often contraindicated owing to refractory thrombocytopenia. Middle meningeal artery embolization (MMAE) recently emerged as a potential alternative to surgical evacuation for patients with chronic SDH. The goal of this study was to evaluate the safety and efficacy of MMAE for chronic SDH in cancer patients with refractory thrombocytopenia.

Methods: A multiinstitutional registry was reviewed for clinical and radiographic outcomes of cancer patients with transfusion-refractory thrombocytopenia and baseline platelet count < 75 K/µl, who underwent MMAE for chronic SDH.

Results: MMAE was performed on a total of 31 SDHs in 22 patients, with a mean ± SD (range) platelet count of 42.1 ± 18.3 (9-74) K/µl. At the longest follow-up, 24 SDHs (77%) had reduced in size, with 15 (48%) showing > 50% reduction. Two patients required surgical evacuation after MMAE. There was only 1 procedural complication; however, 16 patients (73%) ultimately died of cancer-related complications. Median survival was significantly longer in the 16 patients with improved SDH than the 6 patients with worsened SDH after MMAE (185 vs 24 days, p = 0.029). Length of procedure, technical success rate, SDH size reduction, and complication rate were not significantly differ between patients who underwent transfemoral and transradial approaches.

Conclusions: Transfemoral or transradial MMAE is a potential therapeutic option for thrombocytopenic cancer patients with SDH. However, treatment benefit may be marginal for patients with high disease burden and limited life expectancy. A prospective trial is warranted to address these questions.
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http://dx.doi.org/10.3171/2021.5.JNS21109DOI Listing
October 2021

Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study.

Neurosurgery 2021 Nov;89(6):1112-1121

Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: Open surgery has traditionally been preferred for the management of bifurcation middle cerebral artery (MCA) aneurysms. Flow diverting stents present a novel endovascular strategy for aneurysm treatment.

Objective: To add to the limited literature describing the outcomes and complications in the use of flow diverters for the treatment of these complex aneurysms.

Methods: This is a multicenter retrospective review of MCA bifurcation aneurysms undergoing flow diversion. We assessed post-treatment radiological outcomes and both thromboembolic and hemorrhagic complications.

Results: We reviewed the outcomes of 54 aneurysms treated with flow diversion. Four (7.4%) of the aneurysms had a history of rupture (3 remote and 1 acute). Fourteen (25.9%) of the aneurysms already underwent either open surgery or coiling prior to flow diversion. A total of 36 out of the 45 aneurysms (80%) with available follow-up data had adequate aneurysm occlusion with a median follow-up time of 12 mo. There were no hemorrhagic complications but 16.7% (9/54) had thromboembolic complications.

Conclusion: Flow diverting stents may be a viable option for the endovascular treatment of complex bifurcation MCA aneurysms. However, compared to published series on the open surgical treatment of this subset of aneurysms, flow diversion has inferior outcomes and are associated with a higher rate of complications.
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http://dx.doi.org/10.1093/neuros/nyab365DOI Listing
November 2021

Endovascular Transcarotid Artery Revascularization Using the Walrus Balloon Guide Catheter: Preliminary Experience.

World Neurosurg 2021 Dec 14;156:e175-e182. Epub 2021 Sep 14.

Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA. Electronic address:

Background: The Walrus Balloon Guided System Catheter is a new generation of balloon guide catheter (BGC) designed to bypass some technical limitations of conventional BGC devices. Their utility in cervical carotid disease treatment has not been reported. We report our preliminary experience in cervical carotid treatment using the Walrus BGC to perform a modified endovascular transcarotid artery revascularization technique.

Methods: Patients with cervical carotid disease undergoing endovascular treatment using the Walrus BGC at our institution were identified. The pertinent baseline demographics and procedural outcomes were collected and analyzed.

Results: Twelve patients were included (median age, 70; 58.3% females). All patients had an imaging-confirmed cervical carotid disease that indicated intervention: 6 with high-grade cervical arteriosclerotic carotid stenosis, 2 with intraluminal thrombi, 1 with traumatic carotid dissection, and 3 patients with cervical carotid tandem occlusion along with acute ischemic stroke secondary to large vessel occlusion that required mechanical thrombectomy. Carotid artery stenting was performed in all cases, except 2 of the 3 mechanical thrombectomy cases (angioplasty only). All patients had at least periprocedural follow-up of 30 days, with no stroke, myocardial infarction, or death encountered.

Conclusions: We describe a modified endovascular transcarotid artery revascularization technique. We used a standard femoral access to navigate the Walrus catheter in the common carotid artery, followed by balloon inflation for proximal flow arrest or flow reversal (when connected to the aspiration pump) to deploy the carotid stent across the stenosis, while avoiding distal external carotid artery balloon occlusion. Successful treatment was achieved in all cases, with no periprocedural complications encountered.
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http://dx.doi.org/10.1016/j.wneu.2021.09.026DOI Listing
December 2021

Endovascular cerebral aneurysm treatment volume during coronavirus 2019.

Interv Neuroradiol 2021 Sep 13:15910199211040278. Epub 2021 Sep 13.

Department of Neurosurgery, 12338University of Texas Medical Branch, USA.

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http://dx.doi.org/10.1177/15910199211040278DOI Listing
September 2021

Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience.

J Neurointerv Surg 2021 Aug 4. Epub 2021 Aug 4.

Department of Neurology, UTRGV School of Medicine, Harlingen, Texas, USA

Background: Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.

Objective: To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.

Methods: Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.

Results: A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2-20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3-14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.

Conclusion: Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.
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http://dx.doi.org/10.1136/neurintsurg-2021-017818DOI Listing
August 2021

Remodeling of the Posterior Cerebral Artery P1-Segment after Pipeline Flow Diverter Treatment of Posterior Communicating Artery Aneurysms.

Neurol Int 2021 May 7;13(2):195-201. Epub 2021 May 7.

Department of Radiology, Section of Interventional Neuroradiology, NYU Langone Medical Center, New York, NY 10016, USA.

Introduction: Flow diverters such as the pipeline embolization device (PED) cause hemodynamic changes of the treated vessel segment. In posterior communicating artery (PcomA), aneurysms' unique anatomic consideration have to be taken in account due to the connection between the anterior and posterior circulation. We hypothesize that in conjunction with PcomA remodeling, there will also be remodeling of the ipsilateral P1 segment of the posterior cerebral artery (PCA) after PED treatment for PcomA aneurysms.

Methods: We retrospectively collected radiological as well as clinical data of PcomA aneurysm patients treated with PED including PcomA and P1 vessel diameters before and after treatment as well as patient and aneurysm characteristics.

Results: Overall, 14 PcomA aneurysm patients were included for analysis and PED treatment was performed without complications in all patients. In 10 out of 14 patients (71%), a decrease in PcomA diameter was observed and there was a significant mean decrease of 0.78 mm in PcomA diameter on angiographic last follow-up (LFU) ( = 0.003). In the same patient population (10 out of 14 patients), there was meanwhile a significant mean increase of 0.43 mm in the ipsilateral P1 segment diameter observed ( = 0.015). These vessel remodeling effects were in direct correlation with aneurysm occlusion since all of these patients showed aneurysm occlusion at LFU while 29% showed only partial occlusion without vessel remodeling effects. A decrease in PcomA diameter was directly associated with aneurysm occlusion ( = 0.042). There were no neurologic complications on LFU.

Conclusion: In the treatment of PcomA aneurysms with PED, the P1 segment of the PCA increases in diameter while the PcomA diameter decreases. Our results suggest that this remodeling effect is associated with aneurysm occlusion and decrease of PcomA is hemodynamically compensated for by an increase in the ipsilateral P1 diameter.
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http://dx.doi.org/10.3390/neurolint13020020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162531PMC
May 2021

Comparison of Simultaneous Bilateral Internal Carotid Artery (ICA) 3-Dimensional Rotational Venography (3D-RV) versus Separate Bilateral ICA 3D-RV and Postprocessing 3D-3D Fusion.

World Neurosurg 2021 08 27;152:e201-e204. Epub 2021 May 27.

Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Preoperative venogram of the superior sagittal sinus (SSS) is helpful to plan the surgical resection strategy in patients with parasagittal meningiomas invading the SSS.

Methods: Catheter 3-dimensional rotational venography (3D-RV) allows for SSS patency assessment and detection of alternative venous cortical drainage routes in patients with contraindication for magnet resonance venography. It is unknown if separate bilateral internal carotid artery 3D-RV followed by postprocessing 3D-3D fusion (technique 1) achieves the same imaging results as simultaneous bilateral internal carotid artery 3D-RV without postprocessing fusion (technique 2) needed.

Results: In this report we were able to confirm in 2 patients that both techniques achieve comparable imaging quality with similar amount of contrast use.

Conclusions: Although technique 2 requires less radiation, technique 1 is favored due to the need for only 1 vessel access site and catheter with reduced risk for access site and ischemic complications.
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http://dx.doi.org/10.1016/j.wneu.2021.05.063DOI Listing
August 2021

Postmarket American Experience With Woven EndoBridge Device: Adjudicated Multicenter Case Series.

Neurosurgery 2021 07;89(2):275-282

Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.

Background: The Woven EndoBridge (WEB) device was granted premarket approval in the United States following results of the Woven EndoBridge Intrasaccular Therapy (WEB-IT) study. WEB-IT reported excellent adequate angiographic occlusion of treated aneurysms with a high safety profile. These results were achieved, however, in the context of a prospective study with strict inclusion criteria and rigorous training support.

Objective: To review early as-practiced clinical experience with the WEB device in the United States.

Methods: Retrospective review across 6 institutions identified 91 patients undergoing 92 treatment sessions for WEB device placement in treatment of 91 intracranial aneurysms. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database. Angiograms from the index procedure and follow-up studies were reviewed by a blinded and independent adjudicator.

Results: The middle cerebral, anterior communicating, and basilar artery complexes were the commonly treated locations. Eight patients presented with ruptured aneurysms. A mean of 1.2 devices were introduced per case. Technical failure without deployment of a WEB device occurred in 2% (2/92) of sessions. Complete aneurysm occlusion for patients with imaging follow-up was 49% (mean follow-up of 8 mo). Four aneurysms were retreated. 90% of patients had modified Rankin Scale ≤ 2 at last clinical follow-up with no mortalities.

Conclusion: Immediate postmarket experience with the WEB device, newly introduced at American centers, confirms safe procedural use, but long-term efficacy remains unclear. Early challenges include accurate sizing and device selection.
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http://dx.doi.org/10.1093/neuros/nyab158DOI Listing
July 2021

Flared non-flow diverting ends of the FRED flow diverter for cerebral aneurysms facilitate device anchoring at the arterial bifurcation.

Neuroradiol J 2021 Oct 4;34(5):521-524. Epub 2021 May 4.

Department of Neurosurgery, Geisinger, USA.

Introduction: The Flow Redirection Intraluminal Device (FRED) flow diverter has a unique bilayer design, with the outer scaffolding stent extending beyond the inner flow diverting component by about 3 mm at each end. Here, we describe a technique to utilize these unrestrained flared ends for precise flow diverter placement in cases where the aneurysm and an adjacent branch are in close proximity and branch jailing is not desired, such as in posterior communicating artery aneurysms. The distal end of the FRED device is pushed out of the microcatheter at the carotid terminus. Once the distal flared ends are fully open and well situated in the terminus, ideally with at least one of the limbs in the A1 segment of the anterior cerebral artery, the device is unsheathed under gentle forward pressure. This technique stabilizes the device at the distal landing zone and prevents unintended foreshortening at the distal end. This is particularly important for aneurysms located adjacent to the carotid terminus in order to assure adequate neck coverage, as well as avoiding jailing one of the branching parent arteries. An illustrative case is provided.

Conclusions: The non-flow diverting unrestrained flared ends of the FRED stabilize the distal end of the device when deployed directly into the branches at the arterial bifurcation. The technique is useful to provide adequate neck coverage of cerebral aneurysm located directly adjacent to the bifurcation as is frequently the case with posterior communicating artery aneurysms.
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http://dx.doi.org/10.1177/19714009211013508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559017PMC
October 2021

Foramen Magnum Dural Arteriovenous Fistula Presenting With Thoracic Myelopathy: Technical Case Report With 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jun;21(1):E55-E59

Background And Importance: Dural arteriovenous fistulas (dAVFs) are vascular abnormalities of the central nervous system that can cause a wide array of neurological dysfunction depending on their location, flow, and propensity to rupture. Symptomatic dAVFs at the cranio-cervical junction usually result in hemorrhage or cervical myelopathy. Distantly located dAVFs of the foramen magnum are a rare cause of thoracic intrinsic myelopathy.

Clinical Presentation: An 83-yr-old man presented with progressive lower extremity weakness, numbness, and difficulty walking along with episodes of bowel incontinence. Magnetic resonance imaging of the cervical spine demonstrated multilevel cervical disc disease with stenosis and longitudinal cervical cord signal change extending into the upper thoracic spinal cord. Cerebral and spinal angiography revealed a dAVF in the lateral foramen magnum region. Given the location, feeding vasculature, and morphology of the fistula, endovascular embolization was not attempted. Microsurgical resection with confirmative indocyanine green fluorescent imaging was performed with adequate obliteration of the fistula. The patient's neurological baseline was preserved postoperatively with improvement of lower extremity numbness.

Conclusion: We present a brief overview of this neuropathologic entity and demonstrate microsurgical resection of a foramen magnum dAVF through operative video. Craniocervical dAVFs should remain on the differential diagnosis of patients presenting with progressive thoracolumbar myelopathy.
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http://dx.doi.org/10.1093/ons/opab077DOI Listing
June 2021

Crossing the Carotid Siphon: Techniques to Facilitate Distal Access in Tortuous Anatomy: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 06;21(1):E41-E42

Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.

As capabilities for endovascular treatment of intracranial vascular pathologies continue to expand, the need for access to the distal internal carotid artery with rigid support catheter systems continues to increase. One of the dominant factors limiting this access is patient anatomy, specifically vessel tortuosity. Increased tortuosity of the carotid siphon is a frequently encountered anatomic variant and may complicate endovascular procedures in adults and children.1,2 Failed attempts to navigate the carotid siphon with a distal access catheter carry a risk of vessel injury and treatment failure. For this reason, techniques that aid in supporting safe advancement of a distal access catheter across a tortuous carotid siphon are essential.3,4 In this video, we demonstrate 2 ways in which this may be accomplished. The first technique uses a larger diameter microcatheter, such as the AXS Offset catheter (Stryker, Kalamazoo, Michigan), to increase support for the distal access catheter, while the second uses a buddy wire technique to accomplish this increased support. Both of these techniques can help increase the safety of navigating a tortuous carotid siphon and increase the likelihood of successful treatment.  The procedures shown were performed with the informed consent of the patients.
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http://dx.doi.org/10.1093/ons/opab084DOI Listing
June 2021

Double-barrel STA-MCA bypass for cerebral revascularization: lessons learned from a 10-year experience.

J Neurosurg 2021 Mar 19:1-9. Epub 2021 Mar 19.

4St. Luke's Health System, Boise, Idaho.

Objective: In select patients, extracranial-intracranial (EC-IC) bypass remains an important tool for cerebral revascularization. Traditionally, superficial temporal artery-middle cerebral artery (STA-MCA) bypass was performed using one limb of the STA only. In an attempt to augment flow and to direct flow to different ischemic areas of the brain, the authors adopted a "double-barrel" technique in which both branches of the STA are used to revascularize distinct MCA territories.

Methods: A series of consecutive double-barrel STA-MCA bypasses performed between 2010 and 2020 were reviewed. Each anastomosis was directed to augment flow to a territory most at risk based on preoperative perfusion studies, cerebral angiography, and intraoperative indocyanine green data. CT perfusion and CTA were routinely used to evaluate postoperative augmentation and graft patency. Patient perioperative outcomes, surgical complications, and modified Rankin Scale (mRS) scores at the last follow-up were reported.

Results: Forty-four patients (16 males, 28 females) successfully underwent double-barrel STA-MCA bypass on 54 cerebral hemispheres: 28 operations were for moyamoya disease, 23 for atherosclerotic disease refractory to medical therapy, 2 for complex cerebral aneurysms, and 1 for carotid occlusion as a sequela of cavernous meningioma growth. Ten patients underwent multiple operations, 9 of whom had moyamoya disease/syndrome, with the subsequent operation on the contralateral hemisphere. The average patient age at surgery was 45.1 years (range 14-73 years), with a mean follow-up time of 22.1 months. Intraoperative graft patency was confirmed in 100% of cases, and 101 (98.1%) of the 103 anastomoses with imaging follow-up were patent. Perfusion to the revascularized hemisphere was improved in 88.2% of cases. Perioperative ischemic and hemorrhagic complications occurred in 8 procedures (2 were asymptomatic), whereas remote ischemic and hemorrhagic events occurred in 7 cases. There was no mortality in the series, and the mean patient mRS scores were 1.72 at presentation and 1.15 at the last follow-up.

Conclusions: The high rates of intraoperative and postoperative patency support the feasibility of dual-anastomosis STA-MCA bypass for revascularization. The perioperative complication rate is not significantly different from that of single-anastomosis bypass. The functional outcomes at follow-up and perfusion improvement postoperatively support the efficacy and safety of this method as a treatment strategy.
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http://dx.doi.org/10.3171/2020.9.JNS201976DOI Listing
March 2021

Cavernous Malformation Surgery in the United States: Validation of a Novel International Classification of Disease, 10th Edition, Clinical Modification Code Search Algorithm and Volume-Driven Surgical Outcomes.

World Neurosurg 2021 06 25;150:e66-e73. Epub 2021 Feb 25.

Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA. Electronic address:

Objective: The surgical decision-making process for cavernous malformation (CM) must weigh the risks of surgery against the burden of patient symptoms/hemorrhage and anticipated natural history. Here, we sought to internally validate an International Classification of Disease (ICD)-10 search algorithm for CM surgery to use to analyze a nationwide administrative database.

Methods: Institutional records were accessed to test the validity of a novel ICD-10 search algorithm for CM surgery. The algorithm identified patients with positive predictive value (92%), specificity (100%), and sensitivity of 55%. The algorithm was applied to extract our target population from the Nationwide Readmissions Database. Univariate and multivariable analyses were used to identify factors influencing patient outcomes.

Results: We identified 1235 operations for supratentorial (87%) or infratentorial (13%) CM surgery from the Nationwide Readmissions Database (2016-2017). The overall rate of adverse disposition and 30-day readmission were 19.7% and 7.5%, respectively. The rate of adverse disposition was significantly higher for infratentorial (vs. supratentorial cases) (34.3% vs. 17.6%, P = 0.001) and brainstem (vs. cerebellar) cases (55% vs. 28%, P = 0.03). Hospital case-volume percentile was associated with decreasing rates of adverse disposition (1-74th: 22%, 75th: 16%, 90th: 13%, 95th: 7%). Treatment at HVCs was also associated with shorter average length of stay (4.6 vs. 7.3 days, P < 0.001) without significant changes to average cost of hospitalization (P = 0.60).

Conclusions: Our ICD-10 coding algorithm reliably identifies CM surgery with minimal false positives. Outcomes were influenced by patient age, clinical presentation, location of CM, and experience of institution. Centralization of care may improve outcomes and warrants further investigation.
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http://dx.doi.org/10.1016/j.wneu.2021.02.081DOI Listing
June 2021

Surgical selection and outcomes among elderly patients with brain arteriovenous malformations.

Neurosurg Focus 2020 10;49(4):E9

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Objective: Studies of resection of brain arteriovenous malformations (AVMs) in the elderly population are scarce. This study examined factors influencing patient selection and surgical outcome among elderly patients.

Methods: Patients 65 years of age and older who underwent resection of an unruptured or ruptured brain AVM treated by two surgeons at two centers were identified. Patient demographic characteristics, AVM characteristics, clinical presentation, and outcomes measured using the modified Rankin Scale (mRS) were analyzed. For subgroup analyses, patients were dichotomized into two age groups (group 1, 65-69 years old; group 2, ≥ 70 years old).

Results: Overall, 112 patients were included in this study (group 1, n = 61; group 2, n = 51). Most of the patients presented with hemorrhage (71%), a small nidus (< 3 cm, 79%), and a low Spetzler-Martin (SM) grade (grade I or II, 63%) and were favorable surgical candidates according to the supplemented SM grade (supplemented SM grade < 7, 79%). A smaller AVM nidus was statistically significantly more likely to be present in patients with infratentorial AVMs (p = 0.006) and with a compact AVM nidus structure (p = 0.02). A larger AVM nidus was more likely to be treated with preoperative embolization (p < 0.001). Overall outcome was favorable (mRS scores 0-3) in 71% of the patients and was statistically independent from age group or AVM grading. Patients with ruptured AVMs at presentation had significantly better preoperative mRS scores (p < 0.001) and more favorable mRS scores at the last follow-up (p = 0.04) than patients with unruptured AVMs.

Conclusions: Outcomes were favorable after AVM resection in both groups of patients. Elderly patients with brain AVMs treated microsurgically were notable for small nidus size, AVM rupture, and low SM grades. Microsurgical resection is an important treatment modality for elderly patients with AVMs, and supplemented SM grading is a useful tool for the selection of patients who are most likely to achieve good neurological outcomes after resection.

Abbreviations: AVM = arteriovenous malformation; BNI = Barrow Neurological Institute; LY = Lawton-Young; mRS = modified Rankin Scale; SM = Spetzler-Martin; supp-SM = supplemented SM; UCSF = University of California, San Francisco.
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http://dx.doi.org/10.3171/2020.7.FOCUS20464DOI Listing
October 2020

Distal Access Catheters for Coaxial Radial Access for Posterior Circulation Interventions.

World Neurosurg 2021 05 21;149:e1001-e1006. Epub 2021 Jan 21.

Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.

Background: The neurointerventional field is moving towards transradial access (TRA). Among the favorable indications for TRA is for posterior circulation/vertebrobasilar interventions. For some neurointerventions, a triaxial system (guide catheter, distal access catheter [DAC], and microcatheter) is typically used for optimal support. We describe application of a new technique in which we forgo use of the guide catheter, using the DAC only for coaxial access via the radial approach and its potential advantages.

Methods: A retrospective review was performed of our institutional database for cases using our coaxial distal access catheter technique for posterior circulation interventions. Patient characteristics and radiographic and clinical information were reviewed. All reviews were approved by institutional review board and ethics committee, and all patient identifiers were removed.

Results: A total of 12 patients were found that met our criteria. Successful access and procedural completion was achieved in 11 of 12 (92%). Mechanical thrombectomy accounted for 7 cases; 2 of these patients were also stented via the same approach/technique. Other cases included 2 successful aneurysm treatments (1 flow diverter, 1 coil embolization), a balloon test occlusion for a cervical chordoma, and an arteriovenous malformation embolization.

Conclusions: TRA with a distal access catheter provides support equivalent to a triaxial system with a coaxial construct in the posterior circulation. This has the advantage of using a smaller system in the radial and vertebrobasilar artery without losing stability. This technique can be used effectively and safely for a variety of posterior circulation neuroendovascular interventions.
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http://dx.doi.org/10.1016/j.wneu.2021.01.048DOI Listing
May 2021

Direct Carotid Puncture for Emergent Thrombectomy: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 01;20(2):E126-E127

Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas.

Emergent thrombectomy for large vessel occlusion is now a standard procedure within neurosurgery. In general, thrombectomy is attempted via a femoral artery puncture. However, due to anatomic variability and arterial tortuosity, target vessels cannot be catheterized in roughly 5% of patients.1 Radial artery access is an alternative to femoral artery access; however, target arteries for thrombectomy cannot be catheterized via the femoral or radial arteries in a small subset of patients. Direct carotid puncture is an alternative route of access for emergent thrombectomy in acute stroke.2,3 In this video, we present a patient with an acute right middle cerebral artery occlusion who was taken for emergent thrombectomy after consenting for the procedure. Because of unfavorable arterial anatomy, the right internal carotid artery could not be successfully catheterized via femoral or radial arterial punctures. We ultimately catheterized the right internal carotid artery and middle cerebral artery via a direct carotid puncture. We review the technique for direct carotid puncture, and discuss the outcomes associated with this method of access in the setting of acute large vessel occlusion. We also discuss complications associated with direct carotid puncture. Direct carotid puncture is an acceptable bail-out technique in the setting of emergent thrombectomy when femoral and/or radial access is not possible. Figure at 2:18 republished from Sekhar LN, Iwai Y, Wright DC, Bloom M. Vein graft replacement of the middle cerebral artery after unsuccessful embolectomy: case report. Neurosurgery. 1993;33(4):723-727, by permission of the Congress of Neurological Surgeons. Table at 6:05 modified from Roche A, Griffin E, Looby S, et al. Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke. J NeuroIntervent Surg. 2019;11(7):647-652, ©The Authors, 2019, with permission from Dr Sarah Power. Table at 6:22 reproduced from Jadkhav AP, Ribo M, Grandhi R, et al. Transcervical access in acute ischemic stroke. J NeuroIntervent Surg. 2014:6(9):652-657, ©2013, with permission from the BMJ Publishing Group Ltd.
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http://dx.doi.org/10.1093/ons/opaa379DOI Listing
January 2021

Forming the Simmons Catheter for Cerebral Angiography and Neurointerventions via the Transradial Approach-Techniques and Operative Videos.

World Neurosurg 2021 03 17;147:e351-e353. Epub 2020 Dec 17.

Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA. Electronic address:

Objective: Transradial access has been used increasingly for diagnostic cerebral angiography and neurointerventions. This requires development of a new skillset. Forming the Simmons catheter to catheterize the cerebral vessels is the most fundamental. Patient anatomy can complicate the formation of the Simmons catheter and the success of the procedure. The aim of this paper is to identify and describe the techniques that can be used transradially to facilitate the formation of the Simmons catheter for catheterization of the cerebral vessels.

Methods: We reviewed our series of 85 cerebral angiograms performed via a transradial approach at our institution between 2018 and 2019. We identified the techniques employed to form the Simmons catheter and compiled operative videos demonstrating each technique and its nuances.

Results: We have identified 7 techniques used to form the Simmons catheter from a right radial approach: in the ascending aorta, in the descending aorta, in the aortic arch, by deflecting the catheter off of the aortic valve with the glidewire in the common carotid artery, by deflecting the catheter off of the aortic valve with the glidewire in the descending aorta, and directly in the right or left common carotid arteries. We have identified that formation of the Simmons catheter from a left radial approach is most easily done in the descending aorta.

Conclusions: Transradial artery access has become increasingly common in cerebral angiography and neurointerventions. We describe techniques used for the formation of the Simmons catheter, a fundamental skill necessary for transradial cerebral angiogram or neurointervention.
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http://dx.doi.org/10.1016/j.wneu.2020.12.054DOI Listing
March 2021

Incidence and Outcome of Aneurysmal Subarachnoid Hemorrhage: The Swiss Study on Subarachnoid Hemorrhage (Swiss SOS).

Stroke 2021 01 4;52(1):344-347. Epub 2020 Dec 4.

Neuroradiology (L.R., M.D.), Kantonsspital Aarau Switzerland.

Background And Purpose: The purpose of this study was to assess nationwide incidence and outcomes of aneurysmal subarachnoid hemorrhage (aSAH). The Swiss SOS (Swiss Study on Subarachnoid Hemorrhage) was established in 2008 and offers the unique opportunity to provide this data from the point of care on a nationwide level.

Methods: All patients with confirmed aneurysmal subarachnoid hemorrhage admitted between January 1, 2009 and December 31, 2014, within Switzerland were recorded in a prospective registry. Incidence rates were calculated based on time-matched population data. Admission parameters and outcomes at discharge and at 1 year were recorded.

Results: We recorded data of 1787 consecutive patients. The incidence of aneurysmal subarachnoid hemorrhage in Switzerland was 3.7 per 100 000 persons/y. The number of female patients was 1170 (65.5%). With a follow-up rate of 91.3% at 1 year, 1042 patients (58.8%) led an independent life according to the modified Rankin Scale (0-2). About 1 in 10 patients survived in a dependent state (modified Rankin Scale, 3-5; n=185; 10.4%). Case fatality was 20.1% (n=356) at discharge and 22.1% (n=391) after 1 year.

Conclusions: The current incidence of aneurysmal subarachnoid hemorrhage in Switzerland is lower than expected and an indication of a global trend toward decreasing admissions for ruptured intracranial aneurysms. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03245866.
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http://dx.doi.org/10.1161/STROKEAHA.120.029538DOI Listing
January 2021

Ambulatory neurosurgery in the COVID-19 era: patient and provider satisfaction with telemedicine.

Neurosurg Focus 2020 12;49(6):E13

2Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas.

Objective: Telemedicine has rapidly expanded in the recent years as technologies have afforded healthcare practitioners the ability to diagnose and treat patients remotely. Due to the COVID-19 pandemic, nonessential clinical visits were greatly limited, and much of the outpatient neurosurgical practice at the authors' institution was shifted quickly to telehealth. Although there are prior data suggesting that the use of telemedicine is satisfactory in other surgical fields, data in neurosurgery are limited. This study aimed to investigate both patient and provider satisfaction with telemedicine and its strengths and limitations in outpatient neurosurgery visits.

Methods: This quality improvement study was designed to analyze provider and patient satisfaction with telemedicine consultations in an outpatient neurosurgery clinic setting at a tertiary care, large-volume, academic center. The authors designed an 11-question survey for neurosurgical providers and a 13-question survey for patients using both closed 5-point Likert scale responses and multiple choice responses. The questionnaires were administered to patients and providers during the period when the clinic restricted in-person visits. At the conclusion of the study, the overall data were analyzed qualitatively and quantitatively.

Results: During the study period, 607 surveys were sent out to patients seen by telehealth at the authors' academic center, and 122 responses were received. For the provider survey, 85 surveys were sent out to providers at the authors' center and other academic centers, and 40 surveys were received. Ninety-two percent of patients agreed or strongly agreed that they were satisfied with that particular telehealth visit. Eighty-eight percent of patients agreed that their telehealth visit was more convenient for them than an in-person visit, but only 36% of patients stated they would like their future visits to be telehealth. Sixty-three percent of providers agreed that telehealth visits were more convenient for them than in-person visits, and 85% of responding providers stated that they wished to incorporate telehealth into their future practice.

Conclusions: Although the authors' transition to telehealth was both rapid and unexpected, most providers and patients reported positive experiences with their telemedicine visits and found telemedicine to be an effective form of ambulatory neurosurgical care. Not all patients preferred telemedicine visits over in-person visits, but the high satisfaction with telemedicine by both providers and patients is promising to the future expansion of telehealth in ambulatory neurosurgery.
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http://dx.doi.org/10.3171/2020.9.FOCUS20596DOI Listing
December 2020

Endoscopic endonasal transsphenoidal direct access and Onyx embolization of a dural arteriovenous fistula mimicking a carotid-cavernous fistula: case report.

J Neurosurg 2020 Nov 13:1-5. Epub 2020 Nov 13.

1Department of Neurosurgery and.

The classic presentation of a carotid-cavernous fistula (CCF) is unilateral painful proptosis, chemosis, and vision loss. Just as the goal of treatment for a dural arteriovenous fistula (dAVF) is obliteration of the entire fistulous connection and the proximal draining vein, the modern treatment of CCF is endovascular occlusion of the cavernous sinus via a transvenous or transarterial route. Here, the authors present the case of a woman with a paracavernous dAVF mimicking the clinical and radiographic presentation of a CCF. Without any endovascular route available to access the fistulous connection and venous drainage, the authors devised a novel direct hybrid approach by performing an endoscopic endonasal transsphenoidal direct puncture and Onyx embolization of the fistula.
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http://dx.doi.org/10.3171/2020.7.JNS201737DOI Listing
November 2020

Unruptured Giant Intracranial Aneurysms: Risk Factors for Mortality and Long-Term Outcome.

Transl Stroke Res 2021 08 9;12(4):593-601. Epub 2020 Nov 9.

Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.

This study aims to investigate the long-term outcomes of unruptured giant intracranial aneurysms (GIAs) with different treatment modalities and to analyze the factors affecting prognosis. We performed a retrospective medical record review of patients with unruptured GIAs treated at our institution from 2011 to 2018. Prognosis was compared to the best medical treatment without intervention (conservative treatment, CT) and surgical (ST) or endovascular (ET) treatment. Risk factors for mortality were investigated. A total of 276 patients were included in this study. Patients received CT in 16.3%, ST in 30.1%, and ET in 53.6% of cases. After an average 7-year follow-up, the rupture rate after CT was 22.2%, accounting for an annual rupture rate of 7.3%. The postoperative complication rate was 30.1% and 8.1% after ST and ET, respectively. The recurrence rate after ET was 10.1%, compared with ST which was 1.2%. The follow-up mortality in unruptured GIAs was 26.7% after CT, 7.2% after ST, and 5.4% after ET. Older age (50~59, HR 5.877; 60~69, HR 8.565), size ≥ 40 mm (HR 3.916), and posterior circulation location (HR 6.411) were associated with increased mortality. ET significantly decreased mortality (HR 0.191). Unruptured GIAs warrant treatment if feasible due to the high rupture rate and mortality of the natural history. Older age, posterior circulation location, and larger size are risk factors for poor prognosis. Both ST and ET showed a lower mortality rate than CT. ST showed less likely recurrence compared to ET, while ET had a lower complication rate than ST.
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http://dx.doi.org/10.1007/s12975-020-00861-6DOI Listing
August 2021

Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes.

J Neurosurg 2020 Nov 6:1-9. Epub 2020 Nov 6.

5Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Objective: Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment option for patients with moyamoya disease (MMD), intracranial arteriosclerotic disease (ICAD) with symptomatic stenosis despite the best medical management, and complex aneurysms. The therapeutic benefit of cerebral bypass surgery depends on optimal patient selection and the minimization of periprocedural complications. The nationwide burden of readmissions and associated complications following EC-IC bypass surgery has not been previously described. Therefore, the authors sought to analyze a nationwide database to describe the national rates, causes, risk factors, complications, and morbidity associated with readmission following EC-IC bypass surgery for MMD, ICAD, and aneurysms.

Methods: The Nationwide Readmissions Database (NRD) was queried for the years 2010-2014 to identify patients who had undergone EC-IC bypass for MMD, medically failed symptomatic ICAD, or unruptured aneurysms. Predictor variables included demographics, preexisting comorbidities, indication for surgery, and hospital bypass case volume. A high-volume center (HVC) was defined as one that performed 10 or more cases/year. Outcome variables included perioperative stroke, discharge disposition, length of stay, total hospital costs, and readmission (30 days, 90 days). Multivariable analysis was used to identify predictors of readmission and to study the effect of treatment at HVCs on quality outcomes.

Results: In total, 2500 patients with a mean age of 41 years were treated with EC-IC bypass surgery for MMD (63.1%), ICAD (24.5%), or unruptured aneurysms (12.4%). The 30- and 90-day readmission rates were 7.5% and 14.0%, respectively. Causes of readmission included new stroke (2.5%), wound complications (2.5%), graft failure (1.5%), and other infection (1.3%). In the multivariable analysis, risk factors for readmission included Medicaid/self-pay (OR 1.6, 95% CI 1.1-2.4, vs private insurance), comorbidity score (OR 1.2, 95% CI 1.1-1.4, per additional comorbidity), and treatment at a non-HVC (OR 1.9, 95% CI 1.1-3.0). Treatment at an HVC (17% of patients) was associated with significantly lower rates of nonroutine discharge dispositions (13.4% vs 26.7%, p = 0.004), ischemic stroke within 90 days (0.8% vs 2.9%, p = 0.03), 30-day readmission (3.9% vs 8.2%, p = 0.03), and 90-day readmission (8.6% vs 15.2%, p = 0.01). These findings were confirmed in a multivariable analysis. The authors estimate that centralization to HVCs may result in 333 fewer nonroutine discharges (50% reduction), 12,000 fewer hospital days (44% reduction), 165 fewer readmissions (43%), and a cost savings of $15.3 million (11% reduction).

Conclusions: Readmission rates for patients after EC-IC bypass are comparable with those after other common cranial procedures and are primarily driven by preexisting comorbidities, socioeconomic status, and treatment at low-volume centers. Periprocedural complications, including stroke, graft failure, and wound complications, occurred at the expected rates, consistent with those in prior clinical series. The centralization of care may significantly reduce perioperative complications, readmissions, and hospital resource utilization.
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November 2020

Clinical outcomes after revascularization for pediatric moyamoya disease and syndrome: A single-center series.

J Clin Neurosci 2020 Sep 19;79:137-143. Epub 2020 Aug 19.

Departments of Neurology and Pediatrics, University of California, San Francisco, CA, USA. Electronic address:

Moyamoya is a progressive cerebrovascular arteriopathy that affects children of any age. The goal of this study was to determine imaging and clinical outcomes as well as complication rates in a pediatric cohort undergoing either a combined direct/indirect or indirect-only revascularization approach. Patients with moyamoya disease or syndrome ≤ 18 years of age at the time of initial surgery were identified, and clinical data were collected retrospectively. Over a 12-year period, 26 patients underwent revascularization procedures on 49 hemispheres with a median follow-up of 2.6 years from surgery. Median age at surgery was 7.3 years (range 1.4-18.0 years). Thirty-three hemispheres (67.3%) underwent combined revascularization with a direct bypass and encephalomyosynangiosis, and sixteen hemispheres (32.7%) underwent indirect-only revascularization. The rate of 30-day perioperative complication was 10.2%, and the rate of postoperative clinical stroke by end of follow-up was 10.2% by hemisphere. There was a 5.7% rate of intraoperative bypass failure requiring conversion to an indirect revascularization approach. On follow-up imaging, 96.9% of direct bypasses remained patent. On multivariate analysis, higher preoperative Pediatric Stroke Outcome Measure (PSOM) scores were associated with lower rates of good clinical outcome on follow-up (unit OR 0.03; p = 0.03). Patients with age < 5.4 years had lower rates of good clinical outcome on follow-up. In this North American cohort, both combined direct/indirect and indirect only revascularization techniques were feasible. However, younger children < 5.4 years of age have worse outcomes than older children, similar to east Asian cohorts.
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http://dx.doi.org/10.1016/j.jocn.2020.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573194PMC
September 2020

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations.

Neurosurgery 2021 01;88(2):268-277

Department of Neurological Surgery, University of Washington, Seattle, Washington.

Background: Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH).

Objective: To determine the safety and efficacy of MMA embolization.

Methods: Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes.

Results: A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities.

Conclusion: MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.
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http://dx.doi.org/10.1093/neuros/nyaa379DOI Listing
January 2021

Development of a Complication- and Treatment-Aware Prediction Model for Favorable Functional Outcome in Aneurysmal Subarachnoid Hemorrhage Based on Machine Learning.

Neurosurgery 2021 01;88(2):E150-E157

Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.

Background: Current prognostic tools in aneurysmal subarachnoid hemorrhage (aSAH) are constrained by being primarily based on patient and disease characteristics on admission.

Objective: To develop and validate a complication- and treatment-aware outcome prediction tool in aSAH.

Methods: This cohort study included data from an ongoing prospective nationwide multicenter registry on all aSAH patients in Switzerland (Swiss SOS [Swiss Study on aSAH]; 2009-2015). We trained supervised machine learning algorithms to predict a binary outcome at discharge (modified Rankin scale [mRS] ≤ 3: favorable; mRS 4-6: unfavorable). Clinical and radiological variables on admission ("Early" Model) as well as additional variables regarding secondary complications and disease management ("Late" Model) were used. Performance of both models was assessed by classification performance metrics on an out-of-sample test dataset.

Results: Favorable functional outcome at discharge was observed in 1156 (62.0%) of 1866 patients. Both models scored a high accuracy of 75% to 76% on the test set. The "Late" outcome model outperformed the "Early" model with an area under the receiver operator characteristics curve (AUC) of 0.85 vs 0.79, corresponding to a specificity of 0.81 vs 0.70 and a sensitivity of 0.71 vs 0.79, respectively.

Conclusion: Both machine learning models show good discrimination and calibration confirmed on application to an internal test dataset of patients with a wide range of disease severity treated in different institutions within a nationwide registry. Our study indicates that the inclusion of variables reflecting the clinical course of the patient may lead to outcome predictions with superior predictive power compared to a model based on admission data only.
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http://dx.doi.org/10.1093/neuros/nyaa401DOI Listing
January 2021

Trends in academic productivity in the COVID-19 era: analysis of neurosurgical, stroke neurology, and neurointerventional literature.

J Neurointerv Surg 2020 Nov 30;12(11):1049-1052. Epub 2020 Sep 30.

Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA

Background: Academic physicians aim to provide clinical and surgical care to their patients while actively contributing to a growing body of scientific literature. The coronavirus disease 2019 (COVID-19) pandemic has resulted in procedural-based specialties across the United States witnessing a sharp decline in their clinical volume and surgical cases.

Objective: To assess the impact of COVID-19 on neurosurgical, stroke neurology, and neurointerventional academic productivity.

Methods: The study compared the neurosurgical, stroke neurology, and neurointerventional academic output during the pandemic lockdown with the same time period in previous years. Editors from a sample of neurosurgical, stroke neurology, and neurointerventional journals provided the total number of original manuscript submissions, broken down by months, from the year 2016 to 2020. Manuscript submission was used as a surrogate metric for academic productivity.

Results: 8 journals were represented. The aggregated data from all eight journals as a whole showed that a combined average increase of 42.3% was observed on original submissions for 2020. As the average yearly percent increase using the 2016-2019 data for each journal exhibited a combined average increase of 11.2%, the rise in the yearly increase for 2020 in comparison was nearly fourfold. For the same journals in the same time period, the average percent of COVID-19 related publications from January to June of 2020 was 6.87%.

Conclusion: There was a momentous increase in the number of original submissions for the year 2020, and its effects were uniformly experienced across all of our represented journals.
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http://dx.doi.org/10.1136/neurintsurg-2020-016710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528313PMC
November 2020

Comparison of First-Pass Efficacy Among Four Mechanical Thrombectomy Techniques: A Single-Center Experience.

World Neurosurg 2020 12 3;144:e533-e540. Epub 2020 Sep 3.

Department of Neurology, Baylor College of Medicine, Houston, Texas, USA.

Background: First-pass efficacy (FPE) is an established marker of technical and clinical efficacy among mechanical thrombectomy (MT) techniques. It is unclear what the optimal approach is in achieving FPE. We present a single-center experience comparing rates of FPE among 2 MT techniques and evaluate the potential predictors of FPE among other outcomes.

Methods: A single-center retrospective analysis was carried out of patients with consecutive large-vessel occlusion strokes (LVOS) of anterior circulation from September 2015 to April 2019 who underwent MT and for whom data were available on the status of FPE. Four MT techniques were identified: ADAPT (a direct first-pass aspiration), SrADAPT (stent retriever with aspiration), SRBG (stent retriever with balloon guide catheter), and STRAP (stent retriever-aspiration and proximal flow arrest). The primary outcome was FPE and secondary outcomes included the rate of successful reperfusion.

Results: Among 226 patients with LVOS of the anterior circulation who underwent MT, data were available for 164 on FPE for the 4 MT techniques. SRBG was the most prevalent technique. No significant difference was found in rates of FPE among the 4 MT techniques (P = 0.332). No independent predictors of FPE were identified on multivariable analysis. STRAP had the highest rate of successful reperfusion compared with the other techniques (P = 0.049) and was the only independent predictor of that outcome (P = 0.027).

Conclusions: Among patients with LVOS of the anterior circulation, the rate of FPE did not differ among the 4 MT techniques. There were no predictors of FPE among the studied variables. STRAP was the only predictor of successful reperfusion.
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http://dx.doi.org/10.1016/j.wneu.2020.08.209DOI Listing
December 2020
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