Publications by authors named "Kai U Frerichs"

44 Publications

Direct vs Indirect Revascularization in a North American Cohort of Moyamoya Disease.

Neurosurgery 2021 May 6. Epub 2021 May 6.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: In adults with ischemic moyamoya disease (MMD), the efficacy of direct vs indirect revascularization procedures remains a matter of debate.

Objective: To investigate the outcomes of ischemic MMD in a North American cohort treated by direct and indirect revascularizations.

Methods: We retrospectively reviewed medical records of adult patients with MMD with ischemic presentation from 1984 to 2018 at the Brigham and Women's Hospital and Massachusetts General Hospital who underwent either direct or indirect bypasses. Early postoperative events and outcome at more than 6 mo postoperatively were evaluated using multivariable logistic regression analyses. Multivariable Cox proportional hazards regression analyses were used to evaluate delayed ischemic and hemorrhagic events. Analyses were performed per hemisphere.

Results: A total of 95 patients with MMD and 127 hemispheres were included in this study. A total of 3.5% and 8.6% of patients had early surgical complications in the direct and indirect bypass cohorts, respectively (P = .24). Hemispheres with direct bypasses had fewer long-term ischemic and hemorrhagic events at latest follow-up (adjusted hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.058-0.63, P = .007; median follow-up 4.5 [interquartile range, IQR 1-8] yr). There was no difference between the direct and indirect bypass groups when the endpoint was limited to infarction and hemorrhage only (P = .12). There was no difference in outcome (modified Rankin Scale [mRS] ≥ 3) between the 2 cohorts (P = .92).

Conclusion: There was no difference in early postoperative events, long-term infarction or hemorrhage, or clinical outcome between direct and indirect revascularization. However, there was a significant decrease in all ischemic and hemorrhagic events combined in direct revascularizations compared to indirect revascularizations.
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http://dx.doi.org/10.1093/neuros/nyab156DOI Listing
May 2021

Familial Predisposition and Differences in Radiographic Patterns in Spontaneous Nonaneurysmal Subarachnoid Hemorrhage.

Neurosurgery 2021 01;88(2):413-419

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Subarachnoid hemorrhage (SAH) from an intracranial aneurysmal rupture is the most common nontraumatic etiology for SAH, but up to 15% of patients with SAH have no identifiable source.

Objective: To assess familial predisposition to spontaneous nonaneurysmal SAH (naSAH) and to evaluate whether family history affects the severity of presentation and prognosis of this condition.

Methods: We conducted a retrospective analysis of all spontaneous SAH with negative digital subtraction angiography from 2004 to 2018. Patients were divided into 2 groups: patients with first- or second-degree relatives with intracranial aneurysms and patients with no family history. Univariate and multivariate regression analyses were used to study patient presentation, radiographic patterns of hemorrhage, and clinical outcome.

Results: A total of 100 patients met the inclusion criteria. There were no individuals with family history of naSAH. A total of 15 patients (15%) had at least one family member with an intracranial aneurysm, of which 12 (12%) presented as SAH. Patients without family history had a higher percentage of perimesencephalic presentation, whereas those with family history had a higher percentage of nonperimesencephalic SAH presentation (47% vs 13%, odds ratio [OR] 0.17 [95% CI 0.04, 0.81]).

Conclusion: We found a high rate of family history of intracranial aneurysms in patients who presented with naSAH. Although there was no difference in clinical outcome in patients with and without family history, there appears to be a higher percentage of nonperimesencephalic radiographic patterns of SAH in those with family history, suggesting possible different etiologies of these hemorrhages.
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http://dx.doi.org/10.1093/neuros/nyaa396DOI Listing
January 2021

Insulin in the Management of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

World Neurosurg 2020 Apr 16;136:e514-e534. Epub 2020 Jan 16.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: The role of tight glycemic control in the management of acute ischemic stroke remains uncertain. Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke.

Methods: We searched PubMed, CENTRAL, and Embase for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70-135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed-effects and random-effects models. Outcomes were death, independence, and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment.

Results: Twelve RCTs including 2734 patients were included. Compared with conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99; 95% confidence interval [CI], 0.79-1.22]; I = 0%), independence at ≥90 days follow-up (pOR, 0.95; 95% CI, 0.79-1.14; I = 0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014; 95% CI, -0.15 to 0.17; I = 0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR, 5.2; 95% CI, 1.7-15.9; I = 28%).

Conclusions: Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence, or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.
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http://dx.doi.org/10.1016/j.wneu.2020.01.056DOI Listing
April 2020

Predictive Score of Adverse Events After Carotid Endarterectomy: The NSQIP Registry Carotid Endarterectomy Scale.

J Am Heart Assoc 2019 11 30;8(21):e013412. Epub 2019 Oct 30.

Department of Neurosurgery Brigham and Women's Hospital Harvard Medical School Boston MA.

Background The goal of this study was to create a comprehensive, integer-weighted predictive scale of adverse events after carotid endarterectomy (CEA), which may augment risk stratification and patient counseling. Methods and Results The targeted carotid files from the prospective NSQIP (National Surgical Quality Improvement Program) registry (2011-2013) comprised the derivation population. Multivariable logistic regression evaluated predictors of a 30-day adverse event (stroke, myocardial infarction, or death), the effect estimates of which were used to build a weighted predictive scale that was validated using the 2014 to 2015 NSQIP registry release. A total of 10 766 and 8002 patients were included in the derivation and the validation populations, in whom 4.0% and 3.7% developed an adverse event, respectively. The NSQIP registry CEA scale included 14 variables; the highest points were allocated for insulin-dependent diabetes mellitus, high-risk cardiac physiological characteristics, admission source other than home, an emergent operation, American Society of Anesthesiologists' classification IV to V, modified Rankin Scale score ≥2, and presentation with a stroke. NSQIP registry CEA score was predictive of an adverse event (concordance=0.67), stroke or death (concordance=0.69), mortality (concordance=0.76), an extended hospitalization (concordance=0.73), and a nonroutine discharge (concordance=0.83) in the validation population, as well as among symptomatic and asymptomatic subgroups (<0.001). In the validation population, patients with an NSQIP registry CEA scale score >8 and 17 had 30-day stroke or death rates >3% and 6%, the recommended thresholds for asymptomatic and symptomatic patients, respectively. Conclusions The NSQIP registry CEA scale predicts adverse outcomes after CEA and can risk stratify patients with both symptomatic and asymptomatic carotid stenosis using different thresholds for each population.
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http://dx.doi.org/10.1161/JAHA.119.013412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6898838PMC
November 2019

Periprocedural intracranial hemorrhage after embolization of cerebral arteriovenous malformations: a meta-analysis.

J Neurosurg 2019 Sep 13:1-11. Epub 2019 Sep 13.

1Department of Neurological Surgery, Brigham and Women's Hospital.

Objective: The primary goal of the treatment of cerebral arteriovenous malformations (AVMs) is angiographic occlusion to eliminate future hemorrhage risk. Although multimodal treatment is increasingly used for AVMs, periprocedural hemorrhage after transarterial embolization is a potential endovascular complication that is only partially understood and merits quantification.

Methods: Searching the period between 1990 and 2019, the authors of this meta-analysis queried the PubMed and Embase databases for studies reporting periprocedural hemorrhage (within 30 days) after liquid embolization (using cyanoacrylate or ethylene vinyl alcohol copolymer) of AVMs. Random effects meta-analysis was used to evaluate the pooled rate of flow-related hemorrhage (those attributed to alterations in AVM dynamics), technical hemorrhage (those related to procedural complications), and total hemorrhage. Meta-regression was used to analyze the study-level predictors of hemorrhage, including patient age, Spetzler-Martin grade, hemorrhagic presentation, embolysate used, intent of treatment (adjuvant vs curative), associated aneurysms, endovascular angiographic obliteration, year of study publication, and years the procedures were performed.

Results: A total of 98 studies with 8009 patients were included in this analysis, and the mean number of embolization sessions per patient was 1.9. The pooled flow-related and total periprocedural hemorrhage rates were 2.0% (95% CI 1.5%-2.4%) and 2.6% (95% CI 2.1%-3.0%) per procedure and 3.4% (95% CI 2.6%-4.2%) and 4.8% (95% CI 4.0%-5.6%) per patient, respectively. The mortality and morbidity rates associated with hemorrhage were 14.6% and 45.1%, respectively. Subgroup analyses revealed a pooled total hemorrhage rate per procedure of 1.8% (95% CI 1.0%-2.5%) for adjuvant (surgery or radiosurgery) and 4.6% (95% CI 2.8%-6.4%) for curative intent. The treatment of aneurysms (p = 0.04) and larger patient populations (p < 0.001) were significant predictors of a lower hemorrhage rate, whereas curative intent (p = 0.04), angiographic obliteration achieved endovascularly (p = 0.003), and a greater number of embolization sessions (p = 0.03) were significant predictors of a higher hemorrhage rate. There were no significant differences in periprocedural hemorrhage rates according to the years evaluated or the embolysate utilized.

Conclusions: In this study-level meta-analysis, periprocedural hemorrhage was seen after 2.6% of transarterial embolization procedures for cerebral AVMs. The adjuvant use of endovascular embolization, including in the treatment of associated aneurysms and in the presurgical or preradiosurgical setting, was a study-level predictor of significantly lower hemorrhage rates, whereas more aggressive embolization involving curative intent and endovascular angiographic obliteration was a predictor of a significantly higher total hemorrhage rate.
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http://dx.doi.org/10.3171/2019.5.JNS183204DOI Listing
September 2019

Age-Dependent Radiographic Vasospasm and Delayed Cerebral Ischemia in Women After Aneurysmal Subarachnoid Hemorrhage.

World Neurosurg 2019 Oct 13;130:e230-e235. Epub 2019 Jun 13.

Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: Recent literature suggests there are sex differences in delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Our study serves to compare sex differences in radiographic vasospasm, DCI, and clinical outcome after aSAH, and to determine whether there are age-dependent differences.

Methods: A total of 328 patients with ruptured cerebral aneurysms were evaluated for radiographic vasospasm, clinical deterioration, cerebral infarction, and modified Rankin Scale-determined clinical outcome at 6 months to 1 year after rupture. Multivariate regression analyses were performed to evaluate the associations between these outcome measures and sex, adjusting for age, hypertension, aneurysm location, admission Hunt and Hess grade, and modified Fisher grade.

Results: After multivariate adjustment, women had higher rates of radiographic vasospasm (β = 0.35; 95% confidence interval [CI], 0.068-0.63; P = 0.015), clinical deterioration (odds ratio [OR], 2.8; 95% CI, 1.3-6.0; P = 0.008) and cerebral infarction (OR, 2.4; 95% CI, 1.0-5.5; P = 0.039), but no difference was observed in follow-up modified Rankin Scale (mRS) outcome score at 6 months to 1 year (P = 0.96). Older women (age >55 years) have a higher rate of clinical deterioration than men in the same age group (OR, 3.5; 95% CI, 1.0-12; P = 0.043). In contrast, younger women (age ≤55 years) had increased radiographic vasospasm (β = 0.55; 95% CI, 0.17-0.93; P = 0.005) and worse mRS outcome score (β = 0.042; 95% CI, -0.021 to 1.1; P = 0.042) compared with men.

Conclusions: Female sex is associated with a higher risk of radiographic vasospasm, clinical deterioration, and cerebral infarction. Furthermore, this association appears to be age-dependent. This study further supports the unique role of sex, and highlights the need to better understand the possible role of female hormones in the development of complications of subarachnoid hemorrhage.
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http://dx.doi.org/10.1016/j.wneu.2019.06.040DOI Listing
October 2019

Frameless Stereotactic Navigation during Insular Glioma Resection using Fusion of Three-Dimensional Rotational Angiography and Magnetic Resonance Imaging.

World Neurosurg 2019 Jun 18;126:322-330. Epub 2019 Mar 18.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: Perioperative cerebral infarction is a potential complication of glioma resection, of which insular tumors are at higher risk because of the proximity of middle cerebral artery branches, including the lateral lenticulostriates and long insular arteries. In this study, 3 patients received three-dimensional rotational angiography, which was fused with magnetic resonance imaging (MRI) for frameless stereotactic navigation during dominant-hemisphere insular glioma resection.

Methods: All patients obtained a preoperative catheter angiogram with a three-dimensional rotational acquisition of the ipsilateral internal carotid artery. The pixel-based axial three-dimensional angiography data, thin-cut structural MRI, tractography from diffusion tensor imaging, and expressive language activation from functional MRI were uploaded into the iPlan software (Brainlab, Heimstetten, Germany) and fused. The target tumor, regional blood vessels, adjacent functional areas, and their associated fiber tracts were segmented and overlaid on the appropriate MRI sequence. This image fusion was used preoperatively to visualize the relationship of the mass with the adjacent vasculature and intraoperatively for frameless stereotactic navigation to optimize preservation of arterial structures.

Results: Three patients aged 27-60 years with excellent baseline functional status presented with seizures and were found to have a large dominant-hemisphere T2 hyperintense nonenhancing insular mass. Surgical resection was performed using multimodality neuronavigation. None sustained a postoperative arterial infarction or a perioperative neurologic deficit.

Conclusions: Neuronavigation using a fusion of three-dimensional rotational angiography with MRI is a technique that can be used for preoperative planning and during resection of insular gliomas to optimize preservation of adjacent arteries.
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http://dx.doi.org/10.1016/j.wneu.2019.03.096DOI Listing
June 2019

Adverse events after clipping of unruptured intracranial aneurysms: the NSQIP unruptured aneurysm scale.

J Neurosurg 2019 Mar 15;132(4):1123-1132. Epub 2019 Mar 15.

Objective: The complex decision analysis of unruptured intracranial aneurysms entails weighing the benefits of aneurysm repair against operative risk. The goal of the present analysis was to build and validate a predictive scale that identifies patients with the greatest odds of a postsurgical adverse event.

Methods: Data on patients who underwent surgical clipping of an unruptured aneurysm were extracted from the prospective National Surgical Quality Improvement Program registry (NSQIP; 2007-2014); NSQIP does not systematically collect data on patients undergoing intracranial endovascular intervention. Multivariable logistic regression evaluated predictors of any 30-day adverse event; variables screened included patient demographics, comorbidities, functional status, preoperative laboratory values, aneurysm location/complexity, and operative time. A predictive scale was constructed based on statistically significant independent predictors, which was validated using both NSQIP (2015-2016) and the Nationwide Inpatient Sample (NIS; 2002-2011).

Results: The NSQIP unruptured aneurysm scale was proposed: 1 point was assigned for a bleeding disorder; 2 points for age 51-60 years, cardiac disease, diabetes mellitus, morbid obesity, anemia (hematocrit < 36%), operative time 240-330 minutes; 3 points for leukocytosis (white blood cell count > 12,000/μL) and operative time > 330 minutes; and 4 points for age > 60 years. An increased score was predictive of postoperative stroke or coma (NSQIP: p = 0.002, C-statistic = 0.70; NIS: p < 0.001, C-statistic = 0.61), a medical complication (NSQIP: p = 0.01, C-statistic = 0.71; NIS: p < 0.001, C-statistic = 0.64), and a nonroutine discharge (NSQIP: p < 0.001, C-statistic = 0.75; NIS: p < 0.001, C-statistic = 0.66) in both validation populations. Greater score was also predictive of increased odds of any adverse event, a major complication, and an extended hospitalization in both validation populations (p ≤ 0.03).

Conclusions: The NSQIP unruptured aneurysm scale may augment the risk stratification of patients undergoing microsurgical clipping of unruptured cerebral aneurysms.
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http://dx.doi.org/10.3171/2018.12.JNS182873DOI Listing
March 2019

Noninfectious Fever in Aneurysmal Subarachnoid Hemorrhage: Association with Cerebral Vasospasm and Clinical Outcome.

World Neurosurg 2019 Feb 7;122:e1014-e1019. Epub 2018 Nov 7.

Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: The purpose of this study was to evaluate the association between noninfectious fever onset and radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage.

Methods: We evaluated 44 patients for the association between noninfectious fever (greater than 101.5°F) and the development of radiographic vasospasm by digital subtraction angiography (DSA) and transcranial Doppler (TCD), DIND, DCI, and modified Rankin scale outcome score at 6 months to 2 years. Multivariate logistic regression analyses were performed to account for patient age, sex, admission Hunt and Hess grade, and Fisher grade. TCD was additionally used for temporal analysis.

Results: Noninfectious fever was significantly associated with radiographic vasospasm using both DSA (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2-4.5; P = 0.02) and TCD (OR, 2.4; 95% CI, 1.2-5.6; P = 0.02), but it was not associated with DIND, DCI, or outcome. The maximum cross correlation between TCD velocity and temperature occurred for temperatures taken 1 day prior to TCD velocity measurement. A quadratic mixed-effects model demonstrated that TCD velocity was significantly associated with temperature from 1 day prior to TCD velocity measurement (β = 13.5; 95% CI, 0.83-8.79, P = 0.01), posthemorrhage day (β = 20.1; 95% CI, 2.14-7.52; P < 0.001), and (posthemorrhage day) (β = -0.72; 95% CI, -0.26 to -0.11; P < 0.001).

Conclusions: Noninfectious fever was associated with the development of radiographic vasospasm but not with DIND, DCI, or clinical outcome. Furthermore, there is a temporal association between the onset of noninfectious fever and radiographic vasospasm by 1 day. Fever independent of patient's infectious profile may be an early marker for the development of radiographic vasospasm.
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http://dx.doi.org/10.1016/j.wneu.2018.10.203DOI Listing
February 2019

The Timing of Tracheostomy and Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Analysis.

Neurocrit Care 2018 12;29(3):326-335

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

Background: The goal of this study was to investigate the association of tracheostomy timing with outcomes after aneurysmal subarachnoid hemorrhage (SAH) in a national population.

Methods: Poor-grade aneurysmal SAH patients were extracted from the Nationwide Inpatient Sample (2002-2011). Multivariable linear regression was used to analyze predictors of tracheostomy timing and multivariable logistic regression was used to evaluate the association of timing of intervention with mortality, complications, and discharge to institutional care. Covariates included patient demographics, comorbidities, severity of subarachnoid hemorrhage (measured using the NIS-SAH severity scale), hospital characteristics, and other complications and length of stay.

Results: The median time to tracheostomy among 1380 poor-grade SAH admissions was 11 (interquartile range: 7-15) days after intubation. The mean number of days from intubation to tracheostomy in SAH patients at the hospital (p < 0.001) was the strongest predictor of tracheostomy timing for a patient, while comorbidities and SAH severity were not significant predictors. Mortality, neurologic complications, and discharge disposition did not differ significantly by tracheostomy time. However, later tracheostomy (when evaluated continuously) was associated with greater odds of pulmonary complications (p = 0.004), venous thromboembolism (p = 0.04), and pneumonia (p = 0.02), as well as a longer hospitalization (p < 0.001). Subgroup analysis only found these associations between tracheostomy timing and medical complications in patients with moderately poor grade (NIS-SAH severity scale 7-9), while there were no significant differences by timing of intervention in very poor-grade patients (NIS-SAH severity scale > 9).

Conclusions: In this analysis of a large, national data set, variation in hospital practices was the strongest predictor of tracheostomy timing for an individual. In patients with moderately poor grade, later tracheostomy was independently associated with pulmonary complications, venous thromboembolism, pneumonia, and a longer hospitalization, but not with mortality, neurological complications, or discharge disposition. However, tracheostomy timing was not significantly associated with outcomes in very poor-grade patients.
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http://dx.doi.org/10.1007/s12028-018-0619-4DOI Listing
December 2018

Treatment of ruptured and unruptured cerebral aneurysms in the USA: a paradigm shift.

J Neurointerv Surg 2018 Jul;10(Suppl 1):i69-i76

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: Integration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.

Objective: To describe patterns of use and in-hospital mortality associated with surgical and endovascular treatments of cerebral aneurysms over the past decade.

Materials And Methods: The data are 34 899 hospital discharges with a diagnosis of ruptured or unruptured cerebral aneurysm from 1998 to 2007 identified from the Nationwide Inpatient Sample (NIS). The rates of endovascular coiling and surgical clipping and in-hospital mortality among patients with an aneurysm are examined over a decade by hospital and patient demographic characteristics.

Results: From 1998 to 2007, 20 134 discharges with a ruptured aneurysm and 14 765 discharges with an unruptured aneurysm were identified. Over this decade, the number of patients discharged with a ruptured aneurysm was stable while the number discharged with an unruptured aneurysm increased significantly. The use of endovascular coiling increased at least twofold for both groups of patient (p<0.001) with the majority of unruptured aneurysms treated with coiling by 2007. Although whites were more likely than non-whites to undergo coiling versus clipping for a ruptured aneurysm (OR=1.30; 95% CI 1.13 to 1.48) and men with unruptured aneurysms were more likely than women to undergo coiling (OR=1.26; 95% CI 1.13 to 1.40), by 2007 differences in treatment selection by gender and racial subgroups were decreased or statistically non-significant. Over time the use of coiling spread from primarily large, teaching hospitals to smaller, non-teaching hospitals.

Conclusions: The majority of unruptured aneurysms in the USA are now treated with endovascular coiling. Although surgical clipping is used for treatment of most ruptured aneurysms, its use is decreasing over time. Dissemination of endovascular procedures appears widespread across patient and hospital subgroups.
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http://dx.doi.org/10.1136/jnis.2011.004978.repDOI Listing
July 2018

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients.

J Neurosurg 2018 Jun 1:1-8. Epub 2018 Jun 1.

1Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and.

OBJECTIVEParaclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%-40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling.METHODSThe authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention.RESULTSA total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03).CONCLUSIONSIn a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.
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http://dx.doi.org/10.3171/2018.1.JNS171774DOI Listing
June 2018

Cigarette smoking and outcomes after aneurysmal subarachnoid hemorrhage: a nationwide analysis.

J Neurosurg 2018 08 27;129(2):446-457. Epub 2017 Oct 27.

OBJECTIVE Although cigarette smoking is one of the strongest risk factors for cerebral aneurysm development and rupture, there are limited data evaluating the impact of smoking on outcomes after aneurysmal subarachnoid hemorrhage (SAH). Additionally, two recent studies suggested that nicotine replacement therapy was associated with improved neurological outcomes among smokers who had sustained an SAH compared with smokers who did not receive nicotine. METHODS Patients who underwent endovascular or microsurgical repair of a ruptured cerebral aneurysm were extracted from the Nationwide Inpatient Sample (NIS, 2009-2011) and stratified by cigarette smoking. Multivariable logistic regression analyzed in-hospital mortality, complications, tracheostomy or gastrostomy placement, and discharge to institutional care (a nursing or an extended care facility). Additionally, the composite NIS-SAH outcome measure (based on mortality, tracheostomy or gastrostomy, and discharge disposition) was evaluated, which has been shown to have excellent agreement with a modified Rankin Scale score greater than 3. Covariates included in regression constructs were patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities (including hypertension, drug and alcohol abuse), the NIS-SAH severity scale (previously validated against the Hunt and Hess grade), treatment modality used for aneurysm repair, and hospital characteristics. A sensitivity analysis was performed matching smokers to nonsmokers on age, sex, number of comorbidities, and NIS-SAH severity scale score. RESULTS Among the 5784 admissions evaluated, 37.1% (n = 2148) had a diagnosis of tobacco use, of which 31.1% (n = 1800) were current and 6.0% (n = 348) prior tobacco users. Smokers were significantly younger (mean age 51.4 vs 56.2 years) and had more comorbidities compared with nonsmokers (p < 0.001). There were no significant differences in mortality, total complications, or neurological complications by smoking status. However, compared with nonsmokers, smokers had significantly decreased adjusted odds of tracheostomy or gastrostomy placement (11.9% vs 22.7%, odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51-0.78, p < 0.001), discharge to institutional care (OR 0.71, 95% CI 0.57-0.89, p = 0.002), and a poor outcome (OR 0.65, 95% CI 0.55-0.77, p < 0.001). Similar statistical associations were noted in the matched-pairs sensitivity analysis and in a subgroup of poor-grade patients (the upper quartile of the NIS-SAH severity scale). CONCLUSIONS In this nationwide study, smokers experienced SAH at a younger age and had a greater number of comorbidities compared with nonsmokers, highlighting the negative ramifications of cigarette smoking among patients with cerebral aneurysms. However, smoking was also associated with paradoxical superior outcomes on some measures, and future research to confirm and further understand the basis of this relationship is needed.
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http://dx.doi.org/10.3171/2016.10.JNS16748DOI Listing
August 2018

Readmission After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Readmission Database Analysis.

Stroke 2017 09 28;48(9):2383-2390. Epub 2017 Jul 28.

From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.).

Background And Purpose: The goal of this nationwide study is to evaluate the suitability of readmission as a quality indicator in the aneurysmal subarachnoid hemorrhage (SAH) population.

Methods: Patients with aneurysmal SAH were extracted from the Nationwide Readmission Database (2013). Multivariable Cox proportional hazard regression was used to evaluate predictors of a 30-day readmission, and multivariable linear regression was used to analyze the association of hospital readmission rates with hospital mortality rates. Predictors screened included patient demographics, comorbidities, severity of SAH, complications from the SAH hospitalization, and hospital characteristics.

Results: The 30-day readmission rate was 10.2% (n=346) among the 3387 patients evaluated, and the most common reasons for readmission were neurological, hydrocephalus, infectious, and venous thromboembolic complications. Greater number of comorbidities, increased severity of SAH, and discharge disposition other than to home were independent predictors of readmission (≤0.03). Although hydrocephalus during the SAH hospitalization was associated with readmission for the same diagnosis, other readmissions were not associated with having sustained the same complication during the SAH hospitalization. Hospital mortality rate was inversely associated with hospital SAH volume (=0.03) but not significantly associated with hospital readmission rate; hospital SAH volume was also not associated with SAH readmissions.

Conclusions: In this national analysis, readmission was primarily attributable to new medical complications in patients with greater comorbidities and severity of SAH rather than exacerbation of complications from the SAH hospitalization. Additionally, hospital readmission rates did not correlate with other established quality metrics. Therefore, readmission may be a suboptimal quality indicator in the SAH population.
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http://dx.doi.org/10.1161/STROKEAHA.117.016702DOI Listing
September 2017

Hemodynamic Impact of a Spontaneous Cervical Dissection on an Ipsilateral Saccular Aneurysm.

J Cerebrovasc Endovasc Neurosurg 2016 Jun 30;18(2):110-114. Epub 2016 Jun 30.

Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.

The dynamic, hemodynamic impact of a cervical dissection on an ipsilateral, intracranial saccular aneurysm has not been well illustrated. This 45-year-old female was found to have a small, supraclinoid aneurysm ipsilateral to a spontaneous cervical internal carotid artery dissection. With healing of the dissection, the aneurysm appeared to have significantly enlarged. Retrospective review of the magnetic resonance imaging (MRI) at the time of the initial dissection demonstrated thrombus, similar in overall morphology to the angiographic appearance of the "enlarged" aneurysm. As the dissection healed far proximal to the intradural portion of the internal carotid artery, this suggested that the aneurysm was likely a typical, saccular posterior communicating artery aneurysm that had thrombosed and then recanalized secondary to flow changes from the dissection. The aneurysm was coiled uneventfully, in distinction from more complex treatment approaches such as flow diversion or proximal occlusion to treat an enlarging, dissecting pseudoaneurysm. This case illustrates that flow changes from cervical dissections may result in thrombosis of downstream saccular aneurysms. With healing, these aneurysms may recanalize and be misidentified as enlarging dissecting pseudoaneurysms. Review of an MRI from the time of the dissection facilitated the conclusion that the aneurysm was a saccular posterior communicating artery aneurysm, influencing treatment approach.
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http://dx.doi.org/10.7461/jcen.2016.18.2.110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5081495PMC
June 2016

The impact of body habitus on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis.

J Neurosurg 2017 Jul 15;127(1):36-46. Epub 2016 Jul 15.

Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

OBJECTIVE Although the prevalence of obesity is increasing rapidly both nationally and internationally, few studies have analyzed outcomes among obese patients undergoing cranial neurosurgery. The goal of this study, which used a nationwide data set, was to evaluate the association of both obesity and morbid obesity with treatment outcomes among patients with aneurysmal subarachnoid hemorrhage (SAH); in addition, the authors sought to analyze how postoperative complications for obese patients with SAH differ by the treatment modality used for aneurysm repair. METHODS Clinical data for adult patients with SAH who underwent microsurgical or endovascular aneurysm repair were extracted from the Nationwide Inpatient Sample (NIS). The body habitus of patients was classified as nonobese (body mass index [BMI] < 30 kg/m), obese (BMI ≥ 30 kg/m and ≤ 40 kg/m), or morbidly obese (BMI > 40 kg/m). Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality rate, complications, discharge disposition, and poor outcome as defined by the composite NIS-SAH outcome measure. Covariates included patient demographics, comorbidities (including hypertension and diabetes), health insurance status, the NIS-SAH severity scale, treatment modality used for aneurysm repair, and hospital characteristics. RESULTS In total, data from 18,281 patients were included in this study; the prevalence of morbid obesity increased from 0.8% in 2002 to 3.5% in 2011. Obese and morbidly obese patients were significantly younger and had a greater number of comorbidities than nonobese patients (p < 0.001). Mortality rates for obese (11.5%) and morbidly obese patients (10.5%) did not significantly differ from those for nonobese patients (13.5%); likewise, no differences in neurological complications or poor outcome were observed among these 3 groups. Morbid obesity was associated with significantly increased odds of several medical complications, including venous thromboembolic (OR 1.52, 95% CI 1.01-2.30, p = 0.046) and renal (OR 1.64, 95% CI: 1.11-2.43, p = 0.01) complications and infections (OR 1.34, 95% CI 1.08-1.67, p = 0.009, attributable to greater odds of urinary tract and surgical site infections). Moreover, morbidly obese patients had higher odds of a nonroutine hospital discharge (OR 1.33, 95% CI 1.03-1.71, p = 0.03). Patients with milder obesity had decreased odds of some medical complications, including cardiac, pulmonary, and infectious complications, primarily among patients who had undergone coil embolization. CONCLUSIONS In this study involving a nationwide administrative database, milder obesity was not significantly associated with increased mortality rates, neurological complications, or poor outcomes after SAH. Morbid obesity, however, was associated with increased odds of venous thromboembolic, renal, and infectious complications, as well as of a nonroutine hospital discharge. Notably, milder obesity was associated with decreased odds of some medical complications, primarily in patients treated with coiling.
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http://dx.doi.org/10.3171/2016.4.JNS152562DOI Listing
July 2017

Stent deployment protocol for optimized real-time visualization during endovascular neurosurgery.

J Neurosurg 2017 May 24;126(5):1614-1621. Epub 2016 Jun 24.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Successful application of endovascular neurosurgery depends on high-quality imaging to define the pathology and the devices as they are being deployed. This is especially challenging in the treatment of complex cases, particularly in proximity to the skull base or in patients who have undergone prior endovascular treatment. The authors sought to optimize real-time image guidance using a simple algorithm that can be applied to any existing fluoroscopy system. Exposure management (exposure level, pulse management) and image post-processing parameters (edge enhancement) were modified from traditional fluoroscopy to improve visualization of device position and material density during deployment. Examples include the deployment of coils in small aneurysms, coils in giant aneurysms, the Pipeline embolization device (PED), the Woven EndoBridge (WEB) device, and carotid artery stents. The authors report on the development of the protocol and their experience using representative cases. The stent deployment protocol is an image capture and post-processing algorithm that can be applied to existing fluoroscopy systems to improve real-time visualization of device deployment without hardware modifications. Improved image guidance facilitates aneurysm coil packing and proper positioning and deployment of carotid artery stents, flow diverters, and the WEB device, especially in the context of complex anatomy and an obscured field of view.
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http://dx.doi.org/10.3171/2016.4.JNS16194DOI Listing
May 2017

The impact of aspirin and anticoagulant usage on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis.

J Neurosurg 2017 Feb 8;126(2):537-547. Epub 2016 Apr 8.

Cushing Neurosurgical Outcomes Center.

OBJECTIVE Although aspirin usage may be associated with a decreased risk of rupture of cerebral aneurysms, any potential therapeutic benefit from aspirin must be weighed against the theoretical risk of greater hemorrhage volume if subarachnoid hemorrhage (SAH) occurs. However, few studies have evaluated the association between prehemorrhage aspirin use and outcomes. This is the first nationwide analysis to evaluate the impact of long-term aspirin and anticoagulant use on outcomes after SAH. METHODS Data from the Nationwide Inpatient Sample (NIS; 2006-2011) were extracted. Patients with a primary diagnosis of SAH who underwent microsurgical or endovascular aneurysm repair were included; those with a diagnosis of an arteriovenous malformation were excluded. Multivariable logistic regression was performed to calculate the adjusted odds of in-hospital mortality, a nonroutine discharge (any discharge other than to home), or a poor outcome (death, discharge to institutional care, tracheostomy, or gastrostomy) for patients with long-term aspirin or anticoagulant use. Multivariable linear regression was used to evaluate length of hospital stay. Covariates included patient age, sex, comorbidities, primary payer, NIS-SAH severity scale, intracerebral hemorrhage, cerebral edema, herniation, modality of aneurysm repair, hospital bed size, and whether the hospital was a teaching hospital. Subgroup analyses exclusively evaluated patients treated surgically or endovascularly. RESULTS The study examined 11,549 hospital admissions. Both aspirin (2.1%, n = 245) and anticoagulant users (0.9%, n = 108) were significantly older and had a greater burden of comorbid disease (p < 0.001); severity of SAH was slightly lower in those with long-term aspirin use (p = 0.03). Neither in-hospital mortality (13.5% vs 12.6%) nor total complication rates (79.6% vs 80.0%) differed significantly by long-term aspirin use. Additionally, aspirin use was associated with decreased odds of a cardiac complication (OR 0.57, 95% CI 0.36%-0.91%, p = 0.02) or of venous thromboembolic events (OR 0.53, 95% CI 0.30%-0.94%, p = 0.03). Length of stay was significantly shorter (15 days vs 17 days [12.73%], 95% CI 5.22%-20.24%, p = 0.001), and the odds of a nonroutine discharge were lower (OR 0.63, 95% CI 0.48%-0.83%, p = 0.001) for aspirin users. In subgroup analyses, the benefits of aspirin were primarily noted in patients who underwent coil embolization; likewise, among patients treated endovascularly, the adjusted odds of a poor outcome were lower among long-term aspirin users (31.8% vs 37.4%, OR 0.63, 95% CI 0.42%-0.94%, p = 0.03). Although the crude rates of in-hospital mortality (19.4% vs 12.6%) and poor outcome (53.6% vs 37.6%) were higher for long-term anticoagulant users, in multivariable logistic regression models these variations were not significantly different (mortality: OR 1.36, 95% CI 0.89%-2.07%, p = 0.16; poor outcome: OR 1.09, 95% CI 0.69%-1.73%, p = 0.72). CONCLUSIONS In this nationwide study, neither long-term aspirin nor anticoagulant use were associated with differential mortality or complication rates after SAH. Aspirin use was associated with a shorter hospital stay and lower rates of nonroutine discharge, with these benefits primarily observed in patients treated endovascularly.
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http://dx.doi.org/10.3171/2015.12.JNS151107DOI Listing
February 2017

Hospital-Acquired Infections after Aneurysmal Subarachnoid Hemorrhage: A Nationwide Analysis.

World Neurosurg 2016 Apr 4;88:459-474. Epub 2015 Nov 4.

Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Background: This is the first nationwide study to evaluate the factors associated with developing hospital-acquired infections (HAIs) after aneurysmal subarachnoid hemorrhage (SAH) and analyze their impact on the efficiency of hospital care.

Methods: Data from patients with SAH who underwent aneurysm repair were extracted from the Nationwide Inpatient Sample (2008-2011). Urinary tract infections, pneumonia, central venous catheter (CVC)-associated blood stream infection, and meningitis/ventriculitis were evaluated. Independent predictors of HAIs used in multivariable logistic regression modeling were chosen using forward selection; hierarchical multivariable linear regression assessed length of stay and charges.

Results: Seven thousand five hundred sixteen admissions were included. Independent predictors in the logistic regression for developing a urinary tract infection (23.9%) included older age, female sex, noninfectious complications (P < 0.001), intracerebral hemorrhage (P = 0.009), and diabetes with complications (P = 0.04). Pneumonia (23.0%) was associated with older age (P = 0.003), congestive heart failure, severity of SAH, and noninfectious complications (P < 0.001). Severity of SAH and noninfectious complications were predictors of meningitis/ventriculitis (4.4%; P ≤ 0.02), whereas intracerebral hemorrhage and noninfectious complications were predictors of CVC-associated infections (1.0%; P ≤ 0.02). All HAIs were associated with significantly longer hospitalizations and higher charges. Pneumonia (odds ratio [OR], 2.85; 95% confidence interval (CI), 2.44-3.34) and CVC-associated infections (OR, 2.42; 95% CI, 1.26-4.66) were also independently associated with greater odds of poor outcome (death or institutional care).

Conclusion: In this nationwide analysis, urinary tract infections and pneumonia were the most common hospital-acquired infections after SAH. Although all infections were associated with significantly longer hospitalizations and greater charges, pneumonia and CVC-associated infections were also associated with increased likelihood of a poor outcome.
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http://dx.doi.org/10.1016/j.wneu.2015.10.054DOI Listing
April 2016

Clostridium difficile Infection After Subarachnoid Hemorrhage: A Nationwide Analysis.

Neurosurgery 2016 Mar;78(3):412-20

*Neurosurgical Outcomes Center, Boston, Massachusetts; ‡Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts; §Harvard Medical School, Boston, Massachusetts.

Background: Clostridium difficile infection (CDI) is an important cause of hospital-acquired morbidity and mortality.

Objective: To evaluate the incidence of, predictors for, and effects on outcome by CDI after aneurysmal subarachnoid hemorrhage.

Methods: Data were extracted from the Nationwide Inpatient Sample (2002-2011). Patients with subarachnoid hemorrhage who underwent microsurgical or endovascular aneurysm repair were included. Multivariate logistic regression was used to determine the independent predictors of developing CDI. Additional models were constructed to assess the impact of CDI on mortality, length of stay, and discharge disposition.

Results: Of the 18 007 patients who were included, 1.9% (n = 346) developed CDI. Patients who developed CDI were significantly older and had more comorbidities (P ≤ .001). Independent predictors of developing CDI were Medicaid payer status; ventriculostomy; mechanical ventilation; a greater number of noninfectious complications; and the development of a urinary tract infection; pneumonia; meningitis/ventriculitis; and sepsis (all P ≤ .02). Only 1.5% of patients with CDI required gastrointestinal surgery. Although CDI was not associated with differential mortality, it was associated with increased adjusted odds of a hospital stay of at least 24 days (odds ratio, 3.16; 95% confidence interval, 2.32-4.29; P < .001) and of a nonroutine hospital discharge (odds ratio, 1.64; 95% confidence interval, 1.13-2.39; P = .01).

Conclusion: In this nationwide analysis, both infectious and noninfectious complications, as well as ventriculostomy, mechanical ventilation, and insurance status were independent predictors of CDI. Although CDI was not associated with mortality, it was associated with a longer hospital stay and nonroutine hospital discharge.
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http://dx.doi.org/10.1227/NEU.0000000000001065DOI Listing
March 2016

Intrinsic, Transitional, and Extrinsic Morphological Factors Associated With Rupture of Intracranial Aneurysms.

Neurosurgery 2015 Sep;77(3):433-41; discussion 441-2

*Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; ‡Harvard Medical School, Boston, Massachusetts; §Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York.

Background: As diagnosis and treatment of unruptured intracranial aneurysms continues to increase, management principles remain largely based on size. This is despite mounting evidence that aneurysm location and other morphologic variables could play a role in predicting overall risk of rupture. Morphological parameters can be divided into 3 main groups, those that are intrinsic to the aneurysm, those that are extrinsic to the aneurysm, and those that involve both the aneurysm and surrounding vasculature (transitional).

Objective: We present an evaluation of intrinsic, transitional, and extrinsic factors and their association with ruptured aneurysms.

Methods: Using preoperative computed tomographic angiography, we generated 3-dimensional models of aneurysms and their surrounding vasculature with Slicer software. Using univariate and multivariate analyses, we examined the association of intrinsic, transitional, and extrinsic aspects of aneurysm morphology with rupture.

Results: Between 2005 and 2013, 227 cerebral aneurysms in 4 locations were evaluated/treated at a single institution, and computed tomographic angiographies of 218 patients (97 unruptured and 130 ruptured) were analyzed. Ruptured aneurysms analyzed were associated with clinical factors of absence of multiple aneurysms and history of no prior rupture, and morphologic factors of greater aspect ratio. On multivariate analysis, aneurysm rupture remained associated with history of no prior rupture, greater flow angle, greater daughter-daughter vessel angle, and smaller parent-daughter vessel angle.

Conclusion: By studying the morphology of aneurysms and their surrounding vasculature, we identified several parameters associated with ruptured aneurysms that include intrinsic, transitional, and extrinsic factors of cerebral aneurysms and their surrounding vasculature.
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http://dx.doi.org/10.1227/NEU.0000000000000835DOI Listing
September 2015

Smoking and Intracranial Aneurysm Morphology.

Neurosurgery 2015 Jul;77(1):59-66; discussion 66

*Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; ‡Harvard Medical School, Boston, Massachusetts; §Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York.

Background: Smoking is a well-known independent risk factor for both aneurysm formation and rupture. There is mounting evidence that aneurysm morphology beyond size can have a significant role in aneurysm formation and rupture risk by its effects on aneurysmal hemodynamics.

Objective: To study the variation in aneurysm morphology between smokers and nonsmokers and delineate how changes in these factors might affect aneurysm formation and rupture.

Methods: We generated 3-dimensional models of aneurysms and their surrounding vasculature by analyzing preoperative computed tomography angiograms with Slicer software. We then examined the association between smoking status and intrinsic, transitional, and extrinsic aspects of aneurysm morphology in both univariate and multivariate statistical analyses.

Results: From 2005 to 2013, 199 cerebral aneurysms in never smokers and current smokers were evaluated/treated at a single institution with available computed tomography angiograms (102 in never smokers and 97 in current smokers). Multivariate analysis of current smokers vs never smokers demonstrated that aneurysms in current smokers were significantly associated with multiple aneurysms (odds ratio [OR]: 2.15, P = .03), larger daughter vessel diameters (OR: 3.13, P = .01), larger size ratio (OR: 1.78, P = .01), and location at the basilar apex (OR: 6.26, P = .02).

Conclusion: The differences in aneurysm morphology between smoking and nonsmoking patient populations may elucidate the effects of smoking on aneurysm formation and eventual rupture. We identified several aspects of aneurysm morphology significantly associated with smoking status that may provide the morphological basis for how smoking leads to increased aneurysm rupture.
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http://dx.doi.org/10.1227/NEU.0000000000000735DOI Listing
July 2015

Incidence, risk factors and management of severe post-transsphenoidal epistaxis.

J Clin Neurosci 2015 Jan 21;22(1):116-22. Epub 2014 Aug 21.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

Among the major complications of transsphenoidal surgery, less attention has been given to severe postoperative epistaxis, which can lead to devastating consequences. In this study, we reviewed 551 consecutive patients treated over a 4 year period by the senior author to evaluate the incidence, risk factors, etiology and management of immediate and delayed post-transsphenoidal epistaxis. Eighteen patients (3.3%) developed significant postoperative epistaxis - six immediately and 12 delayed (mean postoperative day 10.8). Fourteen patients harbored macroadenomas (78%) and 11 of 18 (61.1%) had complex nasal/sphenoid anatomy. In the immediate epistaxis group, 33% had acute postoperative hypertension. In the delayed group, one had an anterior ethmoidal pseudoaneurysm, and one had restarted anticoagulation on postoperative day 3. We treated the immediate epistaxis group with bedside nasal packing followed by operative re-exploration if conservative measures were unsuccessful. The delayed group underwent bedside nasal hemostasis; if unsuccessful, angiographic embolization was performed. After definitive treatment, no patients had recurrent epistaxis.
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http://dx.doi.org/10.1016/j.jocn.2014.07.004DOI Listing
January 2015

Endovascular coiling of a ruptured basilar apex aneurysm with associated pseudoaneurysm.

J Clin Neurosci 2014 Sep 24;21(9):1637-40. Epub 2014 Apr 24.

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

Acute intracranial pseudoaneurysms secondary to aneurysmal rupture are a rare entity with no clear evidence-based guidelines for treatment to our knowledge. There are numerous examples of successful treatment of pseudoaneurysms both surgically and endovascularly, the latter mainly within the anterior circulation. Risk of pseudoaneurysm rupture in the acute state during endovascular procedures with subsequent difficulty in controlling the bleeding without sacrificing the feeder artery has led to some reservation in using endovascular treatments more broadly. We report a rare case of a 52-year-old-woman who presented with acute subarachnoid hemorrhage and was found to have a ruptured 5 mm × 8 mm bi-lobulated basilar apex aneurysm on CT angiography. Digital subtraction angiography demonstrated an associated anterior pseudoaneurysm that was formed secondary to the aneurysm rupture. The true aneurysm was successfully coiled with careful avoidance of the pseudoaneurysmal sac. Pseudoaneurysms are frequently identified for the first time during digital subtraction angiography. Recognizing their presence is essential for treatment planning. Acute pseudoaneurysms associated with true aneurysmal rupture can be safely and successfully treated by endovascular coiling of the true aneurysm. Care must be taken to avoid manipulation of the pseudoaneurysmal sac during the embolization.
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http://dx.doi.org/10.1016/j.jocn.2013.11.050DOI Listing
September 2014

Morphological parameters associated with ruptured posterior communicating aneurysms.

PLoS One 2014 14;9(4):e94837. Epub 2014 Apr 14.

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America.

The rupture risk of unruptured intracranial aneurysms is known to be dependent on the size of the aneurysm. However, the association of morphological characteristics with ruptured aneurysms has not been established in a systematic and location specific manner for the most common aneurysm locations. We evaluated posterior communicating artery (PCoA) aneurysms for morphological parameters associated with aneurysm rupture in that location. CT angiograms were evaluated to generate 3-D models of the aneurysms and surrounding vasculature. Univariate and multivariate analyses were performed to evaluate morphological parameters including aneurysm volume, aspect ratio, size ratio, distance to ICA bifurcation, aneurysm angle, vessel angles, flow angles, and vessel-to-vessel angles. From 2005-2012, 148 PCoA aneurysms were treated in a single institution. Preoperative CTAs from 63 patients (40 ruptured, 23 unruptured) were available and analyzed. Multivariate logistic regression revealed that smaller volume (p = 0.011), larger aneurysm neck diameter (0.048), and shorter ICA bifurcation to aneurysm distance (p = 0.005) were the most strongly associated with aneurysm rupture after adjusting for all other clinical and morphological variables. Multivariate subgroup analysis for patients with visualized PCoA demonstrated that larger neck diameter (p = 0.018) and shorter ICA bifurcation to aneurysm distance (p = 0.011) were significantly associated with rupture. Intracerebral hemorrhage was associated with smaller volume, larger maximum height, and smaller aneurysm angle, in addition to lateral projection, male sex, and lack of hypertension. We found that shorter ICA bifurcation to aneurysm distance is significantly associated with PCoA aneurysm rupture. This is a new physically intuitive parameter that can be measured easily and therefore be readily applied in clinical practice to aid in the evaluation of patients with PCoA aneurysms.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0094837PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986342PMC
May 2015

Endovascular treatment of symptomatic moyamoya.

Neurosurg Rev 2014 Oct 3;37(4):579-83. Epub 2014 Apr 3.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA,

Moyamoya is a rare though important source of neurological morbidity as a result of both ischemic and hemorrhagic sequelae. Although a litany of series detailing the endovascular management of cerebral ischemia is present in the literature, only a paucity of such reports exists for moyamoya. A systematic review of the literature was performed for patients with moyamoya managed with endovascular techniques in addition to the contribution of an additional case managed at our institution. We evaluated treatment approach (angioplasty and/or stent), complications, and both angiographic and clinical outcomes at last follow-up. Results from a total of 28 endovascular procedures were collected (11 stenting, 17 angioplasty alone). Procedural success, defined as a lack of both angiographic and clinical recurrence at follow-up, was achieved after seven procedures (25 %). This rate did not significantly differ between disease type (moyamoya disease vs moyamoya syndrome, p = 1.0) and treatment approach (angioplasty alone vs stenting, p = 1.0). The overall monthly angiographic and clinical recurrence rates were 9.3 and 8.0 %, respectively. Clinically devastating intracerebral hemorrhage was seen after two procedures (7 %), and in an additional three procedures, the treated vessel could not be effectively dilated (11 %). There is no evidence that angioplasty or stenting improves the natural history of moyamoya. Both are associated with significant rates of early angiographic and/or clinical recurrence of symptoms. Taken with the risk of procedural complications, the current limited data should advise against attempted endovascular treatment of moyamoya.
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http://dx.doi.org/10.1007/s10143-014-0542-xDOI Listing
October 2014

Transvenous approach to carotid-cavernous fistula via facial vein cut down.

J Clin Neurosci 2014 Jul 7;21(7):1238-40. Epub 2013 Dec 7.

Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Endovascular access to carotid-cavernous sinus fistulae (CCF) can be obtained through a transfemoral approach to the inferior petrosal sinus (IPS) or superior ophthalmic vein (SOV). If the transfemoral approach cannot be utilized, direct surgical exposure of the SOV can provide access to the CCF. The authors present an alternate approach to a CCF in a 66-year-old woman in whom the IPS was thrombosed and the facial vein so tortuous at its origin that it could not be passed with a wire. The facial vein was exposed surgically at the angle of the mandible after percutaneous attempts failed. After localization of the anterior facial vein with ultrasound, a 1 cm skin incision was made over the margin of the mandible. The dissected vein was cannulated using a micropuncture technique and a 0.018 inch wire. A four French short access sheath was inserted and sutured to the vein. Subsequent venogram allowed navigation of an SL-10 microcatheter over a Synchro soft microwire (both Boston Scientific, Natick, MA, USA) via the SOV into the cavernous sinus, and coil embolization was performed with angiographic cure of the fistula. No complications were encountered and the cosmetic result of the small incision of the mandibular region was excellent and less conspicuous than it would have been on the eyelid. This technical note illustrates that facial vein cut down is an attractive and safe alternate approach to endovascular management of CCF via a transvenous route in patients with a focally narrowed and tortuous IPS and common facial vein.
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http://dx.doi.org/10.1016/j.jocn.2013.11.011DOI Listing
July 2014

Analysis of morphological parameters to differentiate rupture status in anterior communicating artery aneurysms.

PLoS One 2013 13;8(11):e79635. Epub 2013 Nov 13.

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Harvard Medical School, Boston, Massachusetts, United States of America.

In contrast to size, the association of morphological characteristics of intracranial aneurysms with rupture has not been established in a systematic manner. We present an analysis of the morphological variables that are associated with rupture in anterior communicating artery aneurysms to determine site-specific risk variables. One hundred and twenty-four anterior communicating artery aneurysms were treated in a single institution from 2005 to 2010, and CT angiograms (CTAs) or rotational angiography from 79 patients (42 ruptured, 37 unruptured) were analyzed. Vascular imaging was evaluated with 3D Slicer© to generate models of the aneurysms and surrounding vasculature. Morphological parameters were examined using univariate and multivariate analysis and included aneurysm volume, aspect ratio, size ratio, distance to bifurcation, aneurysm angle, vessel angle, flow angle, and parent-daughter angle. Multivariate logistic regression revealed that size ratio, flow angle, and parent-daughter angle were associated with aneurysm rupture after adjustment for age, sex, smoking history, and other clinical risk factors. Simple morphological parameters such as size ratio, flow angle, and parent-daughter angle may thus aid in the evaluation of rupture risk of anterior communicating artery aneurysms.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0079635PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3827376PMC
July 2014

Treatment modality and vasospasm after aneurysmal subarachnoid hemorrhage.

World Neurosurg 2014 Dec 14;82(6):e725-30. Epub 2013 Aug 14.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: Vasospasm is the leading source of neurological morbidity after aneurysmal subarachnoid hemorrhage. Our objective was to evaluate the impact of treatment modality on vasospasm, delayed cerebral infarction, and clinical deterioration caused by delayed cerebral ischemia (CD-DCI).

Methods: We reviewed an institutional cohort, comparing rates of vasospasm, delayed cerebral infarction, and CD-DCI between patients managed with only microsurgical clipping and those treated with only endovascular coiling within 72 hours of rupture. Age, sex, smoking status, Hunt-Hess grade, and Fisher grade were adjusted for in a multivariate regression model.

Results: Two hundred three patients were treated with clipping and 52 with coiling. There was no significant difference in patient age, sex, smoking status, aneurysm location, and presenting clinical (Hunt-Hess) and radiographic (Fisher) grade between these two groups. Sixty-percent of patients had moderate or severe vasospasm after clipping compared with 38% after coiling (Multivariate odds ratio [OR] 2.32, 95% confidence interval [95% CI] 1.21-4.47, P = 0.01). Clipping was associated with a greater number of territories with vasospasm (mean of 3.1 vs. 2.3, P = 0.03 after multivariate analysis). Delayed radiographic cerebral infarction was more common in the clipping group (17% vs. 6%, multivariate OR 3.66, 95% CI 1.06-12.71, P = 0.04). For CD-DCI, a trend was seen as 16% of patients treated with clipping had CD-DCI compared with 6% of patients treated with coiling (multivariate OR 3.11, 95% CI 0.89-10.86, P = 0.07).

Conclusion: We demonstrate significantly lower rates of vasospasm and delayed infarction after endovascular coiling of ruptured aneurysms.
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http://dx.doi.org/10.1016/j.wneu.2013.08.017DOI Listing
December 2014

Microsurgical treatment of a ruptured dissecting labyrinthine artery aneurysm.

Clin Neurol Neurosurg 2013 Oct 6;115(10):2277-9. Epub 2013 Aug 6.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston 02115, USA.

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http://dx.doi.org/10.1016/j.clineuro.2013.07.023DOI Listing
October 2013