Publications by authors named "Karim Hafazalla"

12 Publications

  • Page 1 of 1

Decompressive Hemicraniectomy in the Modern Era of Mechanical Thrombectomy.

World Neurosurg 2021 Sep 6. Epub 2021 Sep 6.

Department of Neurosurgery, Division of Critical Care and Neurotrauma, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania. Electronic address:

Objectives: We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes.

Methods: We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion (LVO) that were treated by mechanical thrombectomy from 2010-2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge.

Results: Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-decompressive hemicraniectomy group (p<0.001), had worse reperfusion rates (p=0.024) and larger infarct size (p<0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (p=0.08). From 2010-2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a decompressive hemicraniectomy, while 316 patients underwent mechanical thrombectomy from 2016-2019 and only 5 patients required a decompressive hemicraniectomy (1.6%; p=0.002). Younger age (p<0.001), urinary tract infection (p<0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (p=0.004) CONCLUSIONS: This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for decompressive hemicraniectomy without increasing the risk of hemorrhagic conversion.
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http://dx.doi.org/10.1016/j.wneu.2021.08.138DOI Listing
September 2021

The Impact of Incorporating Evidence-Based Guidelines for Lumbar Fusion Surgery in Neurosurgical Resident Education.

World Neurosurg 2021 Jul 20. Epub 2021 Jul 20.

Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.

Background: Instrumented fusion procedures are essential in the treatment of degenerative lumbar spine disease to alleviate pain and improve neurological function, but they are being performed with increasing incidence and variability. We implemented a training module for neurosurgery residents that is based on evidence-based criteria for lumbar fusion surgery and measured its effectiveness in residents' decision making regarding whether patients should or should not undergo instrumented fusion.

Methods: The study design was a pretest versus posttest experiment conducted from September 2019 until July 2020 to measure improvement after formalized instruction on evidence-based guidelines. Neurosurgery residents of all training levels at our institution participated. A test was administered at the beginning of each academic year. The highest possible score was 18 points in each pretest and posttest.

Results: There was a general trend of test score improvement across all levels of training with a greater degree of change for participants with lower compared with higher pretest scores, indicating a possible ceiling effect. Paired t test demonstrated an overall mean score increase of 2 points (P < 0.0001), equivalent to an 11.11% increase (P < 0.0001). Stratified by training group, mean absolute change in test score was 2 (P = 0.0217), 1.67 (P = 0.0108), and 2.25 (P = 0.0173) points for junior, midlevel, and senior training groups, respectively.

Conclusions: Incorporating a targeted evidence-based learning module for lumbar spine fusion surgery can improve neurosurgery residents' clinical decision making toward a more uniform practice supported by published data.
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http://dx.doi.org/10.1016/j.wneu.2021.07.045DOI Listing
July 2021

Extruded disc causes acute cervical epidural hematoma and cord compression: a case report.

Spinal Cord Ser Cases 2021 May 21;7(1):39. Epub 2021 May 21.

Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.

Introduction: Cervical spontaneous epidural hematoma is a serious neurosurgical pathology that often requires prompt surgical intervention. While a variety of causes may contribute, the authors present the first case in the literature of cervical disc extrusion provoking epidural hemorrhage and acute neurological deterioration.

Case Presentation: A 65 year old male presented with six months of worsening signs and symptoms of cervical myelopathy. He had progressive deterioration over the course of two weeks leading to ambulatory dysfunction requiring a cane for assistance. While undergoing his medical workup in the emergency department, the patient became acutely plegic in the right lower extremity prompting emergent surgical decompression and stabilization.

Discussion: Based on imaging, pathology, and intraoperative findings, it was concluded that the patient had an extruded disc segment that may have precipitated venous bleeding in the epidural space and findings of acute cervical cord compression. Cervical disc extrusion may lead to venous damage, epidural hematoma, and spinal cord compression. If this unique presentation is recognized and addressed in a timely manner, patient outcomes may still be largely positive as this case demonstrates.
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http://dx.doi.org/10.1038/s41394-021-00403-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140160PMC
May 2021

Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19.

Clin Neurol Neurosurg 2021 Jul 13;206:106677. Epub 2021 May 13.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address:

Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.
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http://dx.doi.org/10.1016/j.clineuro.2021.106677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117485PMC
July 2021

Prediction of hematoma expansion in spontaneous intracerebral hemorrhage: Our institutional experience.

J Clin Neurosci 2021 Apr 19;86:271-275. Epub 2021 Feb 19.

Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States. Electronic address:

Background: Spontaneous intracerebral hemorrhage (sICH) is a disease process with high morbidity and mortality. In particular, hematoma expansion (HE) is a feared complication of sICH. With 15-40% of patients experiencing HE, it has become increasingly important to predict which sICH will remain stable and which will expand.

Objective: With new treatment options being developed, it is becoming increasingly important to be able to predict which hemorrhages are at high versus low risk for expansion. The authors of this study hope to reexamine variables associated with hematoma expansion in hopes of generating newer data on risk factors for expansion.

Methods: A retrospective analysis identified 334 patients who presented with sICH. The primary outcome was HE on follow up head CT. HE was defined as a greater than 33% increase or an absolute increase in 6 mL or more in overall volume between the two sets of CT images. Analysis was performed using unpaired t-test, Chi-square, and Fisher's exact tests, as appropriate.

Results: Of the 334 patients, 247 (74.0%) did not experience an expansion of their ICH while 87 (26.0%) did. Multivariable logistic regression was performed demonstrating ICH score of 3 or greater (4.76 (95% CI 2.60-8.72, p < 0.001) , cortical location of the sICH (1.77 (95% CI 1.03-3.04, p = 0.038), and presence of a fluid level (6.46 (95% CI 2.28-18.3, p < 0.001) as significant predictors of HE.

Conclusions: Our study found that fluid-fluid levels on non-contrast CT, an ICH score 3 or greater, and lobar sICH were all more likely to expand.
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http://dx.doi.org/10.1016/j.jocn.2021.01.046DOI Listing
April 2021

Comparison of Transradial vs Transfemoral Access in Neurovascular Fellowship Training: Overcoming the Learning Curve.

Oper Neurosurg (Hagerstown) 2021 06;21(1):E3-E7

Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.

Background: The transradial access (TRA) is rapidly gaining popularity for neuroendovascular procedures as there is strong evidence for its benefits compared to the traditional transfemoral access (TFA). However, the transition to TRA bears some challenges including optimization of the interventional suite set-up and workflow as well as its impact on fellowship training.

Objective: To compare the learning curves of TFA and TRA for diagnostic cerebral angiograms in neuroendovascular fellowship training.

Methods: We prospectively collected diagnostic angiogram procedural data on the performance of 2 neuroendovascular fellows with no prior endovascular experience who trained at our institution from July 2018 until June 2019. Metrics for operator proficiency were minutes of fluoroscopy time, procedure time, and volume of contrast used.

Results: A total of 293 diagnostic angiograms were included in the analysis. Of those, 57.7% were TRA and 42.3% were TFA. The median contrast dose was 60 cc, and the median radiation dose was 14 000 μGy. The overall complication rate was 1.4% consisting of 2 groin hematomas, 1 wrist hematoma, and 1 access-site infection using TFA. The crossover rate to TFA was 2.1%. Proficiency was achieved after 60 femoral and 95 radial cases based on fluoroscopy time, 52 femoral and 77 radial cases based on procedure time, and 53 femoral and 64 radial cases based on contrast volume.

Conclusion: Our study demonstrates that the use of TRA can be safely incorporated into neuroendovascular training without causing an increase in complications or significantly prolonging procedure time or contrast use.
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http://dx.doi.org/10.1093/ons/opab018DOI Listing
June 2021

A comparison of dual-lumen balloon and simple microcatheters in the embolization of DAVFs and AVMs using onyx.

J Clin Neurosci 2020 Nov 20;81:295-301. Epub 2020 Oct 20.

Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States. Electronic address:

Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30-0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04-0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00-11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs.
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http://dx.doi.org/10.1016/j.jocn.2020.10.007DOI Listing
November 2020

Onyx Embolization of Carotid-Cavernous Fistulas and Its Impact on Intraocular Pressure and Recurrence: A Case Series.

Oper Neurosurg (Hagerstown) 2021 01;20(2):174-182

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: Carotid-cavernous fistulas (CCFs) are acquired pathological shunting lesions between the carotid artery and the cavernous sinus leading to elevated intraocular pressure (IOP). CCFs are commonly treated via endovascular embolization, which theoretically restores physiological pressure differentials.

Objective: To present our institutional data with CCF treated with embolization and discuss endovascular routes, recurrence rates, and dynamic IOP changes.

Methods: Retrospective analysis of 42 CCF patients who underwent Onyx (Covidien, Irvine, California) embolization and pre- and postoperative IOP measurement at a single institution.

Results: CCFs were 19.0% direct (type A) and 81.0% indirect (types B, C, or D). Onyx-18 liquid embolisate was used during all embolizations. Overall rate of total occlusion was 83.3% and was statistically similar between direct and indirect fistulas. Preoperative IOP was elevated in 37.5%, 100.0%, 75.0%, and 50% in type A, B, C, and D fistulas, respectively. Average ΔIOP was -7.3 ± 8.5 mmHg (range: -33 to +8). Follow-up time was 4.64 ± 7.62 mo. Full angiographic occlusion was a predictor of symptom resolution at 1 mo (P = .026) and 6 mo (P = .021). Partial occlusion was associated with persistent symptoms postoperatively at 1 mo (P = .038) and 6 mo follow-up (P = .012). Beyond 6 mo, negative ΔIOP was associated with continued symptom improvement. Recurrence occurred in 9.5% of patients, all of which were indirect CCFs.

Conclusion: Onyx embolization of CCF is an effective treatment for CCF and often results in the reversal of IOP elevation. Full occlusion predicts favorable clinical outcomes up to 6 mo. Postoperative IOP reduction may indicate favorable long-term clinical outcomes.
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http://dx.doi.org/10.1093/ons/opaa308DOI Listing
January 2021

Developing standardized titles to classify the adverse events in 7,418 cranial and spinal neurosurgical procedures.

Clin Neurol Neurosurg 2020 11 1;198:106121. Epub 2020 Aug 1.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address:

Background: Neurosurgical procedures are life- and function-saving but carry a risk of adverse events (AE) which can cause permanent neurologic deficits. Unfortunately, there is lack of clearly defined AEs associated with given procedures, and their reporting is non-uniform and often arbitrary. However, with an increasing number of neurosurgical procedures performed, there is a need for standardization of AEs for systematic tracking. Such a system would establish a baseline for future quality improvement strategies.

Objective: To review our institutional AEs and devise standardized titles specific to the spine, tumor, functional, and vascular neurosurgery divisions.

Methods: A review of prospective monthly-reported morbidity and mortality (M&M) conference data within the Department of Neurological Surgery was conducted from January 2017 to December 2019. An AE was defined as any mortality, an "unintended and undesirable diagnostic or therapeutic event", "an event that prolongs the patient's hospital stay", or an outcome with permanent or transient neurologic deficit.

Results: A total of 1096 AEs from 7418 total procedures (14.8 %) were identified. Of those, 418 (5.6 %) were in cerebrovascular, 249 (3.4 %) were in neuro-oncology and 429 (5.8 %) were in the spine & functional divisions. The most common AEs across all divisions were infection (17 %), hemorrhage (11 %) and cerebrospinal fluid (CSF) leak (7.8 %). Other AEs were indirectly related to the neurosurgical procedure, such as deep vein thrombosis or pulmonary embolism (2.7 %), or pneumothorax (0.3 %).

Conclusion: This work illustrates standardized AEs can be implemented universally across the spectrum of neurological surgery. Standardization can help identify recurring AE patterns through better tracking.
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http://dx.doi.org/10.1016/j.clineuro.2020.106121DOI Listing
November 2020

Progression-Free but No Overall Survival Benefit for Adult Patients with Bevacizumab Therapy for the Treatment of Newly Diagnosed Glioblastoma: A Systematic Review and Meta-Analysis.

Cancers (Basel) 2019 Nov 4;11(11). Epub 2019 Nov 4.

Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON M5B 1A6, Canada.

Glioblastoma (GBM) is the most common high-grade primary brain tumor in adults. Standard multi-modality treatment of glioblastoma with surgery, temozolomide chemotherapy, and radiation results in transient tumor control but inevitably gives way to disease progression. The need for additional therapeutic avenues for patients with GBM led to interest in anti-angiogenic therapies, and in particular, bevacizumab. We sought to determine the efficacy of bevacizumab as a treatment for newly diagnosed GBM. We conducted a literature search using the PubMed database and Google Scholar to identify randomized controlled trials (RCTs) since 2014 investigating the safety and efficacy of bevacizumab in the treatment of adult patients (18 years and older) with newly diagnosed GBM. Only Level Ι data that reported progression-free survival (PFS) and overall survival (OS) were included for analysis. Random effects meta-analyses on studies with newly diagnosed glioblastoma were conducted in R to estimate the pooled hazard ratio (HR) for PFS and OS. Six RCTs met requirements for meta-analysis, revealing a pooled estimate of PFS HR suggesting a 33% decreased risk of disease progression (HR 0.67, 95% CI, 0.58-0.78; < 0.001) with bevacizumab therapy, but no effect on OS (HR = 1, 95% CI, 0.85-1.18; = 0.97). A pooled estimate of the mean difference in OS months of -0.13 predicts little difference in time of survival between treatment groups (95% CI, -1.87-1.61). The pooled estimate for the mean difference in PFS months was 2.70 (95% CI, 1.89-3.50; < 0.001). Meta-analysis shows that bevacizumab therapy is associated with a longer PFS in adult patients with newly diagnosed glioblastoma, but had an inconsistent effect on OS in this patient population.
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http://dx.doi.org/10.3390/cancers11111723DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6895972PMC
November 2019

Procarbazine, CCNU and vincristine (PCV) versus temozolomide chemotherapy for patients with low-grade glioma: a systematic review.

Oncotarget 2018 Sep 14;9(72):33623-33633. Epub 2018 Sep 14.

Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

Low-grade gliomas (LGG) encompass a heterogeneous group of tumors that are clinically, histologically and molecularly diverse. Treatment decisions for patients with LGG are directed toward improving upon the natural history while limiting treatment-associated toxiceffects. Recent evidence has documented a utility for adjuvant chemotherapy with procarbazine, CCNU (lomustine), and vincristine (PCV) or temozolomide (TMZ). We sought to determine the comparative utility of PCV and TMZ for patients with LGG, particularly in context of molecular subtype. A literature search of PubMed was conducted to identify studies reporting patient response to PCV, TMZ, or a combination of chemotherapy and radiation therapy (RT). Eligibility criteria included patients 16 years of age and older, notation of LGG subtype, and report of progression-free survival (PFS), overall survival (OS), and treatment course. Level I, II, and III data were included. Adjuvant therapy with PCV resulted in prolonged PFS and OS in patients with newly diagnosed high-risk LGG. This benefit was accrued most significantly by patients with tumors harboring 1p/19q codeletion and IDH1 mutation. Adjuvant therapy with temozolomide was associated with lower toxicity than therapy with PCV. In patients with LGG with an unfavorable natural history, such as with intact 1p/19q and wild-type IDH1, RT/TMZ plus adjuvant TMZ may be the best option. Patients with biologically favorable high-risk LGG are likely to derive the most benefit from RT and adjuvant PCV.
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http://dx.doi.org/10.18632/oncotarget.25890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154749PMC
September 2018
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