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Women in neurosurgery: a cross-sectional demographic study of female neurosurgery residents in the United States

Kareem El Naamani, Maikerly Reyes, Georges Jreij, Marc Ghanem, Rawad Abbas, Marc Mounzer, Victoria Schunemann, Thana Theofanis, Michelle Smith, M. Reid Gooch, Robert H. Rosenwasser, Pascal M. Jabbour, and Stavropoula I. Tjoumakaris

OBJECTIVE

Over the past several decades, the number of women applying to medical school has increased significantly. However, parallel recruitment and retention of women in the field of neurosurgery continues to lag. The aim of this study was to identify the ratio and trend of female neurosurgery residents to the total number of residents during the past 7 years across all US neurosurgery residency programs.

METHODS

The authors conducted a cross-sectional demographic study investigating the ratio of female neurosurgery residents to the total number of neurosurgery residents across US neurosurgical programs from 2016 to 2022. Using the Fellowship and Residency Electronic Interactive Database, all neurosurgical residency programs in the US were collected. Data were further divided into postgraduate years 1–7 to dissect the data collection per residency year. One hundred fourteen programs were included in the study.

RESULTS

The number of female neurosurgery residents was 71 (29.8%) in 2022, 58 (25.2%) in 2021, 65 (27.9%) in 2020, 62 (27.3%) in 2019, 46 (21.4%) in 2018, 33 (15.2%) in 2017, and 34 (15.9%) in 2016. The trend line showed a significant increase using the Mann-Kendall test (p = 0.035). The total number of international medical graduate (IMG) female neurosurgery residents was 3 (4.2%) in 2022, 4 (6.9%) in 2021, 3 (4.6%) in 2020, 1 (1.6%) in 2019, 1 (2.2%) in 2018, 1 (3%) in 2017, and 2 (5.9%) in 2016.

CONCLUSIONS

The number of women matching into neurosurgery residency programs is modestly increasing, especially for IMG women. Future steps toward fewer gender disparities should focus on career advancement and leadership diversification in organized and academic neurosurgery.

In Journal of Neurosurgery Publish Before Print

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Transradial versus transfemoral access routes for diagnostic cerebral angiography: a large single-center comparative cost-analysis study

Elias Atallah, Kareem El Naamani, Arbaz A. Momin, Rawad Abbas, Paarth Jain, Adam Hunt, Abhijeet Sambangi, Angeleah Carreras, Omar El Fadel, M. Reid Gooch, Stavropoula Tjoumakaris, Hekmat Zarzour, Richard F. Schmidt, Nabeel A. Herial, Robert Rosenwasser, and Pascal Jabbour

OBJECTIVE

Recently, the transradial (TR) approach has become a common alternative because of its safety profile and increased patient satisfaction compared with the transfemoral (TF) route. Both routes are associated with their respective associated costs, and differences typically emerge on the basis of patient anatomy, operator expertise, and occurrence of complications. The authors’ objective was to compare the overall costs of diagnostic cerebral angiography via both routes and to shed light on the individual equipment costs of each route.

METHODS

This retrospective single-center study of 926 elective diagnostic angiograms was performed between December 2019 and March 2022.

RESULTS

The study comprised of 314 and 612 angiograms performed through the TF and TR routes, respectively. A significantly greater proportion of female patients were included in the TF cohort (79.3% vs 67.8%, p < 0.001), and most other demographic characteristics and baseline modified Rankin Scale scores were comparable between cohorts. The overall cost of patients utilizing the TR route was comparable to that of the TF route (mean ± SD $12,591.80 ± $19,128.00 vs $12,789.50 ± 18,424.00, p = 0.88). However, the median cost of catheters was significantly higher in TR group ($55.20 vs $12.40, p = 0.03), while the median costs of closure devices ($87.00 vs $20.20 p < 0.001) and sheaths ($44.60 ± 11.3 vs $41.10 ± 3.10, p < 0.001) were significantly higher in the TF group.

CONCLUSIONS

Overall, the authors’ study showed that the TR approach can be a less expensive option for patients undergoing diagnostic cerebral angiography, especially if complications occur. Future studies may corroborate these findings and potentially lead to the adoption of TR as a low-cost, efficient, gold-standard technique for cerebral angiography.

In Journal of Neurosurgery Publish Before Print

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First United States multicenter experience with the new-generation FRED X surface-modified flow diversion stent: feasibility, safety, and short-term efficacy

Rawad Abbas, Matthews Lan, Kareem El Naamani, Elias Atallah, Mohamed Salem, Jan-Karl Burkhardt, Anna Luisa Kühn, Ajit Puri, Andre Monteiro, Elad I. Levy, Nabeel A. Herial, M. Reid Gooch, Jeffrey Jabbour, Robert Rosenwasser, and Stavropoula I. Tjoumakaris

OBJECTIVE

Flow diversion created a paradigm shift in the treatment of intracranial aneurysms. The new flow redirection endoluminal device with X technology (FRED X) is the latest update of the recent Food and Drug Administration–approved FRED. The FRED X is engineered to reduce material thrombogenicity and enhance vessel healing. In this study, the authors aimed to evaluate the feasibility and early safety and efficacy of the new FRED X.

METHODS

The authors retrospectively collected and analyzed data from patients who had undergone flow diversion with the new FRED X at four tertiary cerebrovascular centers in the United States from February 2022 through July 2022.

RESULTS

Forty-four patients with 45 aneurysms treated using 46 devices comprised the overall study cohort and were divided into two groups: 39 patients with unruptured aneurysms and 5 patients with ruptured aneurysms. The mean patient age was 57.7 ± 9.1 years, and most patients were female (84%). Ninety-one percent of the aneurysms were saccular, with the majority (93%) located in the anterior circulation, specifically the posterior communicating (27%) and carotid ophthalmic (27%) territories. The mean maximum aneurysm diameter was 5.6 ± 4.6 mm, and 20% of the lesions had been previously treated. The mean procedure time was 61.6 minutes, with a mean cumulative fluoroscopy time of 24.6 minutes. Additionally, 7% of the lesions received adjunct treatment. Stent placement was successful in 100% of cases, achieving good wall apposition and complete neck coverage. Further, immediate aneurysm contrast stasis > 90% was observed in 61% of cases. Symptomatic postoperative complications occurred in 3 patients in the unruptured cohort and 1 patient in the ruptured cohort. All patients in the study were discharged on dual antiplatelet regimens with a modified Rankin Scale score of 0. At 6 months after treatment, 89% of cases had adequate occlusion, with < 6% of cases having asymptomatic in-stent stenosis. All patients had excellent functional outcomes.

CONCLUSIONS

FRED X for the treatment of an intracranial aneurysm is technically feasible alone or in conjunction with intrasaccular embolization. In addition, the study results showed very promising early safety and efficacy. Follow-up studies should establish the long-term safety and efficacy profiles of this new stent.

In Journal of Neurosurgery Publish Before Print

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Comparison of PED/PED Flex and PED Shield in the treatment of unruptured intracerebral aneurysms

Kareem El Naamani, Panagiotis Mastorakos, Clifford J. Yudkoff, Rawad Abbas, Stavropoula I. Tjoumakaris, M. Reid Gooch, Nabeel A. Herial, Robert H. Rosenwasser, Hekmat Zarzour, Richard F. Schmidt, and Pascal M. Jabbour

OBJECTIVE

The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity.

METHODS

This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors’ institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates.

RESULTS

The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts.

CONCLUSIONS

This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.

In Journal of Neurosurgery Publish Before Print

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Woven EndoBridge versus stent-assisted coil embolization of cerebral bifurcation aneurysms

Kareem El Naamani, Ching-Jen Chen, Rawad Abbas, Ahmad Sweid, Georgios S. Sioutas, Khodr Badih, Sunidhi Ramesh, Stavropoula I. Tjoumakaris, M. Reid Gooch, Nabeel A. Herial, Hekmat Zarzour, Richard F. Schmidt, Robert H. Rosenwasser, and Pascal M. Jabbour

OBJECTIVE

Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices.

METHODS

This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography.

RESULTS

The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385–6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107–0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116–0.795], p = 0.015) and multiple imputations.

CONCLUSIONS

Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.

In Journal of Neurosurgery Volume 137: Issue 6 (Dec 2022)

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Robot-assisted carotid artery stenting: outcomes, safety, and operational learning curve

Rawad Abbas, Fadi Al Saiegh, Kareem El Naamani, Ching-Jen Chen, Lohit Velagapudi, Georgios S. Sioutas, Joshua H. Weinberg, Stavropoula Tjoumakaris, M. Reid Gooch, Nabeel A. Herial, Robert H. Rosenwasser, and Pascal Jabbour

OBJECTIVE

Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution.

METHODS

A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period.

RESULTS

A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively).

CONCLUSIONS

Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.

In Neurosurgical Focus Volume 52 (2022): Issue 1 (Jan 2022): Robotics in Neurosurgery

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The Woven EndoBridge (WEB) device: feasibility, techniques, and outcomes after FDA approval

Nikolaos Mouchtouris, David Hasan, Edgar A. Samaniego, Fadi Al Saiegh, Ahmad Sweid, Rawad Abbas, Kareem El Naamani, Rizwan Tahir, Mario Zanaty, Omaditya Khanna, Nohra Chalouhi, Stavropoula Tjoumakaris, M. Reid Gooch, Robert Rosenwasser, and Pascal Jabbour

OBJECTIVE

Wide-neck bifurcation cerebral aneurysms have historically required either clip ligation or stent- or balloon-assisted coil embolization. This predicament led to the development of the Woven EndoBridge (WEB) aneurysm embolization system, a self-expanding mesh device that achieves intrasaccular flow disruption and does not require antithrombotic medications. The authors report their operative experience and 6-month follow-up occlusion outcomes with the first 115 aneurysms they treated via WEB embolization.

METHODS

The authors reviewed the first 115 cerebral aneurysms they treated by WEB embolization after FDA approval of the WEB embolization device (from February 2019 to January 2021). Data were collected on patient demographics and clinical presentation, aneurysm characteristics, procedural details, postembolization angiographic contrast stasis, and functional outcomes.

RESULTS

A total of 110 patients and 115 aneurysms were included in our study (34 ruptured and 81 unruptured aneurysms). WEB embolization was successful in 106 (92.2%) aneurysms, with a complication occurring in 6 (5.5%) patients. Contrast clearance was seen in the arterial phase in 14 (12.2%) aneurysms, in the capillary phase in 16 (13.9%), in the venous phase in 63 (54.8%), and no contrast was seen in 13 (11.3%) of the aneurysms studied. Follow-up angiography was performed on 60 (52.6%) of the aneurysms, with complete occlusion in 38 (63.3%), neck remnant in 14 (23.3%), and aneurysmal remnant in 8 (13.3%). Six (5.5%) patients required re-treatment for persistent aneurysmal residual on follow-up angiography.

CONCLUSIONS

The WEB device has been successfully used for the treatment of both unruptured and ruptured wide-neck bifurcation aneurysms by achieving intrasaccular flow diversion. Here, the authors have shared their experience with its unique technical considerations and device size selection, as well as critically reviewed complications and aneurysm occlusion rates.

In Journal of Neurosurgery Volume 136: Issue 5 (May 2022)

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Predictors of ventriculostomy infection in a large single-center cohort

Ahmad Sweid, Joshua H. Weinberg, Rawad Abbas, Kareem El Naamani, Stavropoula Tjoumakaris, Christine Wamsley, Erica J. Mann, Christopher Neely, Jeffery Head, David Nauheim, Julie Hauge, M. Reid Gooch, Nabeel Herial, Hekmat Zarzour, Tyler D. Alexander, Symeon Missios, David Hasan, Nohra Chalouhi, James Harrop, Robert H. Rosenwasser, and Pascal Jabbour

OBJECTIVE

External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI).

METHODS

The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018.

RESULTS

A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003).

CONCLUSIONS

The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

In Journal of Neurosurgery Volume 134: Issue null (Apr 2021)