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Diana T. Le, Kinsey A. Barhorst, James Castiglione, George L. Yang, Sanjit J. Shah, Sarah S. Harlan, Shaun P. Keegan, Roman A. Jandarov, Laura B. Ngwenya, and Charles J. Prestigiacomo

OBJECTIVE

Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients.

METHODS

All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test.

RESULTS

Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148).

CONCLUSIONS

This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.

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Charles J. Prestigiacomo, Matthew J. Gounis, L. Fernando Gonzalez, and Juhana Frösen

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Brittany Staarmann, Matthew Smith, and Charles J. Prestigiacomo

Wall shear stress, the frictional force of blood flow tangential to an artery lumen, has been demonstrated in multiple studies to influence aneurysm formation and risk of rupture. In this article, the authors review the ways in which shear stress may influence aneurysm growth and rupture through changes in the vessel wall endothelial cells, smooth-muscle cells, and surrounding adventitia, and they discuss shear stress–induced pathways through which these changes occur.

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Nisha Giridharan, Smruti K. Patel, Amanda Ojugbeli, Aria Nouri, Peyman Shirani, Aaron W. Grossman, Joseph Cheng, Mario Zuccarello, and Charles J. Prestigiacomo

Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure without established etiology. Although there is now consensus on the definition of the disorder, its complex pathophysiology remains elusive. The most common clinical symptoms of IIH include headache and visual complaints. Many current theories regarding the etiology of IIH focus on increased secretion or decreased absorption of cerebrospinal fluid (CSF) and on cerebral venous outflow obstruction due to venous sinus stenosis. In addition, it has been postulated that obesity plays a role, given its prevalence in this population of patients. Several treatments, including optic nerve sheath fenestration, CSF diversion with ventriculoperitoneal or lumboperitoneal shunts, and more recently venous sinus stenting, have been described for medically refractory IIH. Despite the availability of these treatments, no guidelines or standard management algorithms exist for the treatment of this disorder. In this paper, the authors provide a review of the literature on IIH, its clinical presentation, pathophysiology, and evidence supporting treatment strategies, with a specific focus on the role of venous sinus stenting.

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Mark C. Preul, T. Forcht Dagi, Charles J. Prestigiacomo, and Chris A. Sloffer

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Ryan Holland, David Kopel, Peter W. Carmel, and Charles J. Prestigiacomo

Surgery of the mind has a rather checkered past. Though its history begins with the prehistoric trephination of skulls to allow “evil spirits” to escape, the early- to mid-20th century saw a surge in the popularity of psychosurgery. The 2 prevailing operations were topectomy and leukotomy for the treatment of certain mental illnesses. Although they were modified and refined by several of their main practitioners, the effectiveness of and the ethics involved with these operations remained controversial.

In 1947, Dr. J. Lawrence Pool and the Columbia-Greystone Associates sought to rigorously investigate the outcomes of specific psychosurgical procedures. Pool along with R. G. Heath and John Weber believed that nonexcessive bifrontal cortical ablation could successfully treat certain mental illnesses without the undesired consequences of irreversible personality changes. They conducted this investigation at the psychiatric hospital at Greystone Park near Morristown, New Jersey.

Despite several encouraging findings of the Columbia-Greystone project, psychosurgery practices began to decline significantly in the 1950s. The uncertainty of results and ethical debates related to side effects made these procedures unpopular. Further, groups such as the National Association for the Advancement of Colored People and the American Civil Liberties Union condemned the use of psychosurgery, believing it to be an inhumane form of treatment. Today, there are strict guidelines that must be adhered to when evaluating a patient for psychosurgery procedures. It is imperative for the neurosurgery community to remember the history of psychosurgery to provide the best possible current treatment and to search for better future treatments for a particularly vulnerable patient population.

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Victor M. Sabourin, Ryan Holland, Christine Mau, Chirag D. Gandhi, and Charles J. Prestigiacomo

The Civil War era was an age-defining period in the history of the United States of America, the effects of which are still seen in the nation today. In this era, the issue of head injury pervaded society. From the president of the United States, Abraham Lincoln, to the officers and soldiers of the Union and Confederate armies, and to the population at large, head injury and its ramifications gripped the nation. This article focuses on 3 individuals: Major General John Sedgwick, First Lieutenant Alonzo Cushing, and Harriet Tubman, as examples of the impact that head injury had during this era. These 3 individuals were chosen for this article because of their lasting legacies, contributions to society, and interesting connections to one another.

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Prateeka Koul, Christine Mau, Victor M. Sabourin, Chirag D. Gandhi, and Charles J. Prestigiacomo

World War I advanced the development of aviation from the concept of flight to the use of aircraft on the battlefield. Fighter planes advanced technologically as the war progressed. Fighter pilot aces Francesco Baracca and Manfred von Richthofen (the Red Baron) were two of the most famous pilots of this time period. These courageous fighter aces skillfully maneuvered their SPAD and Albatros planes, respectively, while battling enemies and scoring aerial victories that contributed to the course of the war. The media thrilled the public with their depictions of the heroic feats of fighter pilots such as Baracca and the Red Baron. Despite their aerial prowess, both pilots would eventually be shot down in combat. Although the accounts of their deaths are debated, it is undeniable that both were victims of traumatic head injury.

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Ryan Holland, Victor M. Sabourin, Chirag D. Gandhi, Peter W. Carmel, and Charles J. Prestigiacomo

As his fellow soldiers ran past him, Joseph Warren stood bravely on Bunker Hill. It was June 17, 1775, and British troops were fighting the colonists in one of the early battles of the American Revolution. The British had already attempted two major assaults that day, and the third would end with Warren’s death. He was a medical doctor, public figure, and general who spent his life and last living moments fighting for freedom for the American colonists.

After the battle, there was much confusion about what had happened to Joseph Warren. Some thought he had survived the battle; other accounts differed on how exactly he had died. The details of the events on Bunker Hill remained a mystery until the following year, when Paul Revere helped identify Warren’s body by the false teeth that had been implanted years earlier. Warren’s remains showed that his head had been struck by a bullet.

Analysis of the skull helped to sift through the differing tales of Warren’s death and thus unveil the truth about what occurred that day. The smaller bullet wound in the left maxilla suggests that he was not shot while retreating with the rest of the soldiers. The larger exit wound in the right occiput illustrates that the bullet’s trajectory crossed the midline of the brain and most likely injured the brainstem. Therefore, contrary to rumors that circulated at the time, Joseph Warren most likely was killed instantly at the Battle of Bunker Hill while heroically facing his enemy.