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Philipp Dammann, Adib A. Abla, Rustam Al-Shahi Salman, Hugo Andrade-Barazarte, Vladimir Benes, Marco Cenzato, E. Sander Connolly Jr., Jan F. Cornelius, William T. Couldwell, Rafael G. Sola, Santiago Gomez-Paz, Erik Hauck, Juha Hernesniemi, Juri Kivelev, Giuseppe Lanzino, R. Loch Macdonald, Jacques J. Morcos, Christopher S. Ogilvy, Hans-Jakob Steiger, Gary K. Steinberg, Alejandro N. Santos, Laurèl Rauschenbach, Marvin Darkwah Oppong, Börge Schmidt, Robert F. Spetzler, Karl Schaller, Michael T. Lawton, and Ulrich Sure

OBJECTIVE

Indication for surgery in brainstem cavernous malformations (BSCMs) is based on many case series, few comparative studies, and no randomized controlled trials. The objective of this study was to seek consensus about surgical management aspects of BSCM.

METHODS

A total of 29 experts were invited to participate in a multistep Delphi consensus process on the surgical treatment of BSCM.

RESULTS

Twenty-two (76%) of 29 experts participated in the consensus. Qualitative analysis (content analysis) of an initial open-ended question survey resulted in 99 statements regarding surgical treatment of BSCM. By using a multistep survey with 100% participation in each round, consensus was reached on 52 (53%) of 99 statements. These were grouped into 4 categories: 1) definitions and reporting standards (7/14, 50%); 2) general and patient-related aspects (11/16, 69%); 3) anatomical-, timing of surgery–, and BSCM-related aspects (22/37, 59%); and 4) clinical situation–based decision-making (12/32, 38%). Among other things, a consensus was reached for surgical timing, handling of associated developmental venous anomalies, handling of postoperative BSCM remnants, assessment of specific anatomical BSCM localizations, and treatment decisions in typical clinical BSCM scenarios.

CONCLUSIONS

A summary of typical clinical scenarios and a catalog of various BSCM- and patient-related aspects that influence the surgical treatment decision have been defined, rated, and interpreted.

Open access

Evan Joyce, Ramesh Grandhi, and William T. Couldwell

Arteriovenous malformations (AVMs) of the posterior fossa represent just 5%–15% of all intracranial AVMs. Rupture often leads to devastating brainstem compression, with mortality reported as high as 67%. A life-saving decompressive craniectomy with or without hematoma evacuation may be necessary in the acute setting to alleviate mass effect before proceeding with definitive treatment of the vascular pathology. Here, the authors demonstrate the utility of using a generously sized temporizing decompressive suboccipital craniectomy to subsequently allow for a more judicious resection of a Spetzler-Martin grade III AVM fed by the right superior cerebellar artery using a sitting supracerebellar infratentorial approach.

The video can be found here: https://youtu.be/L195wmw3p_4

Free access

Mitchell W. Couldwell, Samuel Cheshier, Philipp Taussky, Vance Mortimer, and William T. Couldwell

Moyamoya is an uncommon disease that presents with stenoocclusion of the major vasculature at the base of the brain and associated collateral vessel formation. Many pediatric patients with moyamoya present with transient ischemic attacks or complete occlusions. The authors report the case of a 9-year-old girl who presented with posterior fossa hemorrhage and was treated with an emergency suboccipital craniotomy for evacuation. After emergency surgery, an angiogram was performed, and the patient was diagnosed with moyamoya disease. Six months later, the patient was treated for moyamoya using direct and indirect revascularization; after surgery there was excellent vascularization in both regions of the bypass and no further progression of moyamoya changes. This case illustrates a rare example of intracerebral hemorrhage associated with moyamoya changes in the posterior vascularization in a pediatric patient and subsequent use of direct and indirect revascularization to reduce the risk of future hemorrhage and moyamoya progression.

Free access

Brianna C. Theriault, Julia Pazniokas, Anusha S. Adkoli, Edward K. Cho, Naina Rao, Meic Schmidt, Chad Cole, Chirag Gandhi, William T. Couldwell, Fawaz Al-Mufti, and Christian A. Bowers

OBJECTIVE

Frailty has been recognized as a predictor of adverse surgical outcomes across multiple surgical disciplines, but until now the relationship between frailty and intracranial meningioma surgery has not been studied. The goal of the present study was to determine the relationship between increasing frailty (determined using the modified Frailty Index [mFI]) and intracranial meningioma resection outcomes (including hospital length of stay [LOS], discharge location, and reoperation and readmission rates).

METHODS

This is a single-center retrospective cohort study of patients who underwent intracranial meningioma resection between August 2012 and May 2018. Seventy-six patients met the inclusion criteria.

RESULTS

Frailty was associated with increased hospital LOS (p = 0.0218), increased reoperation rate (p = 0.029), and discharge to a higher level of care: an inpatient rehabilitation facility or a skilled nursing facility (p = 0.0002). After multivariable analysis, frailty was determined to be an independent risk factor for increased LOS, worse discharge disposition, and subsequent readmission.

CONCLUSIONS

Frailty is an independent risk factor for worse outcomes following intracranial meningioma resection, including increased LOS, reoperations, and worse discharge disposition. Frailty may help stratify preoperative surgical risk, and thus may provide important clinical information to help neurosurgeons and elderly patients weigh the risks and benefits of resection.

Open access

Mitchell W. Couldwell, Vance Mortimer, AS, and William T. Couldwell

Microvascular decompression is a well-established technique used to relieve abnormal vascular compression of cranial nerves and associated pain. Here the authors describe three cases in which a sling technique was used in the treatment of cranial nerve pain syndromes: trigeminal neuralgia with predominant V2 distribution, hemifacial spasm, and geniculate neuralgia and right-sided ear pain. In each case, the artery was mobilized from the nerve and tethered with a sling. All three patients had reduction of symptoms within 6 weeks.

The video can be found here: https://youtu.be/iM7gukvPz6E

Free access

Martin H. Weiss, Gabriel Zada, John D. Carmichael, and William T. Couldwell

Free access

Douglas Kondziolka, William T. Couldwell, and James T. Rutka

Free access

Doug Kondziolka, William T. Couldwell, and James T. Rutka

Open access

Evan Joyce, Michael Karsy, Serge Makarenko, Gretchen M. Oakley, and William T. Couldwell

Anterior skull base approaches have included endoscopic or open microsurgical approaches for intracranial pathologies. However, discussion of a combined hybrid, cranioendoscopic approach, leveraging the benefits of both techniques, has been limited. Here we describe a case of a combined endoscopic, endonasal, and open microsurgical frontotemporal approach for resection of a complex anterior skull base lesion. A 62-year-old man with a large meningioma extending intradurally through the cribiform plate and sphenoethmoidal sinuses underwent a cranioendoscopic resection. Surgical techniques, including repair of the anterior skull base defect as well as complication avoidance and the coordination of multiple surgeons, are discussed.

The video can be found here: https://youtu.be/Ti9tUUdWgJc.