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Piyush Kalakoti, Shyamal C. Bir, Richard D. Murray, Osama Ahmed and Anil Nanda

Broad-necked middle cerebral artery aneurysms present unique challenges for the vascular neurosurgeon, who must contend with smaller vessels and often a complex clipping strategy. Due to their superficial location, these lesions are still commonly selected for microsurgical clipping. We present a case of a 42-year-old woman with significant vascular disease with a right middle cerebral artery aneurysm. We discuss the key surgical steps, demonstrate the microsurgical dissection and intraoperative rupture encountered and the final clipping strategy, as well as the postoperative course in this operative video presentation.

The video can be found here: http://youtu.be/qZ2gvqz7XdQ.

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Piyush Kalakoti, Osama Ahmed, Papireddy Bollam, Symeon Missios, Jessica Wilden and Anil Nanda

OBJECT

With limited data available on association of risk factors and effect of hospital case volume on outcomes following deep brain stimulation (DBS), the authors attempted to identify these associations using a large population-based database.

METHODS

The authors performed a retrospective cohort study involving patients who underwent DBS for 3 primary movement disorders: Parkinson’s disease, essential tremor, and dystonia from 2002 to 2011 using the National (Nationwide) Inpatient Sample (NIS) database. Using national estimates, the authors identified associations of patient demographics, clinical characteristics, and hospital characteristics on short-term postoperative outcomes following DBS. Additionally, effect of hospital volume on unfavorable outcomes was investigated.

RESULTS

Overall, 33, 642 patients underwent DBS for 3 primary movement disorders across 234 hospitals in the US. The mean age of the cohort was 63.42 ± 11.31 years and 36% of patients were female. The inpatients’ postoperative risks were 5.9% for unfavorable discharge, 10.2% for prolonged length of stay, 14.6% for high-end hospital charges, 0.5% for wound complications, 0.4% for cardiac complications, 1.8% for venous thromboembolism, and 5.5% for neurological complications, including those arising from an implanted nervous system device. Compared with low-volume centers, odds of having an unfavorable discharge, prolonged LOS, high-end hospital charges, wound, and cardiac complications were significantly lower in the high-volume and medium-volume centers.

CONCLUSIONS

The authors’ study provides individualized estimates of the risks of postoperative complications based on patient demographics and comorbidities and hospital characteristics, which could potentially be used as an adjunct for risk stratification for patients undergoing DBS.

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Piyush Kalakoti, Richard D. Murray, Shyamal C. Bir, Osama Ahmed and Anil Nanda

With the advent of endovascular modalities, endovascular coiling has become a progressively more common method of addressing intracranial aneurysms. When despite coiling, an aneurysm continues to enlarge, open microsurgical clipping is a viable, though technically demanding option. We present a unique case of failed coiling of a giant ophthalmic region aneurysm, in which the aneurysm was successfully managed via open microsurgical approach. We highlight the unique challenges faced and demonstrate the surgical process in an operative video presentation.

The video can be found here: http://youtu.be/k2P4c4Lvq7g.

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Imad Saeed Khan, Osama Ahmed, Jai Deep Thakur, Cedric D. Shorter and Bharat Guthikonda

Klippel-Feil syndrome, or brevicollis, is a complex congenital disorder caused by the improper segmentation of the cervical vertebrae. The authors present the very rare case of a patient with Klippel-Feil syndrome who presented with an intradural arachnoid cyst at the craniocervical junction. They also examine possible factors contributing to this association.

A 46-year-old woman presented with complaints of progressively worsening headaches and dizziness of 18 months' duration. She also demonstrated mild bilateral upper-extremity weakness. Magnetic resonance imaging revealed fused cervical vertebrae and a dorsal intradural arachnoid cyst at the craniocervical junction, extending down to the fourth cervical level. Because of worsening myelopathy and the presence of brainstem compression, the patient underwent surgical excision of the arachnoid cyst, which was approached via a midline posterior suboccipital/upper cervical route. An endoscope was introduced through a gap between the occiput and fused upper cervical vertebrae, and the arachnoid cyst was widely fenestrated. Postoperatively, the patient has remained symptom free for more than 2 years with evidence of good radiological decompression.

The authors report a unique association between craniocervical arachnoid cyst and Klippel-Feil syndrome. To their knowledge, no other cases of this association have been reported in the literature. Arachnoid cysts should be part of the differential diagnosis in the presence of worsening myelopathic symptoms or pain in patients with Klippel-Feil syndrome.