Browse

You are looking at 1 - 10 of 22 items for

  • By Author: Choudhri, Omar x
Clear All
Free access

Gregory Glauser, Tracy M. Flanders and Omar Choudhri

This video is a presentation of technical tenets for the microsurgical clipping of a tentorial dural arteriovenous fistula presenting with thalamic venous hypertension. These cases are easily misdiagnosed and often supplied by the tentorial artery of Davidoff and Schecter. The cases shown in the video uniquely illustrate a supracerebellar infratentorial approach to identify and clip an arterialized tentorial vein utilizing intraoperative Doppler and fluorescein, with navigation and an intraoperative cerebral angiogram in a hybrid neuroangiography operative suite. Both patients were found to have thalamic edema on preoperative imaging, which significantly improved postoperatively.

The video can be found here: https://youtu.be/HmUO6Ye53QI.

Restricted access

Michael Iv, Omar Choudhri, Robert L. Dodd, Shreyas S. Vasanawala, Marcus T. Alley, Michael Moseley, Samantha J. Holdsworth, Gerald Grant, Samuel Cheshier and Kristen W. Yeom

OBJECTIVE

Patients with brain arteriovenous malformations (AVMs) often require repeat imaging with MRI or MR angiography (MRA), CT angiography (CTA), and digital subtraction angiography (DSA). The ideal imaging modality provides excellent vascular visualization without incurring added risks, such as radiation exposure. The purpose of this study is to evaluate the performance of ferumoxytol-enhanced MRA using a high-resolution 3D volumetric sequence (fe-SPGR) for visualizing and grading pediatric brain AVMs in comparison with CTA and DSA, which is the current imaging gold standard.

METHODS

In this retrospective cohort study, 21 patients with AVMs evaluated by fe-SPGR, CTA, and DSA between April 2014 and August 2017 were included. Two experienced raters graded AVMs using Spetzler-Martin criteria on all imaging studies. Lesion conspicuity (LC) and diagnostic confidence (DC) were assessed using a 5-point Likert scale, and interrater agreement was determined. The Kruskal-Wallis test was performed to assess the raters’ grades and scores of LC and DC, with subsequent post hoc pairwise comparisons to assess for statistically significant differences between pairs of groups at p < 0.05.

RESULTS

Assigned Spetzler-Martin grades for AVMs on DSA, fe-SPGR, and CTA were not significantly different (p = 0.991). LC and DC scores were higher with fe-SPGR than with CTA (p < 0.05). A significant difference in LC scores was found between CTA and fe-SPGR (p < 0.001) and CTA and DSA (p < 0.001) but not between fe-SPGR and DSA (p = 0.146). A significant difference in DC scores was found among DSA, fe-SPGR, and CTA (p < 0.001) and between all pairs of the groups (p < 0.05). Interrater agreement was good to very good for all image groups (κ = 0.77–1.0, p < 0.001).

CONCLUSIONS

Fe-SPGR performed robustly in the diagnostic evaluation of brain AVMs, with improved visual depiction of AVMs compared with CTA and comparable Spetzler-Martin grading relative to CTA and DSA.

Free access

Brian P. Walcott, Jae Seung Bang, Omar Choudhri, Sirin Gandhi, Halima Tabani, Arnau Benet and Michael T. Lawton

A 46-year-old male presented with an incidentally discovered left ventricular body arteriovenous malformation (AVM). It measured 2 cm in diameter and had drainage via an atrial vein into the internal cerebral vein (Spetzler-Martin Grade III, Supplementary Grade 4). Preoperative embolization of the posterior medial choroidal artery reduced nidus size by 50%. Subsequently, he underwent a right-sided craniotomy for a contralateral transcallosal approach to resect the AVM. This case demonstrates strategic circumferential disconnection of feeding arteries (FAs) to the nidus, the use of aneurysm clips to control large FAs, and the use of dynamic retraction and importance of a generous callosotomy. Postoperatively, he was neurologically intact, and angiogram confirmed complete resection.

The video can be found here: https://youtu.be/j0778LfS3MI.

Full access

Kimon Bekelis, Ian D. Connolly, Huy M. Do and Omar Choudhri

OBJECTIVE

The impact of procedural volume on the outcomes of cerebrovascular surgery in children has not been determined. In this study, the authors investigated the association of operative volume on the outcomes of cerebrovascular neurosurgery in pediatric patients.

METHODS

The authors performed a cohort study of all pediatric patients who underwent a cerebrovascular procedure between 2003 and 2012 and were registered in the Kids' Inpatient Database (KID). To control for confounding, the authors used multivariable regression models, propensity-score conditioning, and mixed-effects analysis to account for clustering at the hospital level.

RESULTS

During the study period, 1875 pediatric patients in the KID underwent cerebrovascular neurosurgery and met the inclusion criteria for the study; 204 patients (10.9%) underwent aneurysm clipping, 446 (23.8%) underwent coil insertion for an aneurysm, 827 (44.1%) underwent craniotomy for arteriovenous malformation resection, and 398 (21.2%) underwent bypass surgery for moyamoya disease. Mixed-effects multivariable regression analysis revealed that higher procedural volume was associated with fewer inpatient deaths (OR 0.58; 95% CI 0.40–0.85), a lower rate of discharges to a facility (OR 0.87; 95% CI 0.82–0.92), and shorter length of stay (adjusted difference −0.22; 95% CI −0.32 to −0.12). The results in propensity-adjusted multivariable models were robust.

CONCLUSIONS

In a national all-payer cohort of pediatric patients who underwent a cerebrovascular procedure, the authors found that higher procedural volume was associated with fewer deaths, a lower rate of discharges to a facility, and decreased lengths of stay. Regionalization initiatives should include directing children with such rare pathologies to a center of excellence.

Full access

W. Caleb Rutledge, Omar Choudhri, Brian P. Walcott, Arnau Benet, Christine K. Fox, Nalin Gupta and Michael T. Lawton

Mutations in the smooth muscle–specific isoform of alpha actin (ACTA2) cause smooth muscle dysfunction in arteries. This rare loss-of-function mutation may cause a diffuse occlusive cerebral arteriopathy, resulting in stroke. While ACTA2 arteriopathy is often described as moyamoya-like, it has a distinct phenotype characterized by dilation of the proximal internal carotid artery (ICA) and occlusion of the terminal ICA and proximal middle cerebral artery. Intracranial arteries have an abnormally straight course, often with small aneurysms. There is limited experience with revascularization procedures for ACTA2 arteriopathy, and the safety and efficacy of these procedures are unknown. In this paper the authors present a symptomatic 6-year-old patient with ACTA2 cerebral arteriopathy who underwent both indirect revascularization and direct cerebrovascular bypass. Postoperatively, the patient suffered an ischemic infarct in a neighboring vascular territory. While direct cerebrovascular bypass is technically feasible, patients with ACTA2 arteriopathy may be at increased risk for perioperative stroke compared with patients with moyamoya disease.

Free access

Omar Choudhri and Michael T. Lawton

The middle tentorial incisural space, located lateral to the midbrain and medial to the temporal lobe, contains the ambient cistern through which courses the third, fourth, and fifth cranial nerves, posterior cerebral artery (PCA), superior cerebellar artery, and the choroidal arteries. Arteriovenous malformations (AVMs) in this compartment are supplied by the thalamogeniculate and posterior temporal branches of the PCA, and drain into tributaries of the basal vein of Rosenthal. We present a case of an AVM in this middle tentorial incisural space that persisted after embolization and radiosurgery, and was microsurgically resected through a subtemporal approach. This case demonstrates the anatomy of the middle incisural space and technical aspects in microsurgical resection of these rare AVMs.

The video can be found here: https://youtu.be/V-dIWh8ys3E.

Free access

Omar Choudhri and Gary K. Steinberg

Tentorial dural arteriovenous fistulae (TDAVFs) are complex lesions with the arteriovenous fistula located between the leaves of the tentorium cerebelli. While a large portion of dural arteriovenous fistulae are treated endovascularly, TDAVF may require additional microsurgical treatment given their high risk of hemorrhage and multitude of feeders. We describe the case of a 65-year-old male who presented with hemorrhage from a straight sinus and galenic TDAVF. The straight sinus portion of the fistula was obliterated by 3 endovascular treatments and 1 microsurgical treatment. The galenic component of the TDAVF persisted and was approached via a posterior interhemispheric approach in a lateral position. This video demonstrates surgical technique and anatomy associated with this rarely seen dural arteriovenous fistula.

The video can be found here: https://youtu.be/iOLzWOabLZ0.

Free access

Omar Choudhri and Steven D. Chang

Craniopharyngiomas are benign, partly cystic epithelial tumors that can rarely occur in a retrochiasmatic location with involvement of the third ventricle. The lamina terminalis is an important neurosurgical corridor to these craniopharyngiomas in the anterior portion of the third ventricle. We present a video case of a large midline suprasellar and third ventricular craniopharyngioma in a 32-year-old male with visual disturbances. The tumor was approached with a subfrontal translamina terminalis exposure, and a gross-total resection of the tumor was achieved. This surgery involved working through a lamina terminalis fenestration around the optic nerve, optic chiasm, optic tracts, and the anterior communicating artery complex. This video illustrates the techniques employed in performing a transbasal anterior skull base approach to the third ventricle and demonstrates vivid surgical anatomy of neurovascular structures around the lamina terminalis.

The video can be found here: https://youtu.be/fCYMgx8SnKs.

Free access

Omar Choudhri and Steven D. Chang

Pinealoblastomas are WHO grade IV tumors of the pineal region and comprise up to 50% of all pineal parenchymal tumors. They are highly aggressive tumors that spread along the craniospinal axis and are most commonly seen in children. The standard of care involves maximal surgical resection and chemoradiation following tissue diagnosis. We present the rare case of a large pinealoblastoma in an 18-year-old girl who presented with headaches and Parinaud's syndrome from tectal compression. An attempt was made at endoscopic transventricular biopsy of the tumor at an outside hospital, but it was aborted given bleeding at the biopsy site. We performed a supracerebellar infratentorial approach in a sitting position to achieve a gross-total resection of the tumor. This video case illustrates techniques for setting up a sitting craniotomy and approaching a previously biopsied hemorrhagic pinealoblastoma. The venous conglomerate at the tentorial incisura was found to be enveloped by the tumor and a thickened arachnoid scar. Surgical anatomy of the third ventricle and the pineal region is illustrated in this case through the process of surgical dissection and tumor resection.

The video can be found here: https://youtu.be/CzB0lFQ7AyI.