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John D. Nerva, Peter S. Amenta, and Aaron S. Dumont

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John D. Nerva, Peter S. Amenta, and Aaron S. Dumont

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Tyler Scullen, Mansour Mathkour, John D. Nerva, Aaron S. Dumont, and Peter S. Amenta

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John D. Nerva, Peter S. Amenta, and Aaron S. Dumont

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Christopher Carr, Lora Kahn, Mansour Mathkour, Erin Biro, Cuong J. Bui, and Aaron S. Dumont

OBJECTIVE

The Global Burden of Disease (GBD) is an international collaboration and the largest comprehensive investigation of global health disease burden ever conducted. It has been particularly insightful for understanding disease demographics in middle-income nations undergoing rapid development, such as Vietnam, where 6 of the top 10 causes of death are relevant to the neurosurgeon. The burden of stroke—the number one cause of death in Vietnam—is particularly impressive. Likewise, road injuries, with a disproportionate rate of traumatic brain injury, continue to increase in Vietnam following economic development. Low-back and neck pain is the number one cause of disability. Simultaneously, more patients have access to care, and healthcare spending is increased.

METHODS

It is imperative that neurosurgical capital and infrastructure keep pace with Vietnam’s growth. The authors searched the existing literature for assessments of neurosurgical infrastructure or initiatives to address neurosurgical disease burden. Using GBD data, the authors also abstracted data for death by cause and prevalence of years of life lost due to disability (YLD) for common neurosurgical pathologies for Vietnam and comparison nations.

RESULTS

Interventions aimed at primary prevention of risk factors for neurosurgical disease and focused on the transference of self-sustainable technical skills were found to be analogous to those that have been successful in other regions. Efforts toward stroke prevention have been focused on causal risk factors. Multiple investigators have found that interventions aimed at increasing helmet use were successful in preventing traumatic brain injury. Government-led reforms and equipment donation programs have improved technical capacity. Nevertheless, Vietnam lags behind other nations in neurosurgeons per capita; cause-attributable death and YLD attributable to neurosurgical disease are considerably higher in Vietnam and middle-income nations compared to both lower-income nations and upper-income nations.

CONCLUSIONS

More than two-thirds of deaths attributable to neurosurgical pathologies in Vietnam and other middle-income nations were due to stroke, and one-fifth of both cause-attributable death and YLD was associated with neurosurgical pathologies. Vietnam and other middle-income nations continue to assume a global burden of disease profile that ever more closely resembles that of developed nations, with particular cerebrovascular, neurotrauma, and spinal disease burdens, leading to exponentially increased demand for neurosurgeons that threatens to outpace the training of neurosurgeons.

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Peter S. Amenta, Ricky Medel, and Aaron S. Dumont

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Nohra Chalouhi, Cory D. Bovenzi, Vismay Thakkar, Jeremy Dressler, Pascal Jabbour, Robert M. Starke, Sonia Teufack, L. Fernando Gonzalez, Richard Dalyai, Aaron S. Dumont, Robert Rosenwasser, and Stavropoula Tjoumakaris

Object

Aneurysm recurrence after coil therapy remains a major shortcoming in the endovascular management of cerebral aneurysms. The need for long-term imaging follow-up was recently investigated. This study assessed the diagnostic yield of long-term digital subtraction angiography (DSA) follow-up and determined predictors of delayed aneurysm recurrence and retreatment.

Methods

Inclusion criteria were as follows: 1) available short-term and long-term (> 36 months) follow-up DSA images, and 2) no or only minor aneurysm recurrence (not requiring further intervention, i.e., < 20%) documented on short-term follow-up DSA images.

Results

Of 209 patients included in the study, 88 (42%) presented with subarachnoid hemorrhage. On shortterm follow-up DSA images, 158 (75%) aneurysms showed no recurrence, and 51 (25%) showed minor recurrence (< 20%, not retreated). On long-term follow-up DSA images, 124 (59%) aneurysms showed no recurrence, and 85 (41%) aneurysms showed recurrence, of which 55 (26%) required retreatment. In multivariate analysis, the predictors of recurrence on long-term follow-up DSA images were as follows: 1) larger aneurysm size (p = 0.001), 2) male sex (p = 0.006), 3) conventional coil therapy (p = 0.05), 4) aneurysm location (p = 0.01), and 5) a minor recurrence on short-term follow-up DSA images (p = 0.007). Ruptured aneurysm status was not a predictive factor. The sensitivity of short-term follow-up DSA studies was only 40.0% for detecting delayed aneurysm recurrence and 45.5% for detecting delayed recurrence requiring further treatment.

Conclusions

The results of this study highlight the importance of long-term angiographic follow-up after coil therapy for ruptured and unruptured intracranial aneurysms. Predictors of delayed recurrence and retreatment include large aneurysms, recurrence on short-term follow-up DSA images (even minor), male sex, and conventional coil therapy.

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Stephen J. Monteith, Asterios Tsimpas, Aaron S. Dumont, Stavropoula Tjoumakaris, L. Fernando Gonzalez, Robert H. Rosenwasser, and Pascal Jabbour

Object

Despite advances in surgical and endovascular techniques, fusiform aneurysms remain a therapeutic challenge. Introduction of flow-diverting stents has revolutionized the treatment of aneurysms with wide necks and of complex morphology. The authors report their experience with the endovascular treatment of fusiform aneurysms using the Pipeline Embolization Device.

Methods

A retrospective review of 146 patients with cerebral aneurysms treated with the Pipeline Embolization Device between June 2011 and January 2013 was performed. Twenty-four patients were identified as having fusiform aneurysms. Twenty-four aneurysms in these 24 patients were treated. The mean patient age was 59 years. There were 9 men and 15 women. Angiographic and clinical data (including the modified Rankin Scale [mRS] score) were recorded at the time of treatment and at follow-up. The aneurysms were located in the internal carotid artery in 8 patients (33.3%), middle cerebral artery in 8 patients (33.3%), anterior cerebral artery in 1 patient (4%), and vertebrobasilar circulation in 7 patients (29%). The aneurysms were smaller than 10 mm in 3 patients, 10–25 mm in 16 patients, and larger than 25 mm in 5 patients. The mean largest dimension diameter was 18 mm.

Results

Stent deployment was successful in all cases. The minor procedural morbidity was 4% (1 case). Morbidity and mortality related to aneurysm treatment were 4.2% and 4.2%, respectively. The mean mRS scores preoperatively and at clinical follow-up (median 6.0 months, mean 6.9 months) were 0.71 and 1.2, respectively (91.7% presented with an mRS score of 2 or better, and 79.2% had an mRS score of 2 or better at the 6.0-month follow-up). At clinical follow-up, 82.6% of patients were stable or had improved, 13.0% worsened, and 4.2% had died. Twenty-two (91.7%) of 24 patients had follow-up angiography available (mean follow-up time 6.3 months); 59% had excellent angiographic results (> 95% or complete occlusion), 31.8% had complete aneurysm occlusion, 27.3% had greater than 95% aneurysm occlusion, 18.2% had a moderate decrease in size (50%–95%), 4.5% had a minimal decrease in size (< 50%), 13.6% had not changed, and 4.5% had an increase in size.

Conclusions

This series demonstrates that endovascular treatment of fusiform cerebral aneurysms with flow diversion was a safe and effective treatment. Procedural complications were low. Long-term morbidity and mortality rates were acceptable given the complex nature of these lesions.

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Ana Rodríguez-Hernández, Ahmed J. Awad, and Michael T. Lawton