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Roham Moftakhar and Gregory R. Trost

The development of anterior cervical plates (ACPs) represents a rapidly changing aspect of spine surgery. This paper focuses on a historical overview of ACPs. The authors discuss the disadvantages of earlier generations of plates and demonstrate how current plates have been designed to overcome the presumed shortcomings of their predecessors.

This historical review begins with the earliest plates—unrestricted backout plates—and moves on to newer plates—restricted backout plates and their different subcategories.

Virtually all modern ACPs work equally well in cervical stabilization; however, there are differences in design that warrant future studies to understand the long-term performances of different plates.

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Lee A. Tan, Carter S. Gerard, Sumeet K. Ahuja and Roham Moftakhar

Cerebellopontine angle (CPA) lesions account for up to 10% of all intracranial tumors. The most common CPA lesions are vestibular schwannomas (70–80%), meningiomas (10–15%) and epidermoid cysts (5%). CPA tumors are estimated to be the secondary cause for up to 9.9% patients with trigeminal neuralgia. We demonstrate a case of medically refractory trigeminal neuralgia caused by a CPA meningioma that was successfully treated via retrosigmoid approach. The patient had immediate and dramatic symptomatic improvement after surgery. Detailed surgical techniques of retrosigmoid craniotomy and tumor dissection are presented in high definition video with narration.

The video can be found here: http://youtu.be/55j9QCQEsH8.

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Lee A. Tan, Manish K. Kasliwal, Roham Moftakhar and Lorenzo F. Munoz

Small-bowel ischemia and necrosis due to knotting of the peritoneal catheter is an extremely rare complication related to a ventriculoperitoneal shunt (VPS). A 3-month-old girl, with a history of Chiari II malformation and myelomeningocele (MM) after undergoing right occipital VPS insertion and MM repair at birth, presented to the emergency department with a high-grade fever. Examination of a CSF sample obtained via shunt tap raised suspicion for the presence of infection. Antibiotic therapy was initiated, and subsequently the VPS was removed and an external ventricular drain was placed. Intraoperatively, as attempts at pulling the distal catheter from the scalp incision were met with resistance, the distal catheter was cut and left in the abdomen while the remainder of the shunt system was successfully removed. While the patient was awaiting definitive shunt revision surgery to replace the VPS, she developed abdominal distension due to small-bowel obstruction. An emergency exploratory laparotomy revealed a knot in the distal catheter looping around and strangulating the distal ileum, causing small-bowel ischemia and necrosis in addition to the obstruction. A small-bowel resection with ileostomy was performed, with subsequent placement of ventriculoatrial shunt for treatment of hydrocephalus. The authors report this exceedingly rare clinical scenario to highlight the fact that any retained distal catheter must be carefully managed with immediate abdominal exploration to remove the distal catheter to avoid bowel necrosis as pulling of a knotted peritoneal catheter may strangulate the bowel and cause ischemia, with significant clinical morbidity and possible mortality.

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Lee A. Tan, Andrew K. Johnson, Kiffon M. Keigher, Roham Moftakhar and Demetrius K. Lopes

Y-stent–assisted coiling is a technique used by neuroendovascular surgeons to treat complex, wide-necked, bifurcation aneurysms in locations such as basilar tip and middle cerebral artery bifurcation. Several recent studies have demonstrated low complication rate and favorable clinical and angiographic outcomes. The Y-stent technique is illustrated here in detail and the intraoperative nuances are also discussed to minimize potential complications associated with technique.

The video can be found here: http://youtu.be/77pEmqx_fyQ.

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Lee A. Tan, Andrew K. Johnson, Kiffon M. Keigher, Roham Moftakhar and Demetrius K. Lopes

Cerebral arteriovenous malformations (AVMs) have an estimated 2–4% annual risk of hemorrhage. Treatment options for AVMs include microsurgical resection, stereotactic radiosurgery, and endovascular embolization. As endovascular technology and techniques continue to advance and mature, endovascular embolization is becoming an increasingly vital component of AVM treatment not only as a presurgical treatment to reduce microsurgical risks, but also as a stand-alone curative method in some cases. This case illustrates the successful and curative transarterial embolization of a right frontal AVM in a 17-year-old boy with ethylene-vinyl alcohol copolymer (Onyx).

The video can be found here: http://youtu.be/L4hE1MvCZCY.

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Stephan A. Munich, Lee A. Tan, Kiffon M. Keigher, Michael Chen, Roham Moftakhar and Demetrius K. Lopes

Object

Vertebrobasilar fusiform aneurysms (VFAs) are rare lesions characterized by abnormal dilation and tortuosity of the vertebral and/or basilar arteries. Untreated, these aneurysms have a tendency to progress, often resulting in neurological symptoms or rupture leading to subarachnoid hemorrhage. The microsurgical treatment of these lesions can be difficult due to their location and the circumferential involvement of the arteries. These features make microsurgical treatment prone to high morbidity. The Pipeline Embolization Device (PED) has gained popularity for the treatment of aneurysms of the internal carotid artery. Its use in the posterior circulation has been limited, likely due to a fear of perforating artery occlusion.

Methods

The authors retrospectively reviewed their database of patients treated with the PED and identified 12 patients who had VFAs. The clinical features, complications, and outcomes of these patients were analyzed.

Results

At an average follow-up of 11 months, the mean modified Rankin Scale score was 1.9. Complete aneurysm occlusion was seen in 90% of the patients with radiographic follow-up. Three patients suffered new neurological deficits postoperatively. One of these patients died, while the remaining 2 demonstrated significant clinical improvement at follow-up.

Conclusions

With attention to the anatomy of perforating arteries, staged contralateral vertebral artery sacrifice, and adequate platelet inhibition, PED may be an effective treatment option—alone or in a hybrid construct with stents of less coverage for VFAs—with an acceptable complication rate.

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Roham Moftakhar, Howard A. Rowley, Aquilla Turk, David B. Niemann, Beverly Aagaard Kienitz, Jamie Van Gomple and Mustafa K. Başkaya

Object

Digital subtraction (DS) angiography is the gold standard for detecting cerebral vasospasm after subarachnoid hemorrhage (SAH). Computed tomography (CT) perfusion is a recently developed modality for the evaluation of cerebral hemodynamics. This study was conducted to evaluate the potential of using CT perfusion to detect vasospasm in patients with SAH.

Methods

Fourteen patients between the ages of 41 and 66 years with aneurysmal SAH underwent 23 CT perfusion scans for suspected vasospasm. All patients underwent DS angiography within 12 hours of the CT perfusion scans. The presence of vasospasm on CT perfusion images was determined based on qualitative reading using color maps of mean transit time, cerebral blood flow, and cerebral blood volume as criteria. The presence or absence of vasospasm as retrospectively determined using CT perfusion was compared with DS angiography findings.

Of the 23 CT perfusion scans performed, 21 (91%) were concordant with angiography findings in predicting the presence or absence of vasospasm. In 15 of 23 scans, the presence of vasospasm was detected on CT perfusion scans and confirmed on DS angiography studies. In two cases, vasospasm was revealed on DS angiography but was not confirmed on CT perfusion. The degree of agreement between CT perfusion and DS angiography for detection of vasospasm was high (κ = 0.8, p < 0.0001).

Conclusions

Computed tomography perfusion is an accurate, reliable, and noninvasive method to detect the presence or absence of vasospasm. It can be used as a tool to help guide the decision to pursue DS angiography with the intent to treat vasospasm.

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David A. Stidd, Joshua Wewel, Ali J. Ghods, Stephan Munich, Anthony Serici, Kiffon M. Keigher, Heike Theessen, Roham Moftakhar and Demetrius K. Lopes

Object

Cerebrovascular lesions can have complicated abnormal anatomy that is not completely characterized by CT or MR angiography. Although 3D rotational angiography provides superior spatial and temporal resolution, catheter angiograms are not easily registered to the patient, limiting the use of these images as a source for neuronavigation. However, 3D digital subtraction angiography (DSA) contains not only vascular anatomy but also facial surface anatomy data. The authors report a novel technique to register 3D DSA images by using only the surface anatomy contained within the data set without having to fuse the DSA image set to other imaging modalities or use fiducial markers.

Methods

A cadaver model was first created to assess the accuracy of neuronavigation based on 3D DSA images registered by facial surface anatomy. A 3D DSA scan was obtained of a formalin-fixed cadaver head, with acquisitions of mask and contrast runs. The right common carotid artery was injected prior to the contrast run with a 45% contrast solution diluted with water-soluble red liquid latex. One week later, the head was registered to a neuronavigation system loaded with the 3D DSA images acquired earlier using facial surface anatomy. A right pterional craniotomy was performed and 10 different vascular landmarks were identified and measured for accuracy using the neuronavigation system. Neuronavigation based only on 3D DSA was then used to guide an open clipping procedure for a patient who presented with a ruptured distal lenticulostriate aneurysm.

Results

The accuracy of the measurements for the cadaver model was 0.71 ± 0.25 mm (mean ± SE), which is superior to the 1.8–5 mm reported for neuronavigation. The 3D DSA–based navigation-assisted surgery for the distal lenticulostriate aneurysm aided in localization, resulting in a small craniotomy and minimal brain dissection.

Conclusions

This is the first example of frameless neuronavigation based on 3D catheter angiography registered by only the surface anatomy data contained within the 3D DSA image set. This is an easily applied technique that is beneficial for accurately locating vascular pathological entities and reducing the dissection burden of vascular lesions.