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  • Author or Editor: Aaron Dumont x
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D. Kojo Hamilton, Neal F. Kassell, Mary E. Jensen and Aaron S. Dumont

✓This 34-year-old man with a 10-year history of HIV infection presented with an acute onset of severe headache, fever, nausea, vomiting, and left-sided weakness. Computed tomography (CT) scanning demonstrated diffuse subarachnoid hemorrhage (SAH), and subsequent CT angiography revealed multiple large and giant intracranial aneurysms with diffuse vasculopathy. The patient's CD4-positive cell count was low, although he had been receiving combination antiret-roviral therapy and his viral load was undetectable.

The preponderance of the literature on HIV-infected patients with intracranial vascular involvement has concerned children in whom there is a high viral load. In such children, appropriate antiretroviral therapy may result in the complete resolution of these vascular abnormalities. In the present study, the authors report on the unique case of an HIV-infected adult patient who presented with SAH, diffuse intracranial vasculopathy, and multiple giant and fusiform aneurysms, despite having received adequate antiretroviral treatment and demonstrating an undetectable viral load. Intracranial vascular involvement in these patients may become increasingly common as the management of HIV infection continues to improve and afflicted patients survive for longer periods.

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Ricky Medel, R. Webster Crowley, D. Kojo Hamilton and Aaron S. Dumont

Pseudoaneurysms are rare lesions with a multitude of causes, including infectious, traumatic, and iatrogenic origins. In addition, there are a number of potential treatment options, all of which require consideration to determine the most appropriate management. Historically, surgical intervention has been the method of choice, but because the histopathological features of these lesions make them largely unsuitable for clipping, trapping or excision is often required. More recently endovascular methods have been used, including coil embolization, stent reconstruction, or parent artery occlusion. Although these methods are often successful, situations arise in which they are not technically feasible. The authors describe such a case in a pediatric patient with an iatrogenic pseudoaneurysm. Onyx was used to embolize the lesion and the results were excellent.

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D. Kojo Hamilton, Justin S. Smith, Charles A. Sansur, Aaron S. Dumont and Christopher I. Shaffrey


The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1–2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1–2 instability.


Forty-four consecutive patients (mean age 71 years) underwent C1–2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade.


Among all 44 patients, mean blood loss was 200 ml (range 100–350 ml) and mean operative time was 129 minutes (range 87–240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13–72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function.


In this series of C1–2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1–2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1–2 instrumented arthrodesis with C-2 neurectomy.