Browse

You are looking at 1 - 10 of 23 items for

  • By Author: Amin-Hanjani, Sepideh x
Clear All
Restricted access

Lukas Andereggen, Sepideh Amin-Hanjani, Marwan El-Koussy, Rajeev K. Verma, Kenya Yuki, Daniel Schoeni, Kety Hsieh, Jan Gralla, Gerhard Schroth, Juergen Beck, Andreas Raabe, Marcel Arnold, Michael Reinert and Robert H. Andres

OBJECTIVE

Cerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk.

METHODS

In this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors.

RESULTS

Twenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS.

CONCLUSIONS

Cerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.

Full access

Alexander Ivanov, Andreas Linninger, Chih-Yang Hsu, Sepideh Amin-Hanjani, Victor A. Aletich, Fady T. Charbel and Ali Alaraj

OBJECT

The use of digital subtraction angiography (DSA) for semiquantitative cerebral blood flow(CBF) assessment is a new technique. The aim of this study was to determine whether patients with aneurysmal subarachnoid hemorrhage (aSAH) with higher Hunt and Hess grades also had higher angiographic contrast transit times (TTs) than patients with lower grades.

METHODS

A cohort of 30 patients with aSAH and 10 patients without aSAH was included. Relevant clinical information was collected. A method to measure DSA TTs by color-coding reconstructions from DSA contrast-intensity images was applied. Regions of interest (ROIs) were chosen over major cerebral vessels. The estimated TTs included time-to-peak from 0% to 100% (TTP0–100), TTP from 25% to 100% (TTP25–100), and TT from 100% to 10% (TT100–10) contrast intensities. Statistical analysis was used to compare TTs between Group A (Hunt and Hess Grade I-II), Group B (Hunt and Hess Grade III-IV), and the control group. The correlation coefficient was calculated between different ROIs in aSAH groups.

RESULTS

There was no difference in demographic factors between Group A (n = 10), Group B (n = 20), and the control group (n = 10). There was a strong correlation in all TTs between ROIs in the middle cerebral artery (M1, M2) and anterior cerebral artery (A1, A2). There was a statistically significant difference between Groups A and B in all TT parameters for ROIs. TT100–10 values in the control group were significantly lower than the values in Group B.

CONCLUSIONS

The DSA TTs showed significant correlation with Hunt and Hess grades. TT delays appear to be independent of increased intracranial pressure and may be an indicator of decreased CBF in patients with a higher Hunt and Hess grade. This method may serve as an indirect technique to assess relative CBF in the angiography suite.

Full access

Matthew R. Reynolds, Robert T. Buckley, Santoshi S. Indrakanti, Ali H. Turkmani, Gerald Oh, Emanuela Crobeddu, Kyle M. Fargen, Tarek Y. El Ahmadieh, Andrew M. Naidech, Sepideh Amin-Hanjani, Giuseppe Lanzino, Brian L. Hoh, Bernard R. Bendok and Gregory J. Zipfel

OBJECT

Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain.

METHODS

This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy.

RESULTS

For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p < 0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p < 0.01).

CONCLUSIONS

For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.

Full access

Tarek Rayan and Sepideh Amin-Hanjani

With large or giant aneurysms, the use of multiple tandem clips can be essential for complete obliteration of the aneurysm. One potential disadvantage, however, is the considerable cumulative weight of these clips, which may lead to kinking of the underlying parent vessels and obstruction of flow. The authors describe a simple technique to address this problem, guided by intraoperative blood flow measurements, in a patient with a ruptured near-giant 2.2 × 1.7–cm middle cerebral artery bifurcation aneurysm that was treated with the tandem clipping technique. A total of 11 clips were applied in a vertical stacked fashion. The cumulative weight of the clips caused kinking of the temporal M2 branch of the bifurcation with reduction of flow. A 4-0 Nurolon suture tie was applied to the hub of one of the clips and was tethered to the dura of the sphenoid ridge by a small mini-clip and reinforced by application of tissue sealant. The patient underwent intraoperative indocyanine green videoangiography as well as catheter angiography, which demonstrated complete aneurysmal obliteration and preservation of vessel branches. Postoperative angiography confirmed patency of the bifurcation vessels with mild vasospasm. The patient had a full recovery with no postoperative complications and was neurologically intact at her 6-month follow-up. The suture retraction technique allows a simple solution to parent vessel obstruction following aneurysm tandem clipping, in conjunction with the essential guidance provided by intraoperative flow measurements.

Restricted access

Troy A. Munson, Tibor Valyi-Nagy, Manuel Utset, Zachary Lewis and Sepideh Amin-Hanjani

Hemangioendotheliomas have only rarely been encountered in the neuraxis. Here, the authors present a case of an intramedullary hobnail hemangioendothelioma of the spinal cord, the first case described of this particular pathological entity in the neuraxis. The authors discuss their treatment and review the pertinent literature regarding management.

Restricted access

Ziad A. Hage, Sepideh Amin-Hanjani, Dennis Wen and Fady T. Charbel

In this article, the authors describe the case of a 27-year-old female presenting with a 2-year history of neck pain and radiculopathy attributable to compression of the right C-7 nerve root by tortuosity of the vertebral artery at the level of the C6–7 cervical foramina. An anterolateral approach to the transverse foramen was used to perform a vascular decompression to decompress the nerve root. The procedure was uneventful, and the patient woke up with almost all of her symptoms resolved. The authors also include a literature review of techniques performed in this setting, showing that multiple surgical approaches can be used and should be tailored to the patient symptoms and lesion characteristics.

Restricted access

Omar M. Qahwash, Ali Alaraj, Victor Aletich, Fady T. Charbel and Sepideh Amin-Hanjani

Object

The goal of this study was to demonstrate feasibility and evaluate technical aspects of early endovascular access through extracranial-intracranial (EC-IC) bypass grafts.

Methods

Patients undergoing endovascular interventions through the graft in the acute postoperative period following EC-IC bypass are presented. Results, complications, and technical nuances are reviewed.

Results

Fourteen endovascular procedures were performed in 5 patients after EC-IC bypass for ruptured aneurysms in 4 patients and posterior circulation ischemia in 1 patient. In 2 patients, a saphenous vein graft (SVG) was used to bypass the common carotid artery (CCA) to the middle cerebral artery (MCA). One patient underwent a superficial temporal artery (STA)–MCA bypass, and in 2 other patients the STA stump was connected to the intracranial circulation via an interposition SVG. The interval from surgery to endovascular intervention spanned 2–18 days; the indication was intracranial vasospasm in all patients. One case involved angioplasty of the proximal anastomosis on postoperative Day 14. All other interventions entailed proximal access through the bypass conduit for intraarterial infusion of vasodilators. Significant vasospasm of the STA itself was encountered in 2 patients during endovascular manipulation, and it was treated with intraarterial nitroglycerin. There were no cases of anastomotic disruption.

Conclusions

Endovascular catheterization and intervention involving a recent EC-IC bypass is feasible. The main limitation in this series was catheter-induced vasospasm involving the STA. A vein graft may be the more appropriate option in patients with subarachnoid hemorrhage who may require subsequent endovascular intervention for vasospasm.

Restricted access

Ali Alaraj, Troy Munson, Sebastian R. Herrera, Victor Aletich, Fady T. Charbel and Sepideh Amin-Hanjani

Object

Cerebrospinal fluid hypotension, or “brain sag,” is a recently described phenomenon most commonly seen following craniotomy for the clipping of ruptured aneurysms along with preoperative lumbar drain placement. The clinical features and CT findings have been previously described. Clinical presentation can be similar to and often mistaken for cerebral vasospasm. In this study, the authors report on the angiographic findings in patients with brain sag.

Methods

Five cases of brain sag were diagnosed (range 1–4 days) after the surgical treatment of ruptured aneurysms at the University of Illinois at Chicago. All patients met the clinical and CT criteria for brain sag. Admission cerebral angiograms and subsequent angiograms during symptoms of brain sag were obtained in all patients. In 3 patients, angiography was performed after the resolution of symptoms.

Results

In all 5 patients, the level of the basilar artery apex was displaced inferiorly with respect to the posterior clinoid processes during brain sag. This displacement was significant enough to create a noticeable kink in the basilar artery (“cobra sign”) in 3 patients. Other angiographic findings included foreshortening or kinking of the intracranial vertebral artery. In all patients, the posterior cerebral arteries were displaced medially and inferiorly. Three patients were treated for simultaneous severe radiological vasospasm. In 4 patients, the brain sag was recognized, and the patients' conditions improved when they were placed flat or in the Trendelenburg position, at times combined with an epidural blood patch. Patients with follow-up angiography studies after the symptoms had resolved displayed a reversal of the angiographic features.

Conclusions

Brain sag appears to be associated with characteristic angiographic features. Recognizing these features may help to diagnose brain sag as the cause of neurological deterioration in this patient population.