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Badih Daou, Christine Hammer, Nohra Chalouhi, Robert M. Starke, Pascal Jabbour, Robert H. Rosenwasser and Stavropoula Tjoumakaris

OBJECTIVE

Dissection of the carotid and vertebral arteries can result in the development of aneurysmal dilations. These dissecting pseudoaneurysms can enlarge and cause symptoms. The objective of this study is to provide insight into the progression of dissecting pseudoaneurysms and the treatments required to manage them.

METHODS

A review of the electronic medical records was conducted to detect patients with carotid and vertebral artery dissection. An imaging review was conducted to identify patients with dissecting pseudoaneurysms. One hundred twelve patients with 120 dissecting pseudoaneurysms were identified. Univariate and multivariate analyses were conducted to assess the factors associated with undergoing further interventions other than medical treatment, pseudoaneurysm enlargement, pseudoaneurysms resulting in ischemic and nonischemic symptoms, and clinical outcome.

RESULTS

Overall, 18.3% of pseudoaneurysms were intracranial and 81.7% were extracranial, and the average size was 7.3 mm. The mean follow-up time was 29.3 months; 3.3% of patients had a recurrent transient ischemic attack, no patients had a recurrent stroke, and 14.2% of patients had recurrence of nonischemic symptoms (headache, neck pain, Horner syndrome, or cranial nerve palsy). Follow-up imaging demonstrated that 13.8% of pseudoaneurysms had enlarged, 30.2% had healed, and 56% had remained stable. In total, 20.8% of patients had an intervention other than medical treatment. Interventions included stenting, coiling, flow diversion, and clipping. Predictors of intervention included increasing size, size > 10 mm, location in the C2 (petrous) segment of the internal carotid artery (ICA), younger age, hyperlipidemia, pseudoaneurysm enlargement, and any symptom development. Significant predictors of enlargement included smoking, history of trauma, C2 location, hyperlipidemia, and larger initial pseudoaneurysm size. Predictors of pseudoaneurysm resulting in recurrent ischemic and nonischemic symptoms included increasing size and location in the petrous segment of the ICA. Smoking was a predictor of unfavorable outcome.

CONCLUSIONS

Dissecting pseudoaneurysms have a benign course and most will not cause symptoms or enlarge on follow-up. Medical treatment can be a sufficient, initial treatment for dissecting pseudoaneurysms.

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Thana Theofanis, Nohra Chalouhi, Richard Dalyai, Robert M. Starke, Pascal Jabbour, Robert H. Rosenwasser and Stavropoula Tjoumakaris

Object

The authors conducted a study to assess the safety and efficacy of microsurgical resection of arteriovenous malformations (AVMs) and determine predictors of complications.

Methods

A total of 264 patients with cerebral AVMs were treated with microsurgical resection between 1994 and 2010 at the Jefferson Hospital for Neuroscience. A review of patient data was performed, including initial hemorrhage, clinical presentation, Spetzler-Martin (SM) grade, treatment modalities, clinical outcomes, and obliteration rates. Univariate and multivariate analyses were used to determine predictors of operative complications.

Results

Of the 264 patients treated with microsurgery, 120 (45%) patients initially presented with hemorrhage. There were 27 SM Grade I lesions (10.2%), 101 Grade II lesions (38.3%), 96 Grade III lesions (36.4%), 31 Grade IV lesions (11.7%), and 9 Grade V lesions (3.4%). Among these patients, 102 (38.6%) had undergone prior endovascular embolization. In all patients, resection resulted in complete obliteration of the AVM. Complications occurred in 19 (7.2%) patients and resulted in permanent neurological deficits in 5 (1.9%). In multivariate analysis, predictors of complications were increasing AVM size (OR 3.2, 95% CI 1.5–6.6; p = 0.001), increasing number of embolizations (OR 1.6, 95% CI 1.1–2.2; p = 0.01), and unruptured AVMs (OR 2.7, 95% CI 1–7.2; p = 0.05).

Conclusions

Microsurgical resection of AVMs is highly efficient and can be undertaken with low rates of morbidity at high-volume neurovascular centers. Unruptured and larger AVMs were associated with higher complication rates.

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Badih Daou, Elias Atallah, Nohra Chalouhi, Robert M. Starke, Jeffrey Oliver, Maria Montano, Pascal Jabbour, Robert H. Rosenwasser and Stavropoula I. Tjoumakaris

OBJECTIVE

The Pipeline embolization device (PED) has become a valuable tool in the treatment of cerebral aneurysms. Although failures with PED treatment have been reported, the characteristics and course of these aneurysms remain a topic of uncertainty.

METHODS

Electronic medical records and imaging studies were reviewed for all patients treated with the PED between July 2010 and March 2015 to identify characteristics of patients and aneurysms with residual filling after PED treatment.

RESULTS

Of 316 cases treated at a single institution, 281 patients had a long-term follow-up. A total of 52 (16.4%) aneurysms with residual filling were identified and constituted the study population. The mean patient age in this population was 58.8 years. The mean aneurysm size was 10.1 mm ± 7.15 mm. Twelve aneurysms were fusiform (23%). Of the aneurysms with residual filling, there were 20 carotid ophthalmic (CO) aneurysms (20% of all CO aneurysms treated), 10 other paraclinoid aneurysms (16.4% of all paraclinoid aneurysms), 7 posterior communicating artery (PCoA) aneurysms (21.9% of all PCoA aneurysms), 7 cavernous internal carotid artery (ICA) aneurysms (14.9% of all cavernous ICA aneurysms), 4 vertebrobasilar (VB) junction aneurysms (14.8% of all VB junction aneurysms), and 3 middle cerebral artery (MCA) aneurysms (25% of all MCA aneurysms). Eleven patients underwent placement of more than one PED (21.2%), with a mean number of devices of 1.28 per case. Eight of 12 aneurysms were previously treated with a stent (15.4%). Nineteen patients underwent re-treatment (36.5%); the 33 patients who did not undergo re-treatment (63.5%) were monitored by angiography or noninvasive imaging. In multivariate analysis, age older than 65 years (OR 2.65, 95% CI 1.33–5.28; p = 0.05), prior stent placement across the target aneurysm (OR 2.94, 95% CI 1.15–7.51; p = 0.02), aneurysm location in the distal anterior circulation (MCA, PCoA, and anterior choroidal artery: OR 2.72, 95% CI 1.19–6.18; p = 0.017), and longer follow-up duration (OR 1.06, 95% CI 1.03–1.09; p < 0.001) were associated with incomplete aneurysm occlusion.

CONCLUSIONS

While the PED can allow for treatment of large, broad-necked aneurysms with high efficacy, treatment failures do occur (16.4%). Aneurysm size, shape, and previous treatment may influence treatment outcome.

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Badih Daou, Elias Atallah, Nohra Chalouhi, Robert M. Starke, Jeffrey Oliver, Maria Montano, Pascal Jabbour, Robert H. Rosenwasser and Stavropoula I. Tjoumakaris

OBJECTIVE

The Pipeline embolization device (PED) has become a valuable tool in the treatment of cerebral aneurysms. Although failures with PED treatment have been reported, the characteristics and course of these aneurysms remain a topic of uncertainty.

METHODS

Electronic medical records and imaging studies were reviewed for all patients treated with the PED between July 2010 and March 2015 to identify characteristics of patients and aneurysms with residual filling after PED treatment.

RESULTS

Of 316 cases treated at a single institution, 281 patients had a long-term follow-up. A total of 52 (16.4%) aneurysms with residual filling were identified and constituted the study population. The mean patient age in this population was 58.8 years. The mean aneurysm size was 10.1 mm ± 7.15 mm. Twelve aneurysms were fusiform (23%). Of the aneurysms with residual filling, there were 20 carotid ophthalmic (CO) aneurysms (20% of all CO aneurysms treated), 10 other paraclinoid aneurysms (16.4% of all paraclinoid aneurysms), 7 posterior communicating artery (PCoA) aneurysms (21.9% of all PCoA aneurysms), 7 cavernous internal carotid artery (ICA) aneurysms (14.9% of all cavernous ICA aneurysms), 4 vertebrobasilar (VB) junction aneurysms (14.8% of all VB junction aneurysms), and 3 middle cerebral artery (MCA) aneurysms (25% of all MCA aneurysms). Eleven patients underwent placement of more than one PED (21.2%), with a mean number of devices of 1.28 per case. Eight of 12 aneurysms were previously treated with a stent (15.4%). Nineteen patients underwent re-treatment (36.5%); the 33 patients who did not undergo re-treatment (63.5%) were monitored by angiography or noninvasive imaging. In multivariate analysis, age older than 65 years (OR 2.65, 95% CI 1.33–5.28; p = 0.05), prior stent placement across the target aneurysm (OR 2.94, 95% CI 1.15–7.51; p = 0.02), aneurysm location in the distal anterior circulation (MCA, PCoA, and anterior choroidal artery: OR 2.72, 95% CI 1.19–6.18; p = 0.017), and longer follow-up duration (OR 1.06, 95% CI 1.03–1.09; p < 0.001) were associated with incomplete aneurysm occlusion.

CONCLUSIONS

While the PED can allow for treatment of large, broad-necked aneurysms with high efficacy, treatment failures do occur (16.4%). Aneurysm size, shape, and previous treatment may influence treatment outcome.

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Nohra Chalouhi, Pascal Jabbour, Robert M. Starke, Stavropoula I. Tjoumakaris, L. Fernando Gonzalez, Samantha Witte, Robert H. Rosenwasser and Aaron S. Dumont

Object

Surgical clipping of posterior inferior cerebellar artery (PICA) aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies. The authors assess the feasibility, safety, and efficacy of endovascular therapy in the largest series of proximal and distal PICA aneurysms to date.

Methods

A total of 76 patients, 54 with proximal and 22 with distal PICA aneurysms, underwent endovascular treatment at Jefferson Hospital for Neuroscience between 2001 and 2011.

Results

Endovascular treatment was successful in 52 patients (96.3%) with proximal aneurysms and 19 patients (86.4%) with distal aneurysms. Treatment consisted of selective aneurysm coiling in 60 patients (84.5%) (including 4 with stent assistance and 4 with balloon assistance) and parent vessel trapping in 11 patients (15.5%). Specifically, a deconstructive procedure was necessary in 9.6% of proximal aneurysms (5 of 52) and 31.6% of distal aneurysms (6 of 19). There were 9 overall procedural complications (12.7%), 6 infarcts (8.5%; 4 occurring after deliberate occlusion of the PICA), and 3 intraprocedural ruptures (4.2%). The rate of procedure-related permanent morbidity was 2.8%. Complete aneurysm occlusion was achieved in 63.4% of patients (45 of 71). One patient (1.4%) treated with selective aneurysm coiling suffered a rehemorrhage on postoperative Day 15. The mean angiographic follow-up time was 17.2 months. Recurrence and re-treatment rates were, respectively, 20% and 17.1% for proximal aneurysms compared with 30.8% and 23.1% for distal aneurysms. Favorable outcomes (moderate, mild, or no disability) at follow-up were seen in 93% of patients with unruptured aneurysms and in 78.7% of those with ruptured aneurysms.

Conclusions

Endovascular therapy is a feasible, safe, and effective treatment in patients with proximal and distal PICA aneurysms, providing excellent patient outcomes and adequate protection against rehemorrhage. The long-term incidence of aneurysm recanalization appears to be high, especially in distal aneurysms, and requires careful angiographic follow-up.

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Badih Daou, Edison P. Valle-Giler, Nohra Chalouhi, Robert M. Starke, Stavropoula Tjoumakaris, David Hasan, Robert H. Rosenwasser, Ryan Hebert and Pascal Jabbour

OBJECTIVE

The Pipeline Embolization Device (PED) has become an effective treatment strategy for some cerebral aneurysms. Concerns regarding the patency of branch arteries have been raised. The objective of this study was to assess the patency of the posterior communicating artery (PCoA) following treatment of PCoA aneurysms using the PED.

METHODS

All patients with PCoA aneurysms treated with the PED who had angiographic follow-up were retrospectively identified. The patency of the PCoA at follow-up was evaluated by 2 authors who were not involved in the intervention. Univariate and multivariate analyses were performed to identify factors associated with the following: 1) PCoA patency versus no or diminished flow, and 2) PCoA patency and diminished flow versus PCoA occlusion.

RESULTS

Thirty patients with an angiographic follow-up of 6 months were included. Aneurysm obliteration was achieved in 25 patients (83.3%). The PCoA was patent in 7 patients (23.3%), had diminished flow in 7 patients (23.3%), and was occluded in 16 patients (53.3%). In the univariate analysis of outcome, there was a trend for aneurysms with incomplete occlusion, aneurysms not previously treated, those with presence of a fetal PCoA, and those with an artery coming from the aneurysm to have higher odds of the PCoA remaining patent. In univariate and multivariate analyses of factors associated with outcome, fetal PCoA and presence of an artery coming from the aneurysm were associated with the PCoA remaining open with or without diminished flow. No patients had symptoms related to PCoA occlusion.

CONCLUSIONS

Occlusion and diminished flow through the PCoA is common following PED treatment of PCoA aneurysms. However, it is clinically insignificant in most cases.

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Badih Daou, Nohra Chalouhi, Robert M. Starke, Guilherme Barros, Lina Ya'qoub, John Do, Stavropoula Tjoumakaris, Robert H. Rosenwasser and Pascal Jabbour

OBJECTIVE

With the increasing number of aneurysms treated with endovascular coiling, more recurrences are being encountered. The aim of this study was to evaluate the efficacy and safety of microsurgical clipping in the treatment of recurrent, previously coiled cerebral aneurysms and to identify risk factors that can affect the outcomes of this procedure.

METHODS

One hundred eleven patients with recurrent aneurysms whose lesions were managed by surgical clipping between January 2002 and October 2014 were identified. The rates of aneurysm occlusion, retreatment, complications, and good clinical outcome were retrospectively determined. Univariate and multivariate logistic regressions were performed to identify factors associated with these outcomes.

RESULTS

The mean patient age was 50.5 years, the mean aneurysm size was 7 mm, and 97.3% of aneurysms were located in the anterior circulation. The mean follow-up was 22 months. Complete aneurysm occlusion, as assessed by intraoperative angiography, was achieved in 97.3% of aneurysms (108 of 111 patients). Among patients, 1.8% (2 of 111 patients) had a recurrence after clipping. Retreatment was required in 4.5% of patients (5 of 111) after clipping. Major complications were observed in 8% of patients and mortality in 2.7%. Ninety percent of patients had a good clinical outcome. Aneurysm size (OR 1.4, 95% CI 1.08–1.7; p = 0.009) and location in the posterior circulation were significantly associated with higher complications. All 3 patients who had coil extraction experienced a postoperative stroke. Aneurysm size (OR 1.2, 95% CI 1.02–1.45; p = 0.025) and higher number of interventions prior to clipping (OR 5.3, 95% CI 1.3–21.4; p = 0.019) were significant predictors of poor outcome. An aneurysm size > 7 mm was a significant predictor of incomplete obliteration and retreatment (p = 0.018).

CONCLUSIONS

Surgical clipping is safe and effective in treating recurrent, previously coiled cerebral aneurysms. Aneurysm size, location, and number of previous coiling procedures are important factors to consider in the management of these aneurysms.

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Badih Daou, Anthony P. Kent, Maria Montano, Nohra Chalouhi, Robert M. Starke, Stavropoula Tjoumakaris, Robert H. Rosenwasser and Pascal Jabbour

OBJECT

Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that puts them at risk of death unless intervention is performed. The purpose of this study was to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke.

METHODS

The authors conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both. Ninety-five individuals were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months).

RESULTS

The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4–6) in patients with a history of stroke (OR 6.54 [95% CI1.39–30.66]; p = 0.017), peak midline shift (MLS) > 10 mm (OR 3.35 [95% CI 1.33–8.47]; p = 0.011), or a history of myocardial infarction (OR 8.95 [95% CI1.10–72.76]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke (OR 9.14 [95% CI 1.78–47.05]; p = 0.008), MLS > 10 mm (OR 5.15 [95% CI 1.58–16.79; p = 0.007), a history of diabetes (OR 5.63 [95% CI 1.52–20.88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02–1.72]; p = 0.037), and evidence of pupillary dilation prior to DH (OR 4.19 [95% CI 1.06–16.51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days (OR 4.73 [95% CI 1.36–16.44]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outcome (OR 1.63 [95% CI 0.61–4.34]; p = 0.328).

CONCLUSIONS

History of stroke, diabetes, myocardial infarction, peak MLS > 10 mm, increasing duration from onset of stroke to DH, and presence of pupillary dilation prior to intervention are associated with a worse functional outcome.

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Nikolaos Mouchtouris, Michael J. Lang, Kaitlyn Barkley, Guilherme Barros, Justin Turpin, Ahmad Sweid, Robert M. Starke, Nohra Chalouhi, Pascal Jabbour, Robert H. Rosenwasser and Stavropoula Tjoumakaris

OBJECTIVE

The authors sought to determine the predictors of late neurological and hospital-acquired medical complications (HACs) in patients with low-grade aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

The authors conducted a retrospective study of 424 patients with low-grade aSAH admitted to their institution from 2008 to 2015. Data collected included patient comorbidities, Hunt and Hess (HH) grade, ICU length of stay (LOS), and complications. A logistic regression analysis was performed to determine the predictors for neurological and hospital-associated complications.

RESULTS

Out of 424 patients, 50 (11.8%) developed neurological complications after the first week, with a mean ICU stay of 16.3 ± 6.5 days. Of the remaining 374 patients without late neurological complications, 83 (22.2%) developed late HACs with a mean LOS of 15.1 ± 7.6 days, while those without medical complications stayed 11.8 ± 6.2 days (p = 0.001). Of the 83 patients, 55 (66.3%) did not have any HACs in the first week. Smoking (p = 0.062), history of cardiac disease (p = 0.043), HH grade III (p = 0.012), intraventricular hemorrhage (IVH) (p = 0.012), external ventricular drain (EVD) placement (p = 0.002), and early pneumonia/urinary tract infection (UTI)/deep vein thrombosis (DVT) (p = 0.001) were independently associated with late HACs. Logistic regression showed early pneumonia/UTI/DVT (p = 0.026) and increased HH grade (p = 0.057) to be significant risk factors for late medical complications.

CONCLUSIONS

While an extended ICU admission allows closer monitoring, low-grade aSAH patients develop HACs despite being at low risk for neurological complications. The characteristics of low-grade aSAH patients who would benefit from early discharge are reported in detail.

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