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Thomas J. Buell, Davis G. Taylor, Ching-Jen Chen, and Bhiken I. Naik

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Ching-Jen Chen, Dwight Saulle, Kai-Ming Fu, Justin S. Smith, and Christopher I. Shaffrey

Object

This study was undertaken to evaluate the incidence of and risk factors associated with the development of dysphagia following same-day combined anterior-posterior cervical spine surgeries.

Methods

The records of 30 consecutive patients who underwent same-day combined anterior-posterior cervical spine surgery were reviewed. The presence of dysphagia was assessed by a formalized screening protocol using history/clinical presentation and a bedside swallowing test, followed by formal evaluation by speech and language pathologists and/or fiberoptic endoscopic evaluation of swallowing/modified barium swallow when necessary. Age, sex, previous cervical surgeries, diagnoses, duration of procedure, specific vertebral levels and number of levels operated on, degree of sagittal curve correction, use of anterior plate, estimated blood loss, use of recombinant human bone morphogenetic protein-2 (rhBMP-2), and length of hospital stay following procedures were analyzed.

Results

In the immediate postoperative period, 13 patients (43.3%) developed dysphagia. Outpatient follow-up data were available for 11 patients with dysphagia, and within this subset, all cases of dysphagia resolved subjectively within 12 months following surgery. The mean numbers of anterior levels surgically treated in patients with and without dysphagia were 5.1 and 4.0, respectively (p = 0.004). All patients (100%) with dysphagia had an anterior procedure that extended above C-4, compared with 58.8% of patients without dysphagia (p = 0.010). Patients with dysphagia had significantly greater mean correction of C2–7 lordosis than patients without dysphagia (p = 0.020). The postoperative sagittal occiput–C2 angle and the change in this angle were not significantly associated with the occurrence of dysphagia (p = 0.530 and p = 0.711, respectively). Patients with postoperative dysphagia had significantly longer hospital stays than those who did not develop dysphagia (p = 0.004). No other significant difference between the dysphagia and no-dysphagia groups was identified; differences with respect to history of previous anterior cervical surgery (p = 0.141), use of an anterior plate (p = 0.613), and mean length of anterior cervical operative time (p = 0.541) were not significant.

Conclusions

The incidence of dysphagia following combined anterior-posterior cervical surgery in this study was comparable to that of previous reports. The risk factors for dysphagia that were identified in this study were increased number of anterior levels exposed, anterior surgery that extended above C-4, and increased surgical correction of C2–7 lordosis.

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Thomas J. Buell, Daniel M. S. Raper, I. Jonathan Pomeraniec, Dale Ding, Ching-Jen Chen, Davis G. Taylor, and Kenneth C. Liu

Stenosis of the transverse sinus (TS) and sigmoid sinus (SS), with a trans-stenosis pressure gradient, has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH). MRI has shown improvement in TS and SS stenosis after high-volume lumbar puncture (HVLP) in a subset of patients with IIH. The authors present the first report of an IIH patient with immediate post-HVLP TS and SS trans-stenosis pressure gradient reduction and an attendant increase in TS and SS cross-sectional area confirmed using intravascular ultrasonography (IVUS). Recurrence of the patient’s TS-SS stenosis coincided with elevated HVLP opening pressure, and venous sinus stent placement resulted in clinical improvement. This report suggests that TS and SS stenosis may be a downstream effect of elevated intracranial pressure in IIH, rather than its principal etiological mechanism. However, the authors hypothesize that endovascular stenting may obliterate a positive feedback loop involving trans-stenosis pressure gradients, and still benefit appropriately selected patients.

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Davis G. Taylor, Thomas J. Buell, Tony R. Wang, Matthew J. Shepard, Dominic Maggio, Ching-Jen Chen, Min S. Park, and Mark E. Shaffrey

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Adeel Ilyas, Ching-Jen Chen, Dale Ding, Davis G. Taylor, Shayan Moosa, Cheng-Chia Lee, Or Cohen-Inbar, and Jason P. Sheehan

OBJECTIVE

Several recent studies have improved our understanding of the outcomes of volume-staged (VS) and dose-staged (DS) stereotactic radiosurgery (SRS) for the treatment of large (volume > 10 cm3) brain arteriovenous malformations (AVMs). In light of these recent additions to the literature, the aim of this systematic review is to provide an updated comparison of VS-SRS and DS-SRS for large AVMs.

METHODS

A systematic review of the literature was performed using PubMed to identify cohorts of 5 or more patients with large AVMs who had been treated with VS-SRS or DS-SRS. Baseline data and post-SRS outcomes were extracted for analysis.

RESULTS

A total of 11 VS-SRS and 10 DS-SRS studies comprising 299 and 219 eligible patients, respectively, were included for analysis. The mean obliteration rates for VS-SRS and DS-SRS were 41.2% (95% CI 31.4%–50.9%) and 32.3% (95% CI 15.9%–48.8%), respectively. Based on pooled individual patient data, the outcomes for patients treated with VS-SRS were obliteration in 40.3% (110/273), symptomatic radiation-induced changes (RICs) in 13.7% (44/322), post-SRS hemorrhage in 19.5% (50/256), and death in 7.4% (24/323); whereas the outcomes for patients treated with DS-SRS were obliteration in 32.7% (72/220), symptomatic RICs in 12.2% (31/254), post-SRS hemorrhage in 10.6% (30/282), and death in 4.6% (13/281).

CONCLUSIONS

Volume-staged SRS appears to afford higher obliteration rates than those achieved with DS-SRS, although with a less favorable complication profile. Therefore, VS-SRS or DS-SRS may be a reasonable treatment approach for large AVMs, either as stand-alone therapy or as a component of a multimodality management strategy.

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Dylan Russell, Travis Peck, Dale Ding, Ching-Jen Chen, Davis G. Taylor, Robert M. Starke, Cheng-Chia Lee, and Jason P. Sheehan

OBJECTIVE

Embolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).

METHODS

A literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.

RESULTS

Twelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.

CONCLUSIONS

Arteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.

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Adeel Ilyas, Ching-Jen Chen, Dale Ding, Panagiotis Mastorakos, Davis G. Taylor, I. Jonathan Pomeraniec, Cheng-Chia Lee, and Jason Sheehan

OBJECTIVE

Cyst formation can occasionally occur after stereotactic radiosurgery (SRS) for brain arteriovenous malformations (AVMs). Given the limited data regarding post-SRS cyst formation in patients with AVM, the time course, natural history, and management of this delayed complication are poorly defined. The aim of this systematic review was to determine the incidence, time course, and optimal management of cyst formation after SRS for AVMs.

METHODS

A literature review was performed using PubMed to identify studies reporting cyst formation in AVM patients treated with SRS. Baseline and outcomes data, including the incidence and management of post-SRS cysts, were extracted from each study that reported follow-up duration. The mean time to cyst formation was calculated from the subset of studies that reported individual patient data.

RESULTS

Based on pooled data from 22 studies comprising the incidence analysis, the overall rate of post-SRS cyst formation was 3.0% (78/2619 patients). Among the 26 post-SRS cyst patients with available AVM obliteration data, nidal obliteration was achieved in 20 (76.9%). Of the 64 cyst patients with available symptomatology and management data, 21 (32.8%) were symptomatic; 21 cysts (32.8%) were treated with surgical intervention, whereas the remaining 43 (67.2%) were managed conservatively. Based on a subset of 19 studies reporting individual time-to-cyst-formation data from 63 patients, the mean latency period to post-SRS cyst formation was 78 months (6.5 years).

CONCLUSIONS

Cyst formation is an uncommon complication after SRS for AVMs, with a relatively long latency period. The majority of post-SRS cysts are asymptomatic and can be managed conservatively, although enlarging or symptomatic cysts may require surgical intervention. Long-term follow-up of AVM patients is crucial to the appropriate diagnosis and management of post-SRS cysts.

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Panagiotis Mastorakos, Michael A. Hays, James P. Caruso, Ching-Jen Chen, Dale Ding, Davis G. Taylor, M. Beatriz Lopes, and Mark E. Shaffrey

Optic nerve glioblastoma is a rare entity that usually presents with rapidly progressive vision loss, which eventually results in blindness and, ultimately, death. As with malignant gliomas in other anatomical locations, local recurrence is common. Isolated rapid changes in vision, atypical neuroimaging findings, and the rarity of optic nerve glioblastoma may render diagnosis challenging and, thus, delay treatment. The authors present a case of optic nerve glioblastoma that was treated with subtotal resection followed by adjuvant radiation therapy and temozolomide. One year following the initial diagnosis, the patient developed a right cerebellar lesion, which was histopathologically consistent with glioblastoma. This case represents the first report of transtentorial dissemination of an optic nerve glioblastoma. In addition, the authors reviewed the literature regarding optic nerve glioblastomas. Of the 73 previously reported cases of malignant optic nerve gliomas, 32 were histologically confirmed glioblastomas. The mean age at diagnosis was 62 years, and 56% were male; the median survival was 7 months. A malignant glioma of the optic nerve should be considered in the differential diagnosis of a patient with rapidly progressive visual loss. However, the incidence of optic nerve glioblastoma is exceedingly low.

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Davis G. Taylor, Ching-Jen Chen, Thomas J. Buell, Min S. Park, J. Javier Provencio, and M. Yashar S. Kalani

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Ching-Jen Chen, Nisha Dabhi, M. Harrison Snyder, Natasha Ironside, Isaac Josh Abecassis, Ryan T. Kellogg, Min S. Park, and Dale Ding

OBJECTIVE

The long-term safety and efficacy of intrasaccular flow disruption (IFD) for the treatment of brain aneurysms remain unclear. With accumulating experience and increasing use of IFD devices, recent studies have provided additional data regarding their outcomes. This review summarizes the long-term outcomes of IFD-treated brain aneurysms.

METHODS

A systematic literature review was performed on May 23, 2021, in PubMed, Web of Science, and Ovid MEDLINE for aneurysm treatment outcomes with IFD devices. Procedural details, including use of adjunctive devices and complications, were collected. The quality of studies was assessed using the Downs and Black checklist. Angiographic outcomes were classified as complete occlusion, residual neck, and residual aneurysm. Other outcomes included need for retreatment, permanent neurological deficit, and mortality. Pooled analyses were performed.

RESULTS

The final analysis comprised 1217 patients with 1249 aneurysms from 22 studies. The mean aneurysm diameter and neck width were 6.9 and 4.5 mm, respectively, and 27.6% of aneurysms were ruptured. The complete occlusion rates at 12 months and final follow-up (pooled mean duration 15.7 months) were 50.1% and 58.2%, respectively. Adjunctive devices were used in 6.4% of cases. The rates of hemorrhage, symptomatic infarction, permanent neurological deficit, and mortality were 1.2%, 2.8%, 1.0%, and 2.6%, respectively.

CONCLUSIONS

IFD is a very safe treatment for appropriately selected brain aneurysms with low complication and neurological deterioration rates. However, complete occlusion is achieved in only half of IFD-treated aneurysms at 1 year with a modest increase beyond this time point. As the majority of the studies were single arm, the pooled data are subject to selection and reporting biases. Future device developments, increased operator experience, and direct comparisons with alternative endovascular strategies and surgical clipping may clarify the role of IFD in aneurysm management.