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Complex basilar artery aneurysms treated using surgical basilar occlusion: a modern case series

Clinical article

Christopher P. Kellner, Raqeeb M. Haque, Philip M. Meyers, Sean D. Lavine, E. Sander Connolly Jr., and Robert A. Solomon

Object

Complex aneurysms of the basilar artery (BA) apex can be successfully treated using surgical occlusion of the proximal BA. Since the introduction of the Guglielmi detachable coil in 1991, the focus on treating BA aneurysms has been on using endovascular techniques. Outcomes with endovascular techniques have been less than optimal for large and complex aneurysms. The authors therefore report on their current 22-year experience with surgical BA occlusion for complex BA aneurysms and long-term outcome.

Methods

Fifteen patients underwent surgical BA occlusion at Columbia University Medical Center for complex basilar apex aneurysms between 1987 and 2009. The clinical records of each patient were reviewed for details of presentation, hospital course, operative intervention, and outcome.

Results

Postoperatively, all patient encounters were recorded at discharge, at the 1-month and 1-year follow-up evaluations, and at long-term outcome. Twelve (80%) of 15 patients experienced no new postoperative neurological deficits. Three patients presenting with severe neurological impairment (modified Rankin Scale [mRS] score > 3) made excellent recoveries (mRS Scores 1–2) at long-term follow-up. One patient died, 1 suffered a stroke during the postoperative angiogram which resulted in hemiparesis, and 1 suffered internuclear ophthalmoplegia which resolved by the 1-month follow-up. Long-term follow-up occurred at an average of 3 ± 4.5 years, ranging from 2 months (for a recently treated patient) to 18 years. The average mRS score at long-term follow-up was 1 ± 1.5. No patient experienced postoperative hemorrhage, rebleeding, or delayed neurological deterioration.

Conclusions

Surgical occlusion of the BA is an effective treatment option offering a high rate of angiographic cure in a single procedure for patients with complex BA aneurysms. The ability to surgically perform point occlusion of the BA without impairment of brainstem perforators, while maintaining collateral blood flow to the posterior circulation branch vessels, may provide an advantage compared with endovascular treatments.

In Journal of Neurosurgery Volume 115 (2011): Issue 2 (Aug 2011)

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An analysis of malpractice litigation in the surgical management of carotid artery disease

Jack J. Haslett, Lindsey A. LaBelle, Xiangnan Zhang, J Mocco, Joshua Bederson, and Christopher P. Kellner

OBJECTIVE

Carotid artery disease is a common illness that can pose a significant risk if left untreated. Treatment via carotid endarterectomy (CEA) or carotid artery stenting (CAS) can also lead to complications. Given the risk of adverse events related to treating, or failing to treat, carotid artery disease, this is a possible area for litigation. The aim of this review is to provide an overview of the medicolegal factors involved in treating patients suffering carotid artery disease and to compare litigation related to CEA and CAS.

METHODS

Three large legal databases were used to search for jury verdicts and settlements in cases related to untreated carotid artery disease, CEA, and CAS. Search terms included “endarterectomy,” “medical malpractice,” “carotid,” “stenosis,” “stenting,” “stent,” and combinations of those words. Three types of cases were considered relevant: 1) cases in which the primary allegation was negligence performing a CEA or perioperative care (CEA-related cases); 2) cases in which the primary allegation was negligence performing a CAS or perioperative care (CAS-related cases); and 3) cases in which the plaintiff alleged that a CEA or CAS should have been performed (failure-to-treat [FTT] cases).

RESULTS

One hundred fifty-four CEA-related cases, 3 CAS-related cases, and 67 FTT cases were identified. Cases resulted in 133 verdicts for the defense (59%), 64 settlements (29%), and 27 plaintiff verdicts (12%). The average payout in cases that were settled outside of court was $1,097,430 and the average payout in cases that went to trial and resulted in a plaintiff verdict was $2,438,253. Common allegations included a failure to diagnose and treat carotid artery disease in a timely manner, treating with inappropriate indications, procedural error, negligent postprocedural management, and lack of informed consent. Allegations of a failure to timely treat known carotid artery disease were likely to lead to a payout (60% of cases involved a payout). Allegations of procedural error, specifically where the resultant injury was nerve injury, were relatively less likely to lead to a payout (28% of cases involved a payout).

CONCLUSIONS

Both diagnosing and treating carotid artery disease has serious medicolegal implications and risks. In cases resulting in a plaintiff verdict, the payouts were significantly higher than cases resolved outside the courtroom. Knowledge of common allegations in diagnosing and treating carotid artery disease as well as performing CEA and CAS may benefit neurosurgeons. The lack of CAS-related litigation suggests these procedures may entail a lower risk of litigation compared to CEA, even accounting for the difference in the frequency of both procedures.

In Journal of Neurosurgery Volume 132: Issue 6 (Jun 2020)

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Endovascular occlusion of a ruptured transitional aneurysm associated with a developmental venous anomaly

Case report

Andrew F. Ducruet, Christopher P. Kellner, E. Sander Connolly Jr., and Philip M. Meyers

Developmental venous anomalies (DVAs) represent a rare cause of intraparenchymal hemorrhage. This case demonstrates an unusual DVA associated with venous hypertension, arteriovenous shunting, and a ruptured transitional aneurysm. The authors describe the first use of embolization as a treatment method for an unstable ruptured transitional aneurysm associated with a DVA. This 33-year-old man suffered acute onset of headache, gait ataxia, and left hemiparesis. Computed tomography brain scans demonstrated a deep paramedian right frontal intraparenchymal hemorrhage. No cavernous malformation was apparent on MR imaging. Diagnostic angiography revealed arteriovenous shunting from the right anterior and middle cerebral arteries to a large DVA with an associated arteriovenous fistula, with a 3-mm aneurysm in the transition from pericallosal artery to the collecting vein. Both surgical and endovascular treatment options were considered. The patient underwent repeat angiography on hospital Day 7, at which time the aneurysm had increased to 5 mm, and endovascular treatment was selected. Acrylic occlusion of the aneurysm was performed and confirmed angiographically. The patient's neurological symptoms resolved throughout the hospital stay, and he remains symptom free in the 10 months since treatment. Developmental venous anomalies are not usually associated with arteriovenous shunting and aneurysms as a source of intraparenchymal hemorrhage. Endovascular occlusion of the aneurysm without blockage of physiologically necessary venous structures is a possible method of treatment for this complex mixed vascular lesion, and has proven safe and effective in this patient. To the authors' knowledge, this is the first presentation of this situation in the literature.

In Neurosurgical Focus Volume 26: Issue 5 (May 2009): Vascular Neurosurgery

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Brain-computer interfaces: military, neurosurgical, and ethical perspective

Ivan S. Kotchetkov, Brian Y. Hwang, Geoffrey Appelboom, Christopher P. Kellner, and E. Sander Connolly Jr.

Brain-computer interfaces (BCIs) are devices that acquire and transform neural signals into actions intended by the user. These devices have been a rapidly developing area of research over the past 2 decades, and the military has made significant contributions to these efforts. Presently, BCIs can provide humans with rudimentary control over computer systems and robotic devices. Continued advances in BCI technology are especially pertinent in the military setting, given the potential for therapeutic applications to restore function after combat injury, and for the evolving use of BCI devices in military operations and performance enhancement. Neurosurgeons will play a central role in the further development and implementation of BCIs, but they will also have to navigate important ethical questions in the translation of this highly promising technology. In the following commentary the authors discuss realistic expectations for BCI use in the military and underscore the intersection of the neurosurgeon's civic and clinical duty to care for those who serve their country.

In Neurosurgical Focus Volume 28 (2010): Issue 5 (May 2010)

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The evolution of endovascular electroencephalography: historical perspective and future applications

Roberta K. Sefcik, Nicholas L. Opie, Sam E. John, Christopher P. Kellner, J Mocco, and Thomas J. Oxley

Current standard practice requires an invasive approach to the recording of electroencephalography (EEG) for epilepsy surgery, deep brain stimulation (DBS), and brain-machine interfaces (BMIs). The development of endovascular techniques offers a minimally invasive route to recording EEG from deep brain structures. This historical perspective aims to describe the technical progress in endovascular EEG by reviewing the first endovascular recordings made using a wire electrode, which was followed by the development of nanowire and catheter recordings and, finally, the most recent progress in stent-electrode recordings. The technical progress in device technology over time and the development of the ability to record chronic intravenous EEG from electrode arrays is described. Future applications for the use of endovascular EEG in the preoperative and operative management of epilepsy surgery are then discussed, followed by the possibility of the technique's future application in minimally invasive operative approaches to DBS and BMI.

In Neurosurgical Focus Volume 40 (2016): Issue 5 (May 2016): Neurorestoration: Re-Animating the CNS

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Surgical management of ventral intradural spinal lesions

Clinical article

Peter D. Angevine, Christopher Kellner, Raqeeb M. Haque, and Paul C. McCormick

Object

Access to the ventral intradural spinal canal may be required for treatment of a variety of lesions affecting the spinal cord and adjacent intradural structures. Adequate exposure is usually achieved through a standard posterior laminectomy or posterolateral approaches, although formal anterior approaches are used to access lesions in the subaxial cervical spine. Modifications of the standard posterior exposure as well as ventral or ventrolateral approaches are increasingly being used for treating intradural spinal pathologies. In this study, the authors review their experience with 35 consecutive cases of ventral intradural spinal lesions.

Methods

Only patients with intradural lesions located completely ventral to the dentate ligament attachments were included in this retrospective study. Patients with the following lesions were excluded from the study: lesions at the level of the filum terminale/cauda equina, lesions with any component that extended dorsally to the dentate ligament, or lesions with extradural extension (that is, dumbbell tumors) below the C-2 level. Between January 2000 and September 2009, a total of 35 patients (age range 17–72 years, mean 42.6 years) with ventral intradural spinal pathology underwent surgery at the authors' institution.

Results

There were 28 intradural extramedullary mass lesions: 15 meningiomas, 12 solitary schwannomas, and 1 neuroenteric cyst. Surgical approaches to these lesions included 23 posterior or posterolateral approaches, 4 anterior approaches with corpectomy followed by tumor resection and reconstruction, and 1 lateral transforaminal resection. No patient had evidence of instability at follow-up, which ranged from 6 months to 8 years in duration. One patient had worsened spinal cord function following surgery. There were 7 patients with intramedullary lesions: 2 hemangioblastomas, 2 cavernous malformations, 2 perimedullary fistulas, and 1 astrocytoma. All but 1 were superficial pia-based lesions arising ventral to the dentate ligament. Five of the 6 pia-based lesions were successfully resected via a standard posterior laminectomy, partial facetectomy with dentate section, and spinal cord rotation. One midline pial lesion was successfully removed with a minimally invasive retropleural thoracotomy. The astrocytoma was resected through an anterior cervical corpectomy, which was followed by instrumented reconstruction. There were no significant complications or neurological morbidity at follow-up (range 9 months–6 years).

Conclusions

Most intradural spinal lesions can be treated with contemporary microsurgical techniques with long-term control or cure of the lesion and preservation of neurological function. Standard posterior approaches provide adequate exposure to safely remove the vast majority of these lesions without the need for a potentially destabilizing resection of the facet or pedicle. Posterior exposures with varying degrees of lateral bone resection, dentate ligament division, and gentle cord rotation may also provide adequate exposure for safe removal of nonmidline ventrolateral superficial pial presenting spinal cord lesions. Nevertheless, in certain cases of ventral intradural lesions, anterior approaches are necessary and should be considered under appropriate circumstances.

In Journal of Neurosurgery: Spine Volume 15 (2011): Issue 1 (Jul 2011)

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Radiographic absence of the posterior communicating arteries and the prediction of cognitive dysfunction after carotid endarterectomy

Clinical article

Eric S. Sussman, Christopher P. Kellner, Joanna L. Mergeche, Samuel S. Bruce, Michael M. McDowell, Eric J. Heyer, and E. Sander Connolly

Object

Approximately 25% of patients exhibit cognitive dysfunction 24 hours after carotid endarterectomy (CEA). One of the purported mechanisms of early cognitive dysfunction (eCD) is hypoperfusion due to inadequate collateral circulation during cross-clamping of the carotid artery. The authors assessed whether poor collateral circulation within the circle of Willis, as determined by preoperative CT angiography (CTA) or MR angiography (MRA), could predict eCD.

Methods

Patients who underwent CEA after preoperative MRA or CTA imaging and full neuropsychometric evaluation were included in this study (n = 42); 4 patients were excluded due to intraoperative electroencephalographic changes and subsequent shunt placement. Thirty-eight patients were included in the statistical analyses. Patients were stratified according to posterior communicating artery (PCoA) status (radiographic visualization of at least 1 PCoA vs of no PCoAs). Variables with p < 0.20 in univariate analyses were included in a stepwise multivariate logistic regression model to identify predictors of eCD after CEA.

Results

Overall, 23.7% of patients exhibited eCD. In the final multivariate logistic regression model, radiographic absence of both PCoAs was the only independent predictor of eCD (OR 9.64, 95% CI 1.43–64.92, p = 0.02).

Conclusions

The absence of both PCoAs on preoperative radiographic imaging is predictive of eCD after CEA. This finding supports the evidence for an underlying ischemic etiology of eCD. Larger studies are justified to verify the findings of this study. Clinical trial registration no.: NCT00597883 (http://www.clinicaltrials.gov).

In Journal of Neurosurgery Volume 121 (2014): Issue 3 (Sep 2014)

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Demographic and clinical predictors of multiple intracranial aneurysms in patients with subarachnoid hemorrhage

Michael M. McDowell, Yin Zhao, Christopher P. Kellner, Sunjay M. Barton, Eric Sussman, Jan Claassen, Andrew F. Ducruet, and E. Sander Connolly

OBJECTIVE

Pathophysiological differences that underlie the development and subsequent growth of multiple aneurysms may exist. In this study, the authors assessed the factors associated with the occurrence of multiple aneurysms in patients presenting with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

Consecutive patients presenting with aneurysmal SAH between 1996 and 2012 were prospectively enrolled in the Subarachnoid Hemorrhage Outcome Project. Patients harboring 1, 2, or 3 or more aneurysms were stratified into groups, and the clinical and radiological characteristics of each group were compared using multivariate logistic regression.

RESULTS

Of 1277 patients with ruptured intracranial aneurysms, 890 had 1 aneurysm, 267 had 2 aneurysms, and 120 had 3 or more aneurysms. On multinomial regression using the single-aneurysm cohort as base case, risk factors for patients presenting with 2 aneurysms were female sex (relative risk ratio [RRR] 1.80, p < 0.001), higher body mass index (BMI) (RRR 1.02, p = 0.003), more years of smoking (RRR = 1.01, p = 0.004), and black race (RRR 1.83, p = 0.001). The risk factors for patients presenting with 3 or more aneurysms were female sex (RRR 3.10, p < 0.001), higher BMI (RRR 1.03, p < 0.001), aneurysm in the posterior circulation (RRR 2.59, p < 0.001), and black race (RRR 2.15, p = 0.001). Female sex, longer smoking history, aneurysms in the posterior circulation, BMI, and black race were independently associated with the development of multiple aneurysms in our adjusted multivariate multinomial model.

CONCLUSIONS

Significant demographic and clinical differences are found between patients presenting with single and multiple aneurysms in the setting of aneurysmal SAH. These predictors of multiple aneurysms likely reflect a predisposition toward inflammation and endothelial injury.

In Journal of Neurosurgery Volume 128: Issue 4 (Apr 2018)

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Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage

Clinical article

Eric S. Sussman, Christopher P. Kellner, Eric Nelson, Michael M. McDowell, Samuel S. Bruce, Rachel A. Bruce, Zong Zhuang, and E. Sander Connolly Jr.

Object

Ventriculostomy—the placement of an external ventricular drain (EVD)—is a common procedure performed in patients with acute neurological injury. Although generally considered a low-risk intervention, recent studies have cited higher rates of hemorrhagic complications than those previously reported. The authors sought to determine the rate of postventriculostomy hemorrhage in a cohort of patients with intracerebral hemorrhage (ICH) and to identify predictors of hemorrhagic complications of EVD placement.

Methods

Patients with ICH who underwent EVD placement and had both pre- and postprocedural imaging available for analysis were included in this study. Relevant data were prospectively collected for each patient who satisfied inclusion criteria. Variables with a p < 0.20 on univariate analyses were included in a stepwise logistic regression model to identify predictors of postventriculostomy hemorrhage.

Results

Sixty-nine patients were eligible for this analysis. Postventriculostomy hemorrhage occurred in 31.9% of patients. Among all patients with intraparenchymal hemorrhage, the mean hemorrhage volume was 0.66 ± 1.06 cm3. Stratified according to ventricular catheter diameter, patients treated with smaller-diameter catheters had a significantly greater mean hemorrhage volume than patients treated with larger-diameter catheters (0.84 ± 1.2 cm3 vs 0.14 ± 0.12 cm3, p = 0.049). Postventriculostomy hemorrhage was clinically significant in only 1 patient (1.4%). Overall, postventriculostomy hemorrhage was not associated with functional outcome or mortality at either discharge or 90 days. In the multivariate model, an age > 75 years was the only independent predictor of EVD-associated hemorrhage.

Conclusions

Advanced age is predictive of EVD-related hemorrhage in patients with ICH. While postventriculostomy hemorrhage is common, it appears to be of minor clinical significance in the majority of patients.

In Journal of Neurosurgery Volume 120 (2014): Issue 4 (Apr 2014)

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Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation

Muhammad Ali, Xiangnan Zhang, Luis C. Ascanio, Zachary Troiani, Colton Smith, Neha S. Dangayach, John W. Liang, Magdy Selim, J Mocco, and Christopher P. Kellner

OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation.

METHODS

Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression.

RESULTS

A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27–65) ml and the median postoperative volume was 1.2 (0.3–7.5) ml, resulting in a median evacuation percentage of 97% (85%–99%). The median hospital length of stay was 17 (IQR 9–25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67–0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05–0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91–0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90–164, p = 0.01) as compared to those who had undergone evacuation after 48 hours.

CONCLUSIONS

In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

In Journal of Neurosurgery Volume 138: Issue 1 (Jan 2023)