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Felipe C. Albuquerque

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Felipe C. Albuquerque

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Felipe C. Albuquerque

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Robert M. Starke, Felipe C. Albuquerque and Michael T. Lawton

It is with great pleasure that we present this Neurosurgical Focus video supplement on supratentorial cerebral arteriovenous malformations (AVMs). We were privileged to view a remarkable number of outstanding videos demonstrating current state-of-the-art management of brain AVMs using endovascular and microsurgical modalities. Careful and critical review was required to narrow down the submitted videos to a workable volume for this supplement, which reflects the excellent work being done at multiple centers with these lesions.

This issue consists of videos that represent modern microsurgical and neuroendovascular techniques for the treatment of supratentorial cerebral AVMs. The videos demonstrate cutting-edge therapies as well as standard ones, which will be valuable to both novice and expert neurointerventionists and neurosurgeons. We are honored to be involved with this project and proud of its content and expert authors. We believe you will enjoy the video content of this supplement and hope that it will raise the collective expertise of our community of AVM surgeons.

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Felipe C. Albuquerque, David R. Hinton and Martin H. Weiss

✓ The authors report the case of a 48-year-old woman who presented with a nonprolactin-secreting adenoma and a preoperative prolactin level of 662 ng/ml. The patient's neoplasm subsequently enlarged despite normalization of her prolactin level with dopamine agonist therapy. Hyperprolactinemia, with levels of prolactin as high as 150 ng/ml, is commonly associated with sellar tumors and is attributed to disruption of the normal delivery of dopamine to the adenohypophysis. The prolactin level found in this patient represents the highest level attributed to the stalk-section effect reported in the literature and underscores the need for repeated radiographic assessment of patients who are undergoing treatment with bromocriptine and have prolactin levels in the 25 to 1000 ng/ml range.

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Ruth E. Bristol, Felipe C. Albuquerque and Cameron G. McDougall

✓ Endovascular therapy for arteriovenous malformations (AVMs) remains a relatively new approach. Beginning in the 1960s with the use of flow-directed techniques for selective embolization, hemodynamic alterations have been used to treat these lesions. In every aspect of treatment, technological advances, including catheters, embolic materials, angiography suites, and pharmacological agents, have improved outcomes while lowering the risk to patients.

In this article, the authors review the technical evolution of endovascular AVM therapy. Developments in embolic materials, beginning with foreign bodies and autografts and continuing through to highly engineered contemporary substances, are discussed. Finally, changes in treatment paradigms that have occurred over the years are traced. Within neurosurgery, this specialty has shown some of the fastest growth and development in recent decades. As minimally invasive approaches are embraced in all areas of medicine, it is clear that this treatment modality will continue to be refined.

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Michael J. Schneider

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C. Benjamin Newman, Yin C. Hu, Cameron G. McDougall and Felipe C. Albuquerque

Object

Pial arteriovenous fistulas (AVFs) of the brain are rare vascular malformations associated with significant risks of hemorrhage and neurological deficit. Depending on their location and high-flow dynamics, these lesions can present treatment challenges for both endovascular and open cerebrovascular surgeons. The authors describe a novel endovascular treatment strategy that was used successfully to treat 2 pediatric patients with a pial AVF, and they discuss the technical nuances specific to their treatment strategy.

Methods

A single-channel high-flow pial AVF was diagnosed in 2 male patients (6 and 17 years of age). Both patients were treated with endovascular flow arrest using a highly conformable balloon followed by Onyx infusion for definitive closure of the fistula.

Results

Neither patient suffered a complication as a result of the procedure. At the 6-month follow-up in both cases, the simple discontinuation of blood flow had resulted in durable obliteration of the fistula and stable or improved neurological function.

Conclusions

Onyx can be delivered successfully into high-flow lesions after flow arrest to allow a minimally invasive and durable treatment for pial AVFs.

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Hasan A. Zaidi, M. Yashar S. Kalani, Robert F. Spetzler, Cameron G. McDougall and Felipe C. Albuquerque

OBJECT

Pediatric cerebral arteriovenous fistulas (AVFs) are rare but potentially lethal vascular lesions. Management strategies for these lesions have undergone considerable evolution in the last decade with the advent of new endovascular, surgical, and radiosurgical technologies. This study sought to review current treatment strategies and long-term clinical outcomes at a high-volume cerebrovascular institute.

METHODS

A retrospective chart review was performed on patients with a diagnosis of cerebral AVF from 1999 to 2012. Patients with carotid-cavernous fistulas, vein of Galen malformations, and age > 18 years were excluded from final analysis. Medical history, surgical and nonsurgical treatment, and clinical outcomes were documented. Pre- and postoperative angiograms were analyzed to assess for obliteration of the fistula.

RESULTS

Seventeen patients with pial AVFs (29.4%), dural AVFs (64.7%), or mixed pial/dural AVFs (5.9%) were identified. The majority of lesions were paramedian (70.6%) and supratentorial (76.5%). The study population had a mean age of 6.4 years, with a slight male predominance (52.9%), and the most common presenting symptoms were seizures (23.5%), headaches (17.6%), congestive heart failure (11.7%), and enlarging head circumference (11.7%). Among patients who underwent intervention (n = 16), 56.3% were treated with endovascular therapy alone, 6.3% were treated with open surgery alone, and 37.5% required a multimodal approach. Overall, 93.8% of the treated patients received endovascular treatment, 43.8% received open surgery, and 12.5% received radiosurgery. Endovascular embolysates included Onyx (n = 5), N-butyl cyanoacrylate (NBCA; n = 4), or coil embolization (n = 7) with or without balloon assistance (n = 2). Complete angiographic obliteration was achieved in 87.5% at the last follow-up evaluation (mean follow-up 3.1 years). One infant with incomplete AVF obliteration died of congestive heart failure, and 1 patient with complete obliteration died of acute sinus thrombosis, with an overall complication rate of 18.8%.

CONCLUSIONS

Pediatric cerebral AVFs are challenging neurosurgical lesions. Although advancements in endovascular therapy in the last decade have greatly changed the natural course of this disease, a multidisciplinary approach remains necessary for a large subset of patients. Surgeon experience with a thorough analysis of preoperative imaging is paramount to achieving acceptable clinical outcomes.