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Harry J. Cloft, Nasser Razack and David F. Kallmes

Object. The aim of this study was to determine the prevalence of cerebral saccular aneurysms in patients with persistent primitive trigeminal artery (PPTA). The prevalence of cerebral saccular aneurysms in patients with PPTA previously has been reported to be 14 to 32%, but this rate range is unreliable because it is based on collections of published case reports rather than a series of patients chosen in an unbiased manner.

Methods. The authors retrospectively evaluated their own series of 34 patients with PPTA to determine the prevalence of cerebral aneurysms in this population. The prevalence of intracranial aneurysms in patients with PPTA was approximately 3% (95% confidence interval 0–9%).

Conclusions. The prevalence of intracranial aneurysms in patients with PPTA is no greater than the prevalence of intracranial aneurysms in the general population.

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Robert J. McDonald, Harry J. Cloft and David F. Kallmes

Object

The authors sought to identify the presence of a “July effect,” a transient increase in adverse outcomes during July, among a cohort of spontaneous subarachnoid hemorrhage (SAH) admissions recorded in the National Inpatient Sample (NIS).

Methods

The discharge status, admission month, patient demographics, treatment parameters, and hospital characteristics among spontaneous SAH admissions were extracted from the 2001–2008 NIS. Multivariate regression was used to determine whether an unfavorable discharge status and/or in-hospital mortality significantly increased in summer months in a pattern suggestive of a July effect. Additional models were generated to assess the impact of hospital teaching status on these outcomes.

Results

Among 57,663,486 hospital admissions from the 2001–2008 NIS, 52,879 cases of spontaneous SAH (ICD-9-CM 430) were treated at teaching (36,914 cases [70%]) and nonteaching (15,965 cases [30%]) facilities. Regression models failed to reveal a July effect for in-hospital mortality (χ2 = 0.75, p = 1.000) or unfavorable discharges (χ2 = 1.69, p = 0.999) among monthly SAH admissions, although they did suggest a significant reduction in these outcomes (in-hospital mortality, OR = 0.89, p < 0.001; unfavorable discharges, OR = 0.88, p < 0.001) among teaching hospitals as compared with nonteaching hospitals after adjustment for disparities in demographic, treatment, and hospital characteristics.

Conclusions

The discharge disposition among SAH admissions within the NIS was not suggestive of a July effect but did reveal that teaching institutions have significantly lower rates of adverse outcomes when compared with nonteaching hospitals. Note, however, that the origins of this difference related to teaching status remain unclear.

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Waleed Brinjikji, Harry J. Cloft, Giuseppe Lanzino, Leonardo Rangel-Castilla and Pearse P. Morris

Arteriovenous fistulae of the internal maxillary artery are exceedingly rare, with less than 30 cases reported in the literature. Most of these lesions are congenital, iatrogenic, or posttraumatic. The most common presentation of internal maxillary artery fistulae is pulsatile tinnitus and headache. Because these lesions are single-hole fistulae, they can be easily cured with endovascular techniques. The authors present a case of a patient who presented to their institution with a several-year history of pulsatile tinnitus who was found to have an internal maxillary artery arteriovenous fistula, which was treated endovascularly with transarterial coil and Onyx embolization.

The video can be found here: https://youtu.be/fDZVMMwpwRc.

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Ross C. Puffer, David J. Daniels, David F. Kallmes, Harry J. Cloft and Giuseppe Lanzino

Object

The authors conducted a study to review their experience with tentorial dural arteriovenous fistulas (DAVFs) treated with transarterial endovascular embolization in which Onyx was used.

Methods

The authors reviewed prospectively collected data in 9 patients with tentorial DAVFs treated with Onyx embolization between 2008 and 2011. Information reviewed included clinical presentation, angiographic features, treatment, and clinical and radiologically documented outcome. Clinical follow-up was available in every patient. Radiological follow-up studies were available in 8 of 9 patients (mean follow-up 4.6 months).

Results

Six of 9 patients had complete angiographic obliteration (in 5 this was confirmed by a follow-up angiogram obtained 3–6 months later), and 2 patients had near-complete obliteration (faint filling of the venous drainage in the late venous phase). One patient had partial obliteration and required surgical disconnection. In all patients with complete obliteration, transarterial embolization was performed through the posterior branch of the middle meningeal artery. There were no procedural complications, and no morbidity or mortality resulted from Onyx embolization.

Conclusions

Transarterial Onyx embolization is a valid, effective, and safe alternative to surgical disconnection in many patients with tentorial DAVFs. The presence of an adequate posterior branch of the middle meningeal artery is critical to achieve a microcatheter position distal enough to increase the likelihood of complete obliteration.

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Waleed Brinjikji, Harry J. Cloft, Kelly D. Flemming, Simone Comelli and Giuseppe Lanzino

OBJECTIVE

Over the last half century, there have been isolated case reports of purely arterial malformations. In this study, the authors report a consecutive series of patients with pure arterial malformations, emphasizing the clinical and radiological features of these lesions.

METHODS

Pure arterial malformations were defined as dilated, overlapping, and tortuous arteries with a coil-like appearance and/or a mass of arterial loops without any associated venous component. Demographic characteristics of the patients, cardiovascular risk factors, presentation, radiological characteristics, and follow-up data were collected. Primary outcomes were new neurological symptoms including disability, stroke, and hemorrhage.

RESULTS

Twelve patients meeting the criteria were identified. Ten patients were female (83.3%) and 2 were male (16.6%). Their mean age at diagnosis was 26.2 ± 11.6 years. The most common imaging indication was headache (7 patients [58.3%]). In 3 cases the pure arterial malformation involved the anterior cerebral arteries (25.0%); in 4 cases the posterior communicating artery/posterior cerebral artery (33.3%); in 2 cases the middle cerebral artery (16.6%); and in 1 case each, the superior cerebellar artery, basilar artery/anterior inferior cerebellar artery, and posterior inferior cerebellar artery. The mean maximum diameter of the malformations was 7.2 ± 5.0 mm (range 3–16 mm). Four lesions had focal aneurysms associated with the pure arterial malformation, and 5 were partially calcified. In no cases was there associated intracranial hemorrhage or infarction. One patient underwent treatment for the pure arterial malformation. All 12 patients had follow-up (mean 29 months, median 19 months), and there were no cases of disability, stroke, or hemorrhage.

CONCLUSIONS

Pure arterial malformations are rare lesions that are often detected incidentally and probably have a benign natural history. These lesions can affect any of the intracranial arteries and are likely best managed conservatively.

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Lorenzo Rinaldo, Harry J. Cloft, Giuseppe Lanzino and Leonardo Rangel-Castilla

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Giuseppe Lanzino, Anthony M. Burrows and Harry J. Cloft

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Caleb B. Leake, Waleed Brinjikji, David F. Kallmes and Harry J. Cloft

Object

Evidence of better outcomes in patients with aneurysmal subarachnoid hemorrhage treated at higher-volume centers might be expected to result in more of these patients being referred to such centers. The authors evaluated the US National Inpatient Sample for the years 2001 to 2008 for trends in patient admissions for the treatment of ruptured aneurysms at high- and low-volume centers.

Methods

The authors determined the number of ruptured aneurysms treated with clipping or coiling annually at low-volume (≤ 20 patients/year) and high-volume (> 20 patients/year) centers and also counted the number of high- and low-volume centers performing each treatment. Hospitalizations for clipping or coiling ruptured aneurysms were identified by cross-matching International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes for the diagnosis of a ruptured aneurysm (ICD-9-CM 430) with procedure codes for clipping (ICD-9-CM 39.51) or coiling (ICD-9-CM 39.52, 39.79, or 39.72) cerebral aneurysms.

Results

In 2001, 31% (435 of 1392) of the patients who underwent clipping and 0% (0 of 122 patients) of those who underwent coiling did so at high-volume centers, whereas in 2008 these numbers increased to 62% (627 of 1016) and 68% (917 of 1351) of patients, respectively. For clipping procedures, the number of low-volume centers significantly declined from 177 in 2001 to 85 in 2008, whereas the number of high-volume centers remained constant at 13–15. For coiling procedures, the number of low-volume centers decreased from 62 in 2001 to 54 in 2008, whereas the number of high-volume centers substantially increased from 0 in 2001 to 16 in 2005 and remained constant thereafter.

Conclusions

The treatment of ruptured cerebral aneurysms increasingly occurs at high-volume centers in the US. This trend is favorable given that better outcomes are associated with the treatment of these lesions at high-volume centers.