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Jean-Valery C. E. Coumans and Brian P. Walcott

Incidental vertebral lesions on imaging of the spine are commonly encountered in clinical practice. Contributing factors include the aging population, the increasing prevalence of back pain, and increased usage of MR imaging. Additionally, refinements in CT and MR imaging have increased the number of demonstrable lesions. The management of incidental findings varies among practitioners and commonly depends more on practice style than on data or guidelines. In this article we review incidental findings within the vertebral column and review management of these lesions, based on available Class III data.

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Brian P. Walcott, Navid Redjal and Jean-Valery C. E. Coumans

Neurosurgical patients are at a high risk for infectious sequelae following operations. For neurosurgery in particular, the risk of surgical site infection has a unique implication given the proximity of the CSF and the CNS. Patient factors contribute to some degree; for example, cancer and trauma are often associated with impaired nutritional status, known risk factors for infection. Additionally, care-based factors for infection must also be considered, such as the length of surgery, the administration of steroids, and tissue devascularization (such as a craniotomy bone flap). When postoperative infection does occur, attention is commonly focused on potential lapses in surgical “sterility.” Evidence suggests that the surgical field is not free of microorganisms. The authors propose a paradigm shift in the nomenclature of the surgical field from “sterile” to “clean.” Continued efforts aimed at optimizing immune capacity and host defenses to combat potential infection are warranted.

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Andrew Q. Le, Brian P. Walcott, Navid Redjal and Jean-Valery Coumans

Jugular foramen syndrome is a condition characterized by unilateral paresis of cranial nerves IX, X, and XI in the setting of extrinsic compression. Here, the authors describe the case of a giant cervical osteophyte resulting in compression of the jugular foramen. A 74-year-old man who presented with progressive dysphagia and dysarthria was found to have right-sided tongue deviation, left palatal droop, and hypophonia. His dysphagia had progressed to the point that he had lost 25 kg over a 4-month period, necessitating a gastrostomy to maintain adequate nutrition. He underwent extensive workup for his dysphagia with several normal radiographic studies. Ultimately, CT scanning and postcontrast MRI revealed a posterior osteophyte arising from the C1–2 joint space and projecting into the right jugular foramen. This resulted in a jugular foramen syndrome in addition to delayed filling of the patient's right internal jugular vein distal to the osteophyte. Although rare, a posterior cervical osteophyte should be considered in cases of jugular foramen syndrome.

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Brian P. Walcott, Jean-Valery C. E. Coumans and Kristopher T. Kahle

Disorders of the spine are common in clinical medicine, and spine surgery is being performed with increasing frequency in the US. Although many patients with an established diagnosis of a true surgically treatable lesion are referred to a neurosurgeon, the evaluation of patients with spinal disorders can be complex and fraught with diagnostic pitfalls. While “common conditions are common,” astute clinical acumen and vigilance are necessary to identify lesions that masquerade as surgically treatable spine disease that can lead to erroneous diagnosis and treatment. In this review, the authors discuss musculoskeletal, peripheral nerve, metabolic, infectious, inflammatory, and vascular conditions that mimic the syndromes produced by surgical lesions. It is possible that nonsurgical and surgical conditions coexist at times, complicating treatment plans and natural histories. Awareness of these diagnoses can help reduce diagnostic error, thereby avoiding the morbidity and expense associated with an unnecessary operation.

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Jean-Valéry C. E. Coumans, Mary-Kay Reinhardt and Isador H. Lieberman

Object

Over the past 15 years, vertebroplasty has emerged as a treatment for vertebral compression fractures. This technique, however, does not restore vertebral height and is associated with a high rate of cement leakage. Recently, kyphoplasty was developed in an effort to circumvent this problem. Although its immediate results have been reported, it is unclear whether the benefits endure.

Methods

Seventy-eight consecutive patients underwent 188 kyphoplasty procedures. The patients responded to Short Form—36 (SF-36) questionnaires, a visual analog scale (VAS) for pain rating, and the Oswestry disability index (ODI) instrument; additionally they underwent detailed neurological and radiographic examinations pre- and postoperatively. The preoperative SF-36, VAS, and ODI scores, the neurological examination results, and the radiographic data were compared with the postoperative findings.

Thirteen patients died of disease progression or unrelated illness. Of the surviving patients, complete data were available in 62% (minimum follow-up period 12 months, mean 18 months). Complications included one myocardial infarction and five cases of asymptomatic cement extravasation. No case of neurological deterioration occurred during the follow-up period. Significant improvements in seven measures of the SF-36 inventory as well as on the ODI and VAS were noted early postoperatively, and these persisted throughout the follow-up period, despite a statistically insignificant decline in the measure of general health at last follow-up examination.

Conclusions

Kyphoplasty is an effective treatment for vertebral compression fractures. The benefits presented in the early postoperative period and persisted at 1 year posttreatment.

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Jean-Valéry C. E. Coumans, Vance E. Watson, Catherine A. Picken and Kevin M. McGrail

✓ Although the use of carotid artery stents is increasing, the management of recurrent stenosis after their placement is undefined. The authors report on a patient who underwent two left carotid endarterectomies followed by left carotid angioplasty and stent placement for recurrent stenosis. A third symptomatic recurrence was subsequently managed by placement of a saphenous vein interposition graft from the common carotid artery to the distal cervical internal carotid artery. The patient remained without hemispheric or retinal ischemia at his 5-month follow-up visit. Interposition grafting should be considered as a treatment option for carotid restenosis after initial endarterectomy and stent placement.

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Brian P. Walcott, Brian V. Nahed, Kristopher T. Kahle, Navid Redjal and Jean-Valery Coumans

Object

Previous methods to determine stroke prevalence, such as nationwide surveys, are labor-intensive endeavors. Recent advances in search engine query analytics have led to a new metric for disease surveillance to evaluate symptomatic phenomenon, such as influenza. The authors hypothesized that the use of search engine query data can determine the prevalence of stroke.

Methods

The Google Insights for Search database was accessed to analyze anonymized search engine query data. The authors' search strategy utilized common search queries used when attempting either to identify the signs and symptoms of a stroke or to perform stroke education. The search logic was as follows: (stroke signs + stroke symptoms + mini stroke − heat) from January 1, 2005, to December 31, 2010.

The relative number of searches performed (the interest level) for this search logic was established for all 50 states and the District of Columbia. A Pearson product-moment correlation coefficient was calculated from the statespecific stroke prevalence data previously reported.

Results

Web search engine interest level was available for all 50 states and the District of Columbia over the time period for January 1, 2005–December 31, 2010. The interest level was highest in Alabama and Tennessee (100 and 96, respectively) and lowest in California and Virginia (58 and 53, respectively). The Pearson correlation coefficient (r) was calculated to be 0.47 (p = 0.0005, 2-tailed).

Conclusions

Search engine query data analysis allows for the determination of relative stroke prevalence. Further investigation will reveal the reliability of this metric to determine temporal pattern analysis and prevalence in this and other symptomatic diseases.

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Brandyn Castro, Brian P. Walcott, Navid Redjal, Jean-Valery Coumans and Brian V. Nahed

Frontal sinus fractures are heterogeneous, and management of these fractures is often modified based on injury pattern and institutional experience. The optimal initial treatment of frontal sinus fractures is controversial. Treatment strategies are aimed at correcting cosmetic deformity, as well as at preventing delayed complications, including CSF fistulas, mucocele formation, and infection. Existing treatment options include observation, reconstruction, obliteration, cranialization, or a combination thereof. Modalities for treatment encompass both open surgical approaches and endoscopic techniques. In the absence of Class I data, the authors review the existing literature related to treatment strategies of frontal sinus fractures, particularly as they relate to CSF fistulas, to provide recommendations based on the best available evidence.

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Jean-Valery Coumans, Brian P. Walcott, William E. Butler, Brian V. Nahed and Kristopher T. Kahle

Object

Resolution of syringomyelia is common following hindbrain decompression for Chiari malformation, yet little is known about the kinetics governing this process. The authors sought to establish the volumetric rate of syringomyelia resolution.

Methods

A retrospective cohort of patients undergoing hindbrain decompression for a Chiari malformation Type I with preoperative cervical or thoracic syringomyelia was identified. Patients were included in the study if they had at least 3 neuroimaging studies that detailed the entirety of their preoperative syringomyelia over a minimum of 6 months postoperatively. The authors reconstructed the MR images in 3 dimensions and calculated the volume of the syringomyelia. They plotted the syringomyelia volume over time and constructed regression models using the method of least squares. The Akaike information criterion and Bayesian information criterion were used to calculate the relative goodness of fit. The coefficients of determination R 2 (unadjusted and adjusted) were calculated to describe the proportion of variability in each individual data set accounted for by the statistical model.

Results

Two patients were identified as meeting inclusion criteria. Plots of the least-squares best fit were identified as 4.01459e −0.0180804 x and 13.2556e −0.00615859 x. Decay of the syringomyelia followed an exponential model in both patients (R2 = 0.989582 and 0.948864).

Conclusions

Three-dimensional analysis of syringomyelia resolution over time enables the kinetics to be estimated. This technique is yet to be validated in a large cohort. Because syringomyelia is the final common pathway for a number of different pathological processes, it is possible that this exponential only applies to syringomyelia related to treatment of Chiari malformation Type I.

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Ahmed J. Awad, Brian P. Walcott, Christopher J. Stapleton, Vijay Yanamadala, Brian V. Nahed and Jean-Valery Coumans

Dabigatran etexilate (Pradaxa) is a novel oral anticoagulant that has gained FDA approval for the prevention of ischemic stroke and systemic embolism in patients with nonvalvular atrial fibrillation. In randomized trials, the incidence of hemorrhagic events has been demonstrated to be lower in patients treated with dabigatran compared with the traditional anticoagulant warfarin. However, dabigatran does not have reliable laboratory tests to measure levels of anticoagulation and there is no pharmacological antidote. These drawbacks are challenging in the setting of intracerebral hemorrhage. In this article, the authors provide background information on dabigatran, review the existing anecdotal experiences with treating intracerebral hemorrhage related to dabigatran therapy, present a case study of intracranial hemorrhage in a patient being treated with dabigatran, and suggest clinical management strategies. The development of reversal agents is urgently needed given the growing number of patients treated with this medication.