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Melissa A. LoPresti, Joshua Nguyen, and Sandi K. Lam

Head immobilization devices with skull pins are commonly used by neurosurgeons to stabilize the head for microsurgical techniques and to maintain accurate intraoperative neuronavigation. Pediatric patients, who may have open fontanelles, unfused sutures, and thin skulls, are vulnerable to complications during placement in pins. We review the various methods of pinning in pediatric neurosurgery and revisit the modified rubber stopper technique using a commonly available rubber stopper from a medication bottle over a standard adult pin of a Mayfield head clamp to prevent the pins from plunging through the thin pediatric skull.

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Joshua S. Catapano, Fabio A. Frisoli, Candice L. Nguyen, Mohamed A. Labib, Tyler S. Cole, Jacob F. Baranoski, Helen Kim, Robert F. Spetzler, and Michael T. Lawton

OBJECTIVE

Supplemented Spetzler-Martin grading (Supp-SM), which is the combination of Spetzler-Martin and Lawton-Young grades, was validated as being more accurate than stand-alone Spetzler-Martin grading, but an operability cutoff was not established. In this study, the authors surgically treated intermediate-grade AVMs to provide prognostic factors for neurological outcomes and to define AVMs at the boundary of operability.

METHODS

Surgically treated Supp-SM intermediate-grade (5, 6, and 7) AVMs were analyzed from 2011 to 2018 at two medical centers. Worsened neurological outcomes were defined as increased modified Rankin Scale (mRS) scores on postoperative examinations. A second analysis of 2000–2011 data for Supp-SM grade 6 and 7 AVMs was performed to determine the subtypes with improved or unchanged outcomes. Patients were separated into three groups based on nidus size (S1: < 3 cm, S2: 3–6 cm, S3: > 6 cm) and age (A1: < 20 years, A2: 20–40 years, A3: > 40 years), followed by any combination of the combined supplemented grade: low risk (S1A1, S1A2, S2A1), intermediate risk (S2A2, S1A3, S3A1, or high risk (S3A3, S3A2, S2A3).

RESULTS

Two hundred forty-six patients had intermediate Supp-SM grade AVMs. Of these patients, 102 had Supp-SM grade 5 (41.5%), 99 had Supp-SM grade 6 (40.2%), and 45 had Supp-SM grade 7 (18.3%). Significant differences in the proportions of patients with worse mRS scores at follow-up were found between the groups, with 24.5% (25/102) of patients in Supp-SM grade 5, 29.3% (29/99) in Supp-SM grade 6, and 57.8% (26/45) in Supp-SM grade 7 (p < 0.001). Patients with Supp-SM grade 7 AVMs had significantly increased odds of worse postoperative mRS scores (p < 0.001; OR 3.7, 95% CI 1.9–7.3). In the expanded cohort of 349 Supp-SM grade 6 AVM patients, a significantly higher proportion of older patients with larger Supp-SM grade 6 AVMs (grade 6+, 38.6%) had neurological deterioration than the others with Supp-SM grade 6 AVMs (22.9%, p = 0.02). Conversely, in an expanded cohort of 197 Supp-SM grade 7 AVM patients, a significantly lower proportion of younger patients with smaller Supp-SM grade 7 AVMs (grade 7–, 19%) had neurological deterioration than the others with Supp-SM grade 7 AVMs (44.9%, p = 0.01).

CONCLUSIONS

Patients with Supp-SM grade 7 AVMs are at increased risk of worse postoperative neurological outcomes, making Supp-SM grade 6 an appropriate operability cutoff. However, young patients with small niduses in the low-risk Supp-SM grade 7 group (grade 7−) have favorable postoperative outcomes. Outcomes in Supp-SM grade 7 patients did not improve with surgeon experience, indicating that the operability boundary is a hard limit reflecting the complexity of high-grade AVMs.

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Joshua S. Catapano, Kavelin Rumalla, Visish M. Srinivasan, Candice L. Nguyen, Dara S. Farhadi, Brandon Ngo, Caleb Rutledge, Redi Rahmani, Jacob F. Baranoski, Tyler S. Cole, Ashutosh P. Jadhav, Andrew F. Ducruet, and Felipe C. Albuquerque

OBJECTIVE

The incidence and severity of stroke are disproportionately greater among Black patients. In this study, the authors sought to examine clinical outcomes among Black versus White patients after mechanical thrombectomy for stroke at a single US institution.

METHODS

All patients who underwent mechanical thrombectomy at a single center from January 1, 2014, through March 31, 2020, were retrospectively analyzed. Patients were grouped based on race, and demographic characteristics, preexisting conditions, clinical presentation, treatment, and stroke outcomes were compared. The association of race with mortality was analyzed in multivariable logistic regression analysis adjusted for potential confounders.

RESULTS

In total, 401 patients (233 males) with a reported race of Black (n = 28) or White (n = 373) underwent mechanical thrombectomy during the study period. Tobacco use was more prevalent among Black patients (43% vs 24%, p = 0.04), but there were no significant differences between the groups with respect to insurance, coronary artery disease, diabetes, illicit drug use, hypertension, or hyperlipidemia. The mean time from stroke onset to hospital presentation was significantly greater among Black patients (604.6 vs 333.4 minutes) (p = 0.007). There were no differences in fluoroscopy time, procedural success (Thrombolysis in Cerebral Infarction grade 2b or 3), hospital length of stay, or prevalence of hemicraniectomy. In multivariable analysis, Black race was strongly associated with higher mortality (32.1% vs 14.5%, p = 0.01). The disparity in mortality rates resolved after adjusting for the average time from stroke onset to presentation (p = 0.14).

CONCLUSIONS

Black race was associated with an increased risk of death after mechanical thrombectomy for stroke. The increased risk may be associated with access-related factors, including delayed presentation to stroke centers.

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Joshua S. Catapano, Andrew F. Ducruet, Fabio A. Frisoli, Candice L. Nguyen, Christopher E. Louie, Mohamed A. Labib, Jacob F. Baranoski, Tyler S. Cole, Alexander C. Whiting, Felipe C. Albuquerque, and Michael T. Lawton

OBJECTIVE

Takotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs.

METHODS

The authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2.

RESULTS

TC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040).

CONCLUSIONS

TC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.

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Joshua S. Catapano, Andrew F. Ducruet, Fabio A. Frisoli, Candice L. Nguyen, Christopher E. Louie, Mohamed A. Labib, Jacob F. Baranoski, Tyler S. Cole, Alexander C. Whiting, Felipe C. Albuquerque, and Michael T. Lawton

OBJECTIVE

Takotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs.

METHODS

The authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2.

RESULTS

TC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040).

CONCLUSIONS

TC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.

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Joshua S. Catapano, Andrew F. Ducruet, Candice L. Nguyen, Tyler S. Cole, Jacob F. Baranoski, Neil Majmundar, D. Andrew Wilkinson, Vance L. Fredrickson, Daniel D. Cavalcanti, Michael T. Lawton, and Felipe C. Albuquerque

OBJECTIVE

Middle meningeal artery (MMA) embolization is a promising treatment strategy for chronic subdural hematomas (cSDHs). However, studies comparing MMA embolization and conventional therapy (surgical intervention and conservative management) are limited. The authors aimed to compare MMA embolization versus conventional therapy for cSDHs using a propensity-adjusted analysis.

METHODS

A retrospective study of all patients with cSDH who presented to a large tertiary center over a 2-year period was performed. MMA embolization was compared with surgical intervention and conservative management. Neurological outcome was assessed using the modified Rankin Scale (mRS). A propensity-adjusted analysis compared MMA embolization versus surgery and conservative management for all individual cSDHs. Primary outcomes included change in hematoma diameter, treatment failure, and complete resolution at last follow-up.

RESULTS

A total of 231 patients with cSDH met the inclusion criteria. Of these, 35 (15%) were treated using MMA embolization, and 196 (85%) were treated with conventional treatment. On the latest follow-up, there were no statistically significant differences between groups in the percentage of patients with worsening mRS scores. Of the 323 total cSDHs found in 231 patients, 41 (13%) were treated with MMA embolization, 159 (49%) were treated conservatively, and 123 (38%) were treated with surgical evacuation. After propensity adjustment, both surgery (OR 12, 95% CI 1.5–90; p = 0.02) and conservative therapy (OR 13, 95% CI 1.7–99; p = 0.01) were predictors of treatment failure and incomplete resolution on follow-up imaging (OR 6.1, 95% CI 2.8–13; p < 0.001 and OR 5.4, 95% CI 2.5–12; p < 0.001, respectively) when compared with MMA embolization. Additionally, MMA embolization was associated with a significant decrease in cSDH diameter on follow-up relative to conservative management (mean −8.3 mm, 95% CI −10.4 to −6.3 mm, p < 0.001).

CONCLUSIONS

This propensity-adjusted analysis suggests that MMA embolization for cSDH is associated with a greater extent of hematoma volume reduction with fewer treatment failures than conventional therapy.

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Joshua S. Catapano, Mohamed A. Labib, Fabio A. Frisoli, Megan S. Cadigan, Jacob F. Baranoski, Tyler S. Cole, James J. Zhou, Candice L. Nguyen, Alexander C. Whiting, Andrew F. Ducruet, Felipe C. Albuquerque, and Michael T. Lawton

OBJECTIVE

The SAFIRE grading scale is a novel, computable scale that predicts the outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients in acute follow-up. However, this scale also may have prognostic significance in long-term follow-up and help guide further management.

METHODS

The records of all patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) were retrospectively reviewed, and the patients were assigned SAFIRE grades. Outcomes at 1 year and 6 years post-aSAH were analyzed for each SAFIRE grade level, with a poor outcome defined as a modified Rankin Scale score > 2. Univariate analysis was performed for patients with a high SAFIRE grade (IV or V) for odds of poor outcome at the 1- and 6-year follow-ups.

RESULTS

A total of 405 patients with confirmed aSAH enrolled in the BRAT were analyzed; 357 patients had 1-year follow-up, and 333 patients had 6-year follow-up data available. Generally, as the SAFIRE grade increased, so did the proportion of patients with poor outcomes. At the 1-year follow-up, 18% (17/93) of grade I patients, 22% (20/92) of grade II patients, 32% (26/80) of grade III patients, 43% (38/88) of grade IV patients, and 75% (3/4) of grade V patients were found to have poor outcomes. At the 6-year follow-up, 29% (23/79) of grade I patients, 24% (21/89) of grade II patients, 38% (29/77) of grade III patients, 60% (50/84) of grade IV patients, and 100% (4/4) of grade V patients were found to have poor outcomes. Univariate analysis showed that a SAFIRE grade of IV or V was associated with a significantly increased risk of a poor outcome at both the 1-year (OR 2.5, 95% CI 1.5–4.2; p < 0.001) and 6-year (OR 3.7, 95% CI 2.2–6.2; p < 0.001) follow-ups.

CONCLUSIONS

High SAFIRE grades are associated with an increased risk of a poor recovery at late follow-up.

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Aswin Chari, Martin M. Tisdall, and Hani J. Marcus