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  • Author or Editor: Kimberly P. Kicielinski x
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Santiago Gomez-Paz, Kimberly P. Kicielinski, Ajith Thomas and Christopher S. Ogilvy

The decision to resect a cavernous malformation of the brainstem is based on patient- and lesion-specific factors. The patient’s age, comorbidities, neurologic condition, and number and severity of symptomatic hemorrhages are crucial to consider.1,3,5 The proximity to the brainstem surface, amount of hematoma, and true lesion size help dictate the surgical corridor.2,4 We present a patient with a medullary cavernous malformation who had three hemorrhages and neurologic worsening. The surgical approach was based on detailed preoperative imaging. We performed a far lateral posterior fossa exposure to resect the lesion. The details of surgical planning and the microsurgery are presented.

The video can be found here: https://youtu.be/2y-OJ22Zjw8.

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Benjamin J. Ditty, Nidal B. Omar, Paul M. Foreman, Joseph H. Miller, Kimberly P. Kicielinski, Winfield S. Fisher III and Mark R. Harrigan

OBJECTIVE

Patients with cerebral arteriovenous malformations (AVMs) commonly present with seizure. Seizure outcomes in patients treated with stereotactic radiosurgery (SRS) are poorly defined. A case series of patients with cerebral AVMs treated with SRS is presented to evaluate long-term seizure outcome.

METHODS

A retrospective review of the medical record was performed, identifying 204 consecutive patients with AVMs treated with SRS between January 1991 and June 2012. Clinical and radiographic data were evaluated. Seizure outcome was measured using the Engel Epilepsy Surgery Outcome Scale. Mean duration of follow-up was 37.1 months (SD 38.3 months) with a minimum follow-up period of 1 month.

RESULTS

Of the 204 patients with cerebral AVMs treated with SRS, 78 patients (38.2%) presented with seizures and 49 of those patients were treated with antiepileptic drugs (AEDs). Following SRS, 63 (80.8%) of the 78 patients who had had seizures prior to SRS were seizure-free at a mean follow-up time of 37.2 months (SD 41.3 months). Of the 49 patients who had been treated with AEDs, 17 were still taking AEDs at last follow-up. Of the 126 patients who did not present with seizures prior to treatment with SRS, only 5 patients (4.0%) had seizures in the post-SRS period. There was no significant correlation between post-SRS seizure status and patient demographic features, comorbidities, AVM characteristics, history of operative intervention, pre- or posttreatment hemorrhage, or radiographic degree of AVM resolution.

CONCLUSIONS

Stereotactic radiosurgery for treatment of cerebral AVMs is effective at providing long-term control of seizures. A substantial number of patients who were treated with SRS were not only seizure free at their last follow-up, but had been successfully weaned from antiepileptic medications.

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Paul M. Foreman, Christoph J. Griessenauer, Kimberly P. Kicielinski, Philip G. R. Schmalz, Brandon G. Rocque, Matthew R. Fusco, Joseph C. Sullivan III, John P. Deveikis and Mark R. Harrigan

OBJECTIVE

Blunt traumatic cerebrovascular injury (TCVI) represents structural injury to a vessel due to high-energy trauma. The Biffl Scale is a widely accepted grading scheme for these injuries that was developed using digital subtraction angiography. In recent years, screening CT angiography (CTA) has been used to identify patients with TCVI. The reliability of this scale, with injuries assessed using CTA, has not yet been determined.

METHODS

Seven independent raters, including 2 neurosurgeons, 2 neuroradiologists, 2 neurosurgical residents, and 1 neurosurgical vascular fellow, independently reviewed each presenting CTA of the neck performed in 40 patients with confirmed TCVI and assigned a Biffl grade. Ten images were repeated to assess intrarater reliability, for a total of 50 CTAs. Fleiss' multirater kappa (κ) and interclass correlation were calculated as a measure of interrater reliability. Weighted Cohen's κ was used to assess intrarater reliability.

RESULTS

Fleiss' multirater κ was 0.65 (95% CI 0.61–0.69), indicating substantial agreement as to the Biffl grade assignment among the 7 raters. Interclass correlation was 0.82, demonstrating excellent agreement among the raters. Intrarater reliability was perfect (weighted Cohen's κ = 1) in 2 raters, and near perfect (weighted Cohen's κ > 0.8) in the remaining 5 raters.

CONCLUSIONS

Grading of TCVI with CTA using the Biffl Scale is reliable.