Search Results

You are looking at 1 - 7 of 7 items for

  • Author or Editor: Leodante da Costa x
Clear All Modify Search
Full access

Leodante da Costa, Amir R. Dehdashti and Karel G. terBrugg E

Object

Spinal cord vascular malformations are rare, fascinating lesions. In this paper, the authors' goal was to demonstrate how these lesions, more specifically spinal cord arteriovenous malformations and dural arteriovenous fistulas, are assessed, classified, and managed at their institution. They also highlight some aspects of classification and management that may be different from the views of others.

Methods

The authors reviewed the 20-year experience at the senior author's institution regarding the management of spinal cord vascular malformations. They discuss the management, surgical and endovascular treatment results, and the classification that resulted from the combined experience of 3 major reference centers.

Results

The accumulated knowledge on embryological and pathophysiological aspects in such a rare disease resulted in a more global, patient-oriented (and not radiologically oriented) approach to spinal cord shunts.

Conclusions

The multiple classifications proposed for spinal cord vascular malformations reflect the continuous advancement of the authors' understanding. They adopt a classification based on new physiological and genetic data that treats these lesions as expressions of more complex disease processes and not simply a morphological target, with direct impact on therapeutic options.

Full access

Leodante B. da Costa, Thorsteinn Gunnarsson and M. Christopher Wallace

Aneurysmal subarachnoid hemorrhage (SAH) carries a grim prognosis, with high mortality and morbidity rates. The mortality rate in the first 30 days postrupture is estimated to be in the range of 40 to 50%, and almost half of the survivors will be left with a neurological deficit. Unlike patients with aneurysmal SAH, those with unruptured intracranial aneurysms usually experience no neurological deficit, and their treatment is prophylactic, aiming to reduce the risk of future bleeding and its consequences. The risk of rupture therefore assumes special importance when making decisions regarding which patient or aneurysm to treat.

In previous reports the risk of bleeding for unruptured aneurysms has been stated as approximately 2% per year. The retrospective part of the International Study of Unruptured Intracranial Aneurysms (ISUIA) reported very low annual bleeding rates (0.05–1%) and high surgical morbidity and mortality rates (8–18%), prompting discussion in which the benefits of prophylactic treatment in the majority of these lesions were questioned. Prospective data from the second part of the ISUIA recently included rupture rates ranging from 0 to 10% per year. The aim of this paper was to review the evidence that is currently available for neurosurgeons to use when making decisions regarding patients who would benefit from treatment of an unruptured intracranial aneurysm.

Full access

Amir R. Dehdashti, Leodante B. Da Costa, Karel G. terBrugge, Robert A. Willinsky, Michael Tymianski and M. Christopher Wallace

Dural arteriovenous fistulas are the most common vascular malformations of the spinal cord. These benign vascular lesions are considered straightforward targets of surgical treatment and possibly endovascular embolization, but the outcome in these cases depends mainly on the extent of clinical dysfunction at the time of the diagnosis. A timely diagnosis is an equally important factor, with early treatment regardless of the type more likely to yield significant improvements in neurological functioning. The outcomes after surgical and endovascular treatment are similar if complete obliteration of the fistulous site is obtained. In the present study, the authors evaluated the current role of each modality in the management of these interesting lesions.

Restricted access

Christopher R. Pasarikovski, Joel Ramjist, Leodante da Costa, Sandra E. Black and Victor Yang

Studies evaluating individuals for endothelial injury after endovascular thrombectomy (EVT) have been done by means of retrieved human thrombus, MR vessel-wall imaging, and animal histopathological studies. These techniques have limitations, because MR imaging has insufficient spatial resolution to directly visualize endothelium, and histopathological examinations are performed ex vivo and are unable to provide real-time patterns of injury. The purpose of the current study was to obtain in vivo intraluminal imaging after EVT by using optical coherence tomography (OCT), examining for evidence of endothelial injury in real time.

Three consecutive patients with acute basilar artery occlusion underwent OCT imaging immediately after EVT. There were no complications and adequate images were obtained for all patients. Anatomical features of the vessel wall were discernible, including intima, media, adventitia, and internal/external elastic lamina. Basilar artery thick concentric plaque fibrosis was present, causing outward remodeling and loss of the internal/external lamina in certain regions. Evidence of significant residual thrombus was also visible, with mostly red thrombus present despite complete angiographic revascularization. The residual thrombus was not visible on CT, MR, or cerebral angiography and could certainly cause ongoing function-limiting strokes with occlusion of adjacent vital basilar perforators after EVT.

Restricted access

Thomas R. Marotta, Thorsteinn Gunnarsson, Ian Penn, Donald R. Ricci, Ian Mcdougall, Alexei Marko, Gyasi Bourne and Leodante Da Costa

Object

The authors describe a novel device for the endovascular treatment of intracranial aneurysms, the endovascular clip system (eCLIPs). Descriptions of the device and its delivery system as well as the results of flow model tests and the treatment of experimental aneurysms are provided.

Methods

The eCLIPs comprises a flexible hybrid implantable device (an anchor and a covered leaf) and a balloon catheter delivery system, designed to be positioned and activated in the parent vessel in such a way that the covered portion will abut the aneurysm neck. The eCLIPs was subjected to testing in glass, elastomeric, and cadaveric flow models to determine its navigability, orientation, and activation compared with commercially available stents. In a second experiment, 8 carotid artery sidewall aneurysms in swine were treated using eCLIPs. The degree of occlusion was observed on angiography immediately following and 30 days after device activation, and a histological analysis was performed at 30 days.

Results

The device could navigate tortuous glass models and human cadaveric vessels. Compared with commercially available stents, the eCLIPs performed well. It could be navigated, oriented, and activated easily and reliably. With regard to the 8 porcine experimental aneurysms, immediate postactivation angiograms confirmed complete occlusion of 4 lesions and near occlusion of the other 4. Angiographic follow-up at 30 days postactivation showed occlusion of all 8 aneurysms and patency of all parent vessels. Histopathological analysis revealed aneurysm healing, with smooth-muscle cells growing across the lesion neck to allow reendothelialization.

Conclusions

Aneurysm occlusion with a single extrasaccular endovascular device has potential advantages. The authors believe that eCLIPs may prove to be a useful tool in the endovascular treatment of cerebral aneurysms. The system should reduce risks associated with coiling, procedure time, costs, and radiation exposure. The device satisfactorily occluded 8 experimental sidewall aneurysms. The observed healing pattern is similar to that seen after microsurgical clipping.

Restricted access

Amir R. Dehdashti, Laurent Thines, Leodante B. Da Costa, Karel G. terBrugge, Robert A. Willinsky, M. Christopher Wallace and Michael Tymianski

Object

The purpose of this study was to evaluate the authors' initial experience with the integration of high-resolution rotational and biplanar angiography during neurovascular operative procedures.

Methods

Eight patients with intracerebral arteriovenous malformations (AVMs) and aneurysms underwent surgical treatment of their lesions in a combined endovascular surgical suite. After initial head positioning, preoperative biplane and rotational angiography was performed. Resection of the AVM or clipping of the aneurysm was then performed. Further biplane and rotational 3D angiograms were obtained intraoperatively to confirm satisfactory treatment.

Results

One small residual AVM identified intraoperatively necessitated further resection. One aneurysm was clipped during endovascular inflation of an intracarotid balloon for temporary proximal control. The completeness of treatment was confirmed on intraoperative 3D rotational angiography in all cases, and there were no procedure-related complications.

Conclusions

Intraoperative rotational angiography performed in an integrated biplane angiography/surgery suite is a safe and useful adjunct to surgery and may enable combining endovascular and surgical procedures for the treatment of complex vascular lesions.

Restricted access

Jetan H. Badhiwala, Farshad Nassiri, Christopher D. Witiw, Alireza Mansouri, Saleh A. Almenawer, Leodante da Costa, Michael G. Fehlings and Jefferson R. Wilson

OBJECTIVE

Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF.

METHODS

This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score–matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars).

RESULTS

A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score–matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges.

CONCLUSIONS

The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).