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Georgios Alexopoulos, Nabiha Quadri, Maheen Khan, Henna Bazai, Carla Formoso Pico, Connor Fraser, Neha Kulkarni, Joanna Kemp, Jeroen Coppens, Richard Bucholz, and Philippe Mercier

OBJECTIVE

Penetrating brain injury (PBI) is the most lethal of all firearm injuries, with reported survival rates of less than 20%. The projectile trajectory (PT) has been shown to impact mortality, but the significant lobar tracks have not been defined. The aim of this retrospective case-control study was to test for associations between distinct ballistic trajectories, missile types, and patient outcomes.

METHODS

A total of 243 patients who presented with a PBI to the Saint Louis University emergency department from 2008 through 2019 were identified from the hospital registry. Conventional CT scans combined with 3D CT reconstructions and medical records were reviewed for each patient to identify distinct PTs.

RESULTS

A total of 65 ballistic lobar trajectories were identified. Multivariable regression models were used, and the results were compared with those in the literature. Penetrating and perforating types of PBI associated with bitemporal (t-statistic = −2.283, p = 0.023) or frontal-to-contralateral parietal (t-statistic = −2.311, p = 0.025) projectile paths were universally found to be fatal. In the group in which the Glasgow Coma Scale (GCS) score at presentation was lower than 8, a favorable penetrating missile trajectory was one that involved a single frontal lobe (adjusted OR 0.02 [95% CI 0.00–0.38], p = 0.022) or parietal lobe (adjusted OR 0.15 [95% CI 0.02–0.97], p = 0.048). Expanding or fragmenting types of projectiles carry higher mortality rates (OR 2.53 [95% CI 1.32–4.83], p < 0.001) than do nondeformable missiles. Patient age was not associated with worse outcomes when controlled by other significant predictive factors.

CONCLUSIONS

Patients with penetrating or perforating types of PBI associated with bitemporal or frontal-to-contralateral parietal PTs should be considered as potential donor candidates. Trauma patients with penetrating missile trajectories involving a single frontal or parietal lobe should be considered for early neurosurgical intervention, especially in the circumstances of a low GCS score (< 8). Surgeons should not base their decision-making solely on advanced patient age to defer further treatment. Patients with PBIs caused by nondeformable types of projectiles can survive multiple simultaneous intracranial missile trajectories.

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Saleem I. Abdulrauf, Peter Vuong, Ritesh Patel, Raghu Sampath, Ahmed M. Ashour, Lauren M. Germany, Jonathon Lebovitz, Colt Brunson, Yuvraj Nijjar, J. Kyle Dryden, Maheen Q. Khan, Mihaela G. Stefan, Evan Wiley, Ryan T. Cleary, Connor Reis, Jodi Walsh, and Paula Buchanan

OBJECTIVE

Risk of ischemia during aneurysm surgery is significantly related to temporary clipping time and final clipping that might incorporate a perforator. In this study, the authors attempted to assess the potential added benefit to patient outcomes of “awake” neurological testing when compared with standard neurophysiological testing performed under general anesthesia. The procedure is performed after the induction of conscious sedation, and for the neurological testing, the patient is fully awake.

METHODS

The authors conducted an institutional review board–approved prospective study of clipping unruptured intracranial aneurysms (UIAs) in 30 consecutive adult patients who underwent awake clipping. The end points were the incidence of stroke/cerebrovascular accident (CVA), death, discharge to a long-term facility, length of stay, and 30-day modified Rankin Scale score. All clinical and neurophysiological intraoperative monitoring data were recorded.

RESULTS

The median patient age was 52 years (range 27–63 years); 19 (63%) female and 11 (37%) male patients were included. Twenty-seven (90%) aneurysms were anterior, and 3 (10%) were posterior circulation aneurysms. Five (17%) had been coiled previously, 3 (10%) had been clipped previously, 2 (7%) were partially calcified, and 2 (7%) were fusiform aneurysms. Three patients developed synchronous clinical neurological and neurophysiological changes during temporary clipping with consequent removal of the temporary clip and reversal of those clinical and neurophysiological changes. Three patients developed asynchronous clinical neurological and neurophysiological changes. These 3 patients developed hemiparesis without changes in neurophysiological monitoring results. One patient developed linked clinical neurological and neurophysiological changes during final clipping that were not reversed by reapplication of the clip, and the patient had a CVA. Four patients with internal carotid artery ophthalmic segment aneurysms underwent visual testing with final clipping, and 1 of these patients required repositioning of the clip. Three patients who required permanent occlusion of a vessel as part of their aneurysm treatment underwent a 10-minute intraoperative clinical respective-vessel test occlusion. The median length of stay was 3 days (range 1–5 days). The median modified Rankin Scale score was 1 (range 0–3). All of the patients were discharged to home from the hospital except for 1 who developed a CVA and was discharged to a rehabilitation facility. There were no deaths in this series.

CONCLUSIONS

The 3 patients who developed neurological deterioration without a concomitant neurophysiological finding during temporary clipping revealed a potential advantage of awake aneurysm surgery (i.e., in decreasing the risk of ischemic injury).