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Nancy J. Edwards, Wesley H. Jones, Aditya Sanzgiri, Juan Corona, Mark Dannenbaum and Peng Roc Chen

OBJECTIVE

The most frequent procedural complication of the endovascular treatment of intracranial aneurysms is a thromboembolic event (TEE); in a subset of patients, such events will cause permanent neurological disability. In patients with unruptured aneurysms, increasing evidence supports the use of periprocedural antiplatelet therapy to prevent TEEs. The object of this study was to evaluate whether patients with ruptured aneurysms and subarachnoid hemorrhage would also benefit from periprocedural antiplatelet therapy.

METHODS

The authors reviewed a prospective registry of 169 patients with endovascularly treated intracranial aneurysms to delineate angiographic features associated with periprocedural TEEs. They then performed a controlled before-and-after study in 79 patients with ruptured aneurysms who were deemed to be at high risk for TEEs (for example, patients with at least 1 angiographic feature associated with TEEs) to evaluate whether selective aspirin administration would reduce the rate of periprocedural thromboembolism without increasing major hemorrhagic complications.

RESULTS

Six angiographic features were associated with periprocedural TEEs in the study cohort: wide aneurysm neck, coil or loop protrusion, small parent artery diameter, an incorporated branch, intraprocedural thrombus formation, and intracranial parent vessel atherosclerosis. Aspirin administration to high-risk patients significantly decreased the rate of periprocedural TEEs, from 53.8% in the control group to 10.6% in the aspirin-treated group (p = 0.001). The reduction in TEEs in the aspirin-treated group continued to be statistically significant even when adjusted for age, sex, cardiovascular risk factors (smoking, diabetes, hypertension, dyslipidemia, coronary artery disease), and factors associated with TEEs in other large studies (wide aneurysm neck, aneurysm size ≥ 10 mm), with an adjusted OR of 0.16 (95% CI 0.03–0.8). There were no major systemic hemorrhagic complications, and aspirin did not increase the risk of aneurysm rebleeding, symptomatic intracranial hemorrhage, or major external ventricular drain (EVD)–associated hemorrhage (p = 0.3), though there was an increase in asymptomatic, minor (< 1 cm) EVD-associated hemorrhage in the aspirin-treated group (p = 0.02).

CONCLUSIONS

The study findings suggest that for ruptured aneurysm patients with high-risk features, antiplatelet therapy can significantly reduce the rate of periprocedural TEE without increasing major systemic or intracranial hemorrhages.

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Mark Dannenbaum, Bradley C. Lega, Dima Suki, Richard L. Harper and Daniel Yoshor

Object

Microvascular decompression (MVD) of the facial nerve is an effective treatment for hemifacial spasm (HFS), but the procedure is associated with a significant risk of complications such as hearing loss and facial weakness. Many surgeons advocate the use of intraoperative brainstem auditory evoked response (BAER) monitoring in an attempt to improve surgical outcomes. The authors critically assessed a large series of patients with HFS who underwent MVD without neurophysiological monitoring.

Methods

The authors retrospectively identified 114 consecutive patients, with a history of HFS and without a history of HFS surgery, in whom MVD was performed by a single surgeon without the use of neurophysiological monitoring. Postoperative outcomes were determined by reviewing records and through telephone interviews. At least 1 year of postoperative follow-up data were available for 91 of the 114 patients, and the median follow-up duration in all cases was 8 years (range 3 months–23 years). A Kaplan–Meier analysis showed that 86% of the patients were spasm free at 10 years postoperatively.

Results

There were no surgical deaths or major deficits, and complications included 1 case of postoperative deafness, 1 of permanent subtotal hearing loss, and 10 of delayed facial palsy, 2 of which did not completely resolve at last follow-up. The outcomes, rates of hearing loss, and other complications compared well with those reported in studies in which investigators used intraoperative monitoring.

Conclusions

The results suggest that MVD without neurophysiological monitoring is a safe and effective treatment option in patients with HFS. Although BAER monitoring may be a valuable adjunct to surgery at centers experienced with the modality, the absence of intraoperative monitoring should not prevent neurosurgeons from performing MVD in patients with HFS.

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Keyne K. Johnson, Mark J. Dannenbaum, Meenakshi B. Bhattacharjee, Anna Illner, Robert C. Dauser, William E. Whitehead, Andrew Jea and Thomas G. Luerssen

Primary skull lesions, albeit rare in the pediatric population, have been well described and classified. These lesions are usually benign and commonly present as a painless mass. The most common lesions are epidermoid, dermoid, and Langerhans cell histiocytosis. Cranial fasciitis, encountered less frequently, is usually not considered in this differential diagnosis. Given such few cases reported, it is commonly misdiagnosed preoperatively.

The authors retrospectively reviewed data obtained in 4 patients with cranial fasciitis in whom the diagnosis was based on histopathological findings. In 2 patients the onset of the lesion was spontaneous. One patient had a lesion 4 months following a vacuum extraction and subsequent cephalohematoma formation. One patient developed a lesion following a previous craniectomy. Presentation, imaging studies, and histopathological findings were all reviewed and analyzed. All patients presented with a firm nontender mass. Radiological features included a lytic bone lesion with a mildly sclerotic margin, T1 isodensity, T2 heterogeneous hyperdensity, and heterogeneous enhancement. The enhancing portion was not bright on T2-weighted MR images, likely representing the fibrous component; the nonenhancing portion was bright on T2-weighted images, likely representing the myxoid matrix. Histopathological examination revealed proliferating fibroblasts in a myxoid matrix.

Cranial fasciitis is a benign, painless but rapidly growing lesion of the skull mainly limited to the pediatric population. It is histologically similar to nodular fasciitis, a fibroblastic proliferation of varying size. These lesions are often related to trauma but can also be insidious or can develop at a prior craniectomy site. The appropriate clinical picture and distinguishing radiographic features may help to differentiate cranial fasciitis from other lesions of the skull allowing for earlier intervention.