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Syed A. Quadri, Muhammad Waqas, Inamullah Khan, Muhammad Adnan Khan, Sajid S. Suriya, Mudassir Farooqui and Brian Fiani

Since Lynn and colleagues first described the use of focused ultrasound (FUS) waves for intracranial ablation in 1942, many strides have been made toward the treatment of several brain pathologies using this novel technology. In the modern era of minimal invasiveness, high-intensity focused ultrasound (HIFU) promises therapeutic utility for multiple neurosurgical applications, including treatment of tumors, stroke, epilepsy, and functional disorders. Although the use of HIFU as a potential therapeutic modality in the brain has been under study for several decades, relatively few neuroscientists, neurologists, or even neurosurgeons are familiar with it. In this extensive review, the authors intend to shed light on the current use of HIFU in different neurosurgical avenues and its mechanism of action, as well as provide an update on the outcome of various trials and advances expected from various preclinical studies in the near future. Although the initial technical challenges have been overcome and the technology has been improved, only very few clinical trials have thus far been carried out. The number of clinical trials related to neurological disorders is expected to increase in the coming years, as this novel therapeutic device appears to have a substantial expansive potential. There is great opportunity to expand the use of HIFU across various medical and surgical disciplines for the treatment of different pathologies. As this technology gains recognition, it will open the door for further research opportunities and innovation.

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Kunal Vakharia, Stephan A. Munich, Michael K. Tso, Muhammad Waqas and Elad I. Levy

Stent-assisted coiling offers a potential solution for coil embolization of broad-based aneurysms. Challenges associated with navigating a microcatheter beyond these aneurysms sometimes require looping the microcatheter within the aneurysm dome. Reducing microcatheter loops within domes can be difficult, and anchor techniques have been described, including balloon anchor, stent-retriever anchor, and stent anchor techniques. The authors present a patient requiring stent-assisted coiling of an anterior communicating artery aneurysm in whom a stent anchor technique was used to reduce a microcatheter loop within an aneurysm dome before coil embolization. Postembolization angiographic runs showed complete coil occlusion of the aneurysm with approximately 35% packing density.

The video can be found here: https://youtu.be/zHR1ZOArUro.

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Kunal Vakharia, Stephan A. Munich, Muhammad Waqas, Swetadri Vasan Setlur Nagesh and Elad I. Levy

Progressive deconstruction with flow diversion using a Pipeline embolization device (PED; Medtronic) can be utilized to promote thrombosis of broad-based fusiform aneurysms. Current flow diverters require a 0.027-inch microcatheter for deployment. The authors present a patient with a fusiform P2–3 junction posterior cerebral artery aneurysm in which they demonstrate the importance of haptics in microwire manipulation to recognize large-vessel anatomy versus perforator anatomy that may overlap, especially when access is needed in distal tortuous circulations. In addition, the authors demonstrate the need for appropriate visualization before PED deployment. Postembolization runs demonstrated optimal wall apposition with contrast stasis within the aneurysm dome.

The video can be found here: https://youtu.be/8kfsSvN3XqM.

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Hamidreza Rajabzadeh-Oghaz, Muhammad Waqas, Sricharan S. Veeturi, Kunal Vakharia, Michael K. Tso, Kenneth V. Snyder, Jason M. Davies, Adnan H. Siddiqui, Elad I. Levy and Hui Meng

OBJECTIVE

Previous studies have found that ruptured intracranial aneurysms (RIAs) have distinct morphological and hemodynamic characteristics, including higher size ratio and oscillatory shear index and lower wall shear stress. Unruptured intracranial aneurysms (UIAs) that possess similar characteristics to RIAs may be at a higher risk of rupture than those UIAs that do not. The authors previously developed the Rupture Resemblance Score (RRS), a data-driven computer model that can objectively gauge the similarity of UIAs to RIAs in terms of morphology and hemodynamics. The authors aimed to explore the clinical utility of RRS in guiding the management of UIAs, especially for challenging cases such as small UIAs.

METHODS

Between September 2018 and June 2019, the authors retrospectively collected consecutive challenging cases of incidentally identified UIAs that were discussed during their weekly multidisciplinary neurovascular conference. From patient 3D digital subtraction angiography, they reconstructed the aneurysm geometry and performed computer-assisted 3D morphology analysis and computational fluid dynamics simulation. They calculated RRS for every UIA case and compared it against the treatment decision made at the neurovascular conference as well as the recommendation based on the unruptured intracranial aneurysm treatment score (UIATS).

RESULTS

Forty-seven patients with 79 UIAs, 90% of which were < 7 mm in size, were included in this study. The mean RRS (range 0.0–1.0) was 0.24 ± 0.31. At the conferences, treatment was endorsed for 45 of the UIAs (57%). These cases had significantly higher RRSs than the 34 cases suggested for observation (0.33 ± 0.34 vs 0.11 ± 0.19, p < 0.001). The UIATS-based recommendations were “observation” for 24 UIAs (30%), “treatment” for 21 UIAs (27%), and “not definitive” for 34 UIAs (43%). These “not definitive” cases were stratified by RRS based on similarity to RIAs.

CONCLUSIONS

Although not a rupture predictor, RRS is a data-driven model that gauges the similarity of UIAs to RIAs in terms of morphology and hemodynamics. In cases in which the UIATS-based recommendation is not definitive, RRS provides additional stratification to assist the identification of high-risk UIAs. The current study highlights the clinical utility of RRS in a real-world setting as an adjunctive tool for the management of UIAs.

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Adam A. Dmytriw, Anish Kapadia, Alejandro Enriquez-Marulanda, Carmen Parra-Fariñas, Anna Luisa Kühn, Patrick J. Nicholson, Muhammad Waqas, Leonardo Renieri, Caterina Michelozzi, Paul M. Foreman, Kevin Phan, I-Hsiao Yang, Vincent M. Tutino, Christopher S. Ogilvy, Ivan Radovanovic, Mark R. Harrigan, Adnan H. Siddiqui, Elad I. Levy, Nicola Limbucci, Christophe Cognard, Timo Krings, Vitor Mendes Pereira, Ajith J. Thomas, Thomas R. Marotta and Christoph J. Griessenauer

OBJECTIVE

Coverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction.

METHODS

A multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome.

RESULTS

Sixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage.

CONCLUSIONS

FD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.