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M. Yashar S. Kalani, Nikolay L. Martirosyan, Peter Nakaji and Robert F. Spetzler

The supracerebellar infratentorial approach provides access to the dorsal midbrain, pineal region, and tentorial incisura. This approach can be used with the patient in a sitting, prone, park-bench, or supine position. For a patient with a supple neck and favorable anatomy, we prefer the supine position. The ipsilateral shoulder is elevated, the head turned to the contralateral side, the chin is tucked, and the neck extended toward the floor to open the craniocervical angle for added working room. Care must be taken to place the craniotomy laterally to make use of the ascending angle of the tentorium for ease of access to deep-seated lesions.

The video can be found here: https://youtu.be/BZh6ljmE23k.

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Nikolay L. Martirosyan, M. Yashar S. Kalani, Peter Nakaji and Robert F. Spetzler

The anterior interhemispheric approach is a workhorse for treatment of lesions in the third ventricle. In this case, we demonstrate the utility of this approach for resecting a complex third ventricular cavernous malformation. We discuss patient positioning, optimal location of the craniotomy, and surgical resection techniques for safe removal of these lesions. We also demonstrate the importance of gravity retraction using the falx to prevent injury to the dominant frontal lobe.

The video can be found here: https://youtu.be/38woc28er7M.

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M. Yashar S. Kalani, Kaan Yağmurlu, Nikolay L. Martirosyan and Robert F. Spetzler

Dorsal pons lesions at the facial colliculus level can be accessed with a suboccipital telovelar (SOTV) approach using the superior fovea safe entry zone. Opening the telovelar junction allows visualization of the dorsal pons and lateral entry at the level of the fourth ventricle floor. Typically, a lateral entry into the floor of the fourth ventricle is better tolerated than a midline opening. This video demonstrates the use of the SOTV approach to remove a cavernous malformation at the level of the facial colliculus. This case is particularly interesting because of a large venous anomaly and several telangiectasias in the pons. Dissections in the video are reproduced with permission from the Rhoton Collection (http://rhoton.ineurodb.org).

The video can be found here: https://youtu.be/LqzCfN2J3lY.

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M. Yashar S. Kalani, Kaan Yagmurlu, Nikolay L. Martirosyan, Daniel D. Cavalcanti and Robert F. Spetzler

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Alberto Maud, Gustavo J. Rodriguez, Paisith Piriyawat and Salvador Cruz-Flores

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Vernard S. Fennell, Nikolay L. Martirosyan, Sheri K. Palejwala, G. Michael Lemole Jr. and Travis M. Dumont

OBJECT

Endovascular treatment of cerebrovascular pathology, particularly aneurysms, is becoming more prevalent. There is a wide variety in clinical background and training of physicians who treat cerebrovascular pathology through endovascular means. The impact of clinical training background on patient outcomes is not well documented.

METHODS

The authors conducted a retrospective analysis of a large national database, the University HealthSystem Consortium, that was queried in the years 2009–2013. Cases of both unruptured cerebral aneurysms and subarachnoid hemorrhage treated by endovascular obliteration were studied. Outcome measures of morbidity and mortality were evaluated according to the specialty of the treating physician.

RESULTS

Elective embolization of an unruptured aneurysm was the procedure code and primary diagnosis, respectively, for 12,400 cases. Patients with at least 1 complication were reported in 799 cases (6.4%). Deaths were reported in 193 cases (1.6%). Complications and deaths were varied by specialty; the highest incidence of complications (11.1%) and deaths (3.0%) were reported by neurologists. The fewest complications were reported by neurosurgeons (5.4%; 1.4% deaths), with a higher incidence of complications reported in cases performed by neurologists (p < 0.0001 for both complications and deaths) and to a lesser degree interventional radiologists (p = 0.0093 for complications). Subarachnoid hemorrhage was the primary diagnosis and procedure for 8197 cases. At least 1 complication was reported in 2385 cases (29%) and deaths in 983 cases (12%). The number of complications and deaths varied among specialties. The highest incidence of complications (34%) and deaths (13.5%) in subarachnoid hemorrhage was in cases performed by neurologists. The fewest complications were in cases by neurosurgeons (27%), with a higher incidence of complications in cases performed by neurologists (34%, p < 0.0001), and a trend of increased complications with interventional radiologists (30%, p < 0.0676). The lowest incidence of mortality was in cases performed by neurosurgeons (11.5%), with a significantly higher incidence of mortality in cases performed by neurologists (13.5%, p = 0.0372). Mortality rates did not reach statistical significance with respect to interventional radiologists (12.1%, p = 0.4884).

CONCLUSIONS

Physicians of varied training types and backgrounds use endovascular treatment of ruptured and unruptured intracerebral aneurysms. In this study there was a statistically significant finding that neurosurgically trained physicians may demonstrate improved outcomes with respect to endovascular treatment of unruptured aneurysms in this cohort. This finding warrants further investigation.

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M. Yashar S. Kalani, John E. Wanebo, Nikolay L. Martirosyan, Peter Nakaji, Joseph M. Zabramski and Robert F. Spetzler

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Ali M. Elhadi, Samuel Kalb, Nikolay L. Martirosyan, Abhishek Agrawal and Mark C. Preul

Within a few months of Wilhelm Conrad Röntgen's discovery of x-rays in 1895, Fedor Krause acquired an x-ray apparatus and began to use it in his daily interactions with patients and for diagnosis. He was the first neurosurgeon to use x-rays methodically and systematically. In 1908 Krause published the first volume of text on neurosurgery, Chirurgie des Gehirns und Rückenmarks (Surgery of the Brain and Spinal Cord), which was translated into English in 1909. The second volume followed in 1911. This was the first published multivolume text totally devoted to neurosurgery. Although Krause excelled in and promoted neurosurgery, he believed that surgeons should excel at general surgery. Importantly, Krause was inclined to adopt technology that he believed could be helpful in surgery. His 1908 text was the first neurosurgical text to contain a specific chapter on x-rays (“Radiographie”) that showed roentgenograms of neurosurgical procedures and pathology. After the revolutionary discovery of x-rays by Röntgen, many prominent neurosurgeons seemed pessimistic about the use of x-rays for anything more than trauma or fractures. Krause immediately seized on its use to guide and monitor ventricular drainage and especially for the diagnosis of tumors of the skull base. The x-ray images contained in Krause's “Radiographie” chapter provide a seminal view into the adoption of new technology and the development of neurosurgical technique and are part of neurosurgery's heritage.

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M. Yashar S. Kalani, Nikolay L. Martirosyan, Andrew S. Little, Udaya K. Kakarla and Nicholas Theodore

The authors describe a rare case of tumoral calcinosis (TC) of the thoracic spine in a 13-year-old boy with thoracic scoliosis. The patient presented with a 2-year history of back pain. He had no personal or family history of bone disease, deformity, or malignancy. Magnetic resonance imaging revealed a heterogeneously enhancing mass involving the T-7 vertebral body and the left pedicle. Computed tomography findings suggested that the mass was calcified and that this had resulted in scalloping of the vertebral body. The lesion was resected completely by using a left T-7 costotransversectomy and corpectomy. The deformity was corrected with placement of a vertebral body cage and pedicle screw fixation from T-5 to T-9. Pathological analysis of the mass demonstrated dystrophic calcification with marked hypercellularity and immunostaining consistent with TC. This represents the third reported case of vertebral TC in the pediatric population. Pediatric neurosurgeons should be familiar with lesions such as TC, which may be encountered in the elderly and in hemodialysis-dependent populations, and may not always require aggressive resection.

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M. Yashar S. Kalani, Ting Lei, Nikolay L. Martirosyan, Mark E. Oppenlander, Robert F. Spetzler and Peter Nakaji

The mesial temporal lobe can be approached via a pterional or orbitozygomatic craniotomy, the subtemporal approach, or transcortically. Alternatively, the entire mesial temporal lobe can be accessed using a lateral supracerebellar transtentorial (SCTT) approach. Here we describe the technical nuances of patient positioning, craniotomy, supracerebellar dissection, and tentorial disconnection to traverse the tentorial incisura to arrive at the posterior mesial temporal lobe for a cavernous malformation. The SCTT approach is especially useful for lesions in the dominant temporal lobe where an anterolateral approach may endanger language centers or the vein of Labbé.

The video can be found here: https://youtu.be/D8mIR5yeiVw.