Malignant middle cerebral artery stroke carries a very poor prognosis. Significant retrospective data support the hypothesis that decompressive hemicraniectomy decreases mortality rates due to this disease entity. Recently, 3 randomized controlled studies have been published and shed light on these issues and enhance the quality of evidence revolving around this procedure. In this review, the rationale, risks, benefits, and unanswered questions related to hemicraniectomy for acute ischemic stroke are reviewed with an emphasis on how 3 randomized trials have influenced knowledge on this life-saving yet controversial procedure. Further randomized studies are needed to clarify lingering questions regarding age indications and impact on quality of life.
Omar M. Arnaout, Salah G. Aoun, H. Hunt Batjer and Bernard R. Bendok
Alejandro J. Lopez, Robert K. Campbell, Omar Arnaout, Yvonne M. Curran, Ali Shaibani and Nader S. Dahdaleh
The authors report the case of a 28-year-old woman with a spontaneous cerebrospinal fluid leak from the sleeve of a redundant thoracic nerve root. She presented with postural headaches and orthostatic symptoms indicative of intracranial hypotension. CT myelography revealed that the lesion was located at the T-11 nerve root. After failure of conservative management, including blood patches and thrombin glue injections, the patient was successfully treated with surgical decompression and ligation of the duplicate nerve, resulting in full resolution of her orthostatic symptoms.
Omar M. Arnaout, Bradley A. Gross, Christopher S. Eddleman, Bernard R. Bendok, Christopher C. Getch and H. Hunt Batjer
Arteriovenous malformations (AVMs) of the posterior fossa are complex neurovascular lesions that are less common than their supratentorial counterparts, accounting for < 15% of all AVMs. The majority of patients with these lesions present with intracranial hemorrhage, a factor that has been consistently shown to increase one's risk for subsequent bleeding. Studies have additionally shown a posterior fossa or deep AVM location to portend a more aggressive natural history. The authors reviewed the literature on posterior fossa AVMs, finding their annual rupture rates to be as high as 11.6%, an important factor that underscores the importance of aggressive treatment of lesions amenable to intervention as therapeutic options and results continue to improve.
David G. Weinberg, Omar M. Arnaout, Rudy J. Rahme, Salah G. Aoun, H. Hunt Batjer and Bernard R. Bendok
Moyamoya disease (MMD) is a rare cerebrovascular disorder involving stenosis of the major vessels of the circle of Willis and proximal portions of its principal branches. Despite concerted investigation, the pathophysiology of the disorder has not been fully elucidated. Currently, the major proteins believed to play an active role in the pathogenesis include vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), hepatocyte growth factor (HGF), transforming growth factor–β1 (TGFβ1), and granulocyte colony-stimulating factor (G-CSF). In terms of the genetics, recent literature suggests a low penetrance autosomal dominant or polygenic mode of transmission involving chromosomes 3, 6, 8, 12, and 17 for familial MMD. This review summarizes the current knowledge on the histopathology, pathophysiology and genetics of MMD.
A PubMed/Medline systematic study of the literature was performed, from which 45 articles regarding MMD pathophysiology were identified and analyzed.
Moyamoya disease is characterized by the intimal thickening and media attenuation of the proximal vessels of the circle of Willis as well as the development of an aberrant distal vascular network. The primary proteins that are currently implicated in the pathophysiology of MMD include VEGF, bFGF, HGF, TGFβ1, and G-CSF. Furthermore, the current literature on familial MMD has pointed to a low penetrance autosomal dominant or polygenic mode of transmittance at loci on chromosomes 3, 6, 8, 12, and 17.
Joseph A. Osorio, Jonathan D. Breshears, Omar Arnaout, Neil G. Simon, Ashley M. Hastings-Robinson, Pedram Aleshi and Michel Kliot
The objective of this study was to provide a technique that could be used in the preoperative period to facilitate the surgical exploration of peripheral nerve pathology.
The authors describe a technique in which 1) ultrasonography is used in the immediate preoperative period to identify target peripheral nerves, 2) an ultrasound-guided needle electrode is used to stimulate peripheral nerves to confirm their position, and then 3) a methylene blue (MB) injection is performed to mark the peripheral nerve pathology to facilitate surgical exploration.
A cohort of 13 patients with varying indications for peripheral nerve surgery is presented in which ultrasound guidance, stimulation, and MB were used to localize and create a road map for surgeries.
Preoperative ultrasound-guided MB administration is a promising technique that peripheral nerve surgeons could use to plan and execute surgery.
Kevin T. Huang, Michael A. Silva, Alfred P. See, Kyle C. Wu, Troy Gallerani, Hasan A. Zaidi, Yi Lu, John H. Chi, Michael W. Groff and Omar M. Arnaout
Recent advances in computer vision have revolutionized many aspects of society but have yet to find significant penetrance in neurosurgery. One proposed use for this technology is to aid in the identification of implanted spinal hardware. In revision operations, knowing the manufacturer and model of previously implanted fusion systems upfront can facilitate a faster and safer procedure, but this information is frequently unavailable or incomplete. The authors present one approach for the automated, high-accuracy classification of anterior cervical hardware fusion systems using computer vision.
Patient records were searched for those who underwent anterior-posterior (AP) cervical radiography following anterior cervical discectomy and fusion (ACDF) at the authors’ institution over a 10-year period (2008–2018). These images were then cropped and windowed to include just the cervical plating system. Images were then labeled with the appropriate manufacturer and system according to the operative record. A computer vision classifier was then constructed using the bag-of-visual-words technique and KAZE feature detection. Accuracy and validity were tested using an 80%/20% training/testing pseudorandom split over 100 iterations.
A total of 321 total images were isolated containing 9 different ACDF systems from 5 different companies. The correct system was identified as the top choice in 91.5% ± 3.8% of the cases and one of the top 2 or 3 choices in 97.1% ± 2.0% and 98.4 ± 13% of the cases, respectively. Performance persisted despite the inclusion of variable sizes of hardware (i.e., 1-level, 2-level, and 3-level plates). Stratification by the size of hardware did not improve performance.
A computer vision algorithm was trained to classify at least 9 different types of anterior cervical fusion systems using relatively sparse data sets and was demonstrated to perform with high accuracy. This represents one of many potential clinical applications of machine learning and computer vision in neurosurgical practice.
Timothy R. Smith, Rohan R. Lall, Rishi R. Lall, Isaac Josh Abecassis, Omar M. Arnaout, MaryAnne H. Marymont, Kristin R. Swanson and James P. Chandler
Patients with systemic cancer and a single brain metastasis who undergo treatment with resection plus radiotherapy live longer and have a better quality of life than those treated with radiotherapy alone. Historically, whole-brain radiotherapy (WBRT) has been the mainstay of radiation therapy; however, it is associated with significant delayed neurocognitive sequelae. In this study, the authors looked at survival in patients with single and multiple intracranial metastases who had undergone surgery and adjuvant stereotactic radiosurgery (SRS) to the tumor bed and synchronous lesions.
The authors retrospectively reviewed the records from an 8-year period at a single institution for consecutive patients with brain metastases treated via complete resection of dominant lesions and adjuvant radiosurgery. The cohort was analyzed for time to local progression, synchronous lesion progression, new intracranial lesion development, systemic progression, and overall survival. The Kaplan-Meier method (stratified by age, sex, tumor histology, and number of intracranial lesions prior to surgery) was used to calculate both progression-free and overall survival. A Cox proportional-hazards regression model was also fitted with the number of intracranial lesions as the predictor and survival as the outcome controlling for disease severity, age, sex, and primary histology.
The median overall follow-up among the 150-person cohort eligible for analysis was 17 months. Patients had an average age of 46.2 years (range 16–82 years), and 62.7% were female. The mean (± standard deviation) number of intracranial lesions per patient was 2.5 ± 2.3. The mean time between surgery and stereotactic radiosurgery (SRS) was 3.2 ± 4.1 weeks. Primary cancers included lung cancer (43.3%), breast cancer (21.3%), melanoma (10.0%), renal cell carcinoma (6.7%), and colon cancer (6.7%). The average number of isocenters per treated lesion was 7.6 ± 6.6, and the average treatment dose was 17.8 ± 2.8 Gy. One-year survival for patients in this cohort was 52%, and the 1-year local control rate was 77%. The median (±standard error) overall survival was 13.2 ± 1.9 months. There was no difference in survival between patients with a single lesion and those with multiple lesions (p = 0.319) after controlling for age, sex, and histology of primary tumor. Patients with primary breast histology had the greatest overall median survival (22.9 ± 6.2 months); patients with colorectal cancer had the shortest overall median survival (5.3 ± 1.8 months). The most common cause of death in this series was systemic progression (79%).
These results confirm that 1-year survival for patients with multiple intracranial metastases treated with resection followed by SRS to both the tumor bed and synchronous lesions is similar to established outcomes for patients with a single intracranial metastasis.