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Issam Awad and Pascal Jabbour

✓Seizures and epilepsy are frequent clinical manifestations of cerebral cavernous malformations (CCMs) and represent the most common symptomatic presentation of supratentorial lesions. Clinicians often diagnose CCMs in patients after a first seizure, or in some cases after obtaining neuroimaging studies in patients suffering from chronic epilepsy previously thought to be idiopathic. In some cases, the lesion is clinically significant solely because of its epileptogenicity, but in others there may be concern about potential hemorrhage or focal neurological deficits from a similar lesion.

The authors present current pathophysiological concepts related to epilepsy associated with CCMs. They discuss the spectrum of seizure disorders associated with these lesions and review the natural history, prognosis, and options for therapeutic intervention.

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Kenan AlKhalili, Nohra Chalouhi, Stavropoula Tjoumakaris, Robert Rosenwasser, and Pascal Jabbour

Stereotactic radiosurgery is an effective management strategy for properly selected patients with arteriovenous malformations (AVMs). However, the risk of postradiosurgical radiation-related injury is higher in patients with large AVMs. Multistaged volumetric management of large AVMs was undertaken to limit the radiation exposure to the surrounding normal brain. This strategy offers a promising method for obtaining high AVM obliteration rates with minimal normal tissue damage. The use of embolization as an adjunctive method in the treatment of large AVMs remains controversial. Unfortunately, staged-volume radiosurgery (SVR) has a number of potential pitfalls that affect the outcome. The aim of this article is to highlight the role of SVR in the treatment of large AVMs, to discuss the outcome comparing it to other treatment modalities, and to discuss the potential improvement that could be introduced to this method of treatment.

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L. Fernando Gonzalez, Nohra Chalouhi, Stavropoula Tjoumakaris, Pascal Jabbour, Aaron S. Dumont, and Robert H. Rosenwasser

Object

Multiple approaches have been used to treat carotid-cavernous fistulas (CCFs). The transvenous approach has become a popular and effective route. Onyx is a valuable tool in today's endovascular armamentarium. The authors describe the use of a balloon-assisted technique in the treatment of CCFs with Onyx and assess its feasibility, utility, and safety.

Methods

The authors searched their prospectively maintained database for CCFs embolized using Onyx with the assistance of a compliant balloon placed in the internal carotid artery (ICA).

Results

Five patients were treated between July 2009 and July 2011 at the authors' institution. A balloon helped to identify the fistulous point, served as a buttress for coils, protected from inadvertent arterial embolizations, and prevented Onyx and coils from obscuring the ICA during the course of embolization. No balloon-related complications were noted in any of the 5 cases. All 5 fistulas were completely obliterated at the end of the procedure. Four patients had available clinical follow-ups, and all 4 showed reversal of nerve palsies.

Conclusions

Balloon-assisted Onyx embolization of CCFs offers a powerful combination that prevents inadvertent migration of the embolic material into the arterial system, facilitates visualization of the ICA, and serves as a buttress for coils deployed in the cavernous sinus through the fistulous point. Despite adding another layer of technical complexity, an intraarterial balloon can provide valuable assistance in the treatment of CCFs.

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Sonia G. Teufack, Peter Campbell, Pascal Jabbour, Mitchell Maltenfort, James Evans, and John K. Ratliff

Object

The Centers for Medicare and Medicaid Services (CMS) have moved to limit hospital augmentation of diagnosis-related group billing for “never events” (adverse events that are serious, largely preventable, and of concern to the public and health care providers for the purpose of public accountability) and certain hospital-acquired conditions (HACs). Similar restrictions may be applied to physician billing. The financial impact of these restrictions may fall on academic medical centers, which commonly have populations of complex patients with a higher risk of HACs. The authors sought to quantify the potential financial impact of restrictions in never events and periprocedural HAC billing on a tertiary neurosurgery facility.

Methods

Operative cases treated between January 2008 and June 2008 were reviewed after searching a prospectively maintained database of perioperative complications. The authors assessed cases in which there was a 6-month lag time to allow for completion of hospital and physician billing. They speculated that other payers would soon adopt the present CMS restrictions and that procedure-related HACs would be expanded to cover common neurosurgery procedures. To evaluate the impact on physician billing and to directly contrast physician and hospital billing impact, the authors focused on periprocedural HACs, as opposed to entire admission HACs. Billing records were compiled and a comparison was made between individual event data and simultaneous cumulative net revenue and net receipts. The authors assessed the impact of the present regulations, expansion of CMS restrictions to other payers, and expansion to rehospitalization and entire hospitalization case billing due to HACs and never events.

Results

A total of 1289 procedures were completed during the examined period. Twenty-five procedures (2%) involved patients in whom HACs developed; all were wound infections. Twenty-nine secondary procedures were required for this cohort. Length of stay was significantly higher in patients with HACs than in those without (11.6 ± 11.5 vs 5.9 ± 7.0 days, respectively). Fifteen patients required readmission due to HACs. Following present never event and HAC restrictions, hospital and physician billing was minimally affected (never event billing as percent total receipts was 0.007% for hospitals and 0% for physicians). Nonpayment for rehospitalization and reoperation for HACs by CMS and private payers yielded greater financial impact (CMS only, percentage of total receipts: 0.14% hospital, 0.2% physician; all payers: 1.56% hospital, 3.0% physician). Eliminating reimbursement for index procedures yielded profound reductions (CMS only as percentage of total receipts: 0.62% hospital, 0.8% physician; all payers: 5.73% hospital, 8.9% physician).

Conclusions

The authors found potentially significant reductions in physician and facility billing. The expansion of never event and HACs reimbursement nonpayment may have a substantial financial impact on tertiary care facilities. The elimination of never events and reduction in HACs in current medical practices are worthy goals. However, overzealous application of HACs restrictions may remove from tertiary centers the incentive to treat high-risk patients.

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Pascal Jabbour, Christopher Koebbe, Erol Veznedaroglu, Ronald P. Benitez, and Robert Rosenwasser

Object

The treatment of wide-necked cerebral aneurysms represents a challenging problem for neurosurgeons. The recent development of stents has provided clinicians with the ability to treat these aneurysms while keeping the parent vessel patent. The long-term occlusion rate of aneurysms treated with stent-assisted coil placement has yet to be investigated. The authors report the use of a new intracranial stent—the Neuroform microstent—in the treatment of unruptured wide-necked cerebral aneurysms.

Methods

Thirty-two patients harboring unruptured wide-necked intracranial aneurysms underwent a stent-assisted coil placement procedure. Patients were pretreated with antiplatelet agents, and a stent was positioned across the neck of the aneurysm. The next step was the insertion of coils into the aneurysm cavity. Patients received anticoagulation therapy for 24 hours after the procedure.

All 32 patients with unruptured wide-necked cerebral aneurysms were suitable candidates for this procedure. Occlusion of at least 90% of the aneurysm was achieved in 24 patients (75%) and 0% occlusion was observed in five patients (15%). Two patients experienced thromboembolic events, one of which was directly related to the stent. The overall complication rate was 6.3%.

Conclusions

Intracranial stents will be used more frequently in the new era of endovascular management of wide-necked cerebral aneurysms. With some technical improvements and more data on long-term occlusion rates, this new modality should improve the occlusion of wide-necked cerebral aneurysms while protecting the parent vessel.

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Peter G. Campbell, Pascal Jabbour, Sanjay Yadla, and Issam A. Awad

Cerebral cavernous malformations (CCMs) are divided into sporadic and familial forms. For clinical imaging, T2-weighted gradient-echo sequences have been shown to be more sensitive than conventional sequences. Recently more advanced imaging techniques such as high-field and susceptibility-weighted MR imaging have been employed for the evaluation of CCMs. Furthermore, diffusion tensor imaging and functional MR imaging have been applied to the preoperative and intraoperative management of these lesions. In this paper, the authors attempt to provide a concise review of the emerging imaging methods used in the clinical diagnosis and treatment of CCMs.

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Benjamin Zussman, Pascal Jabbour, Kiran Talekar, Richard Gorniak, and Adam E. Flanders

Object

Although dynamic, first-pass cerebral CT perfusion is used in the evaluation of acute ischemic stroke, a lack of standardization restricts the value of this imaging modality in clinical decision-making. The purpose of this study was to comprehensively review the reported sources of variability and error in cerebral CT perfusion results.

Methods

A systematic literature review was conducted, 120 articles were reviewed, and 23 published original research articles were included. Sources of variability and error were thematically categorized and presented within the context of the 3 stages of a typical CT perfusion study: data acquisition, postprocessing, and results interpretation.

Results

Seven factors that caused variability were identified and described in detail: 1) contrast media, the iodinated compound injected intravascularly to permit imaging of the cerebral vessels; 2) data acquisition rate, the number of images obtained by CT scan per unit time; 3) user inputs, the subjective selections that operators make; 4) observer variation, the failure of operators to repeatedly measure a perfusion parameter with precision; 5) software operational mode, manual, semiautomatic, or automatic; 6) software design, the mathematical algorithms used to perform postprocessing; and 7) value type, absolute versus relative values.

Conclusions

Standardization at all 3 stages of the CT perfusion study cycle is warranted. At present, caution should be exercised when interpreting CT perfusion results as these values may vary considerably depending on a variety of factors. Future research is needed to define the role of CT perfusion in clinical decision-making for acute stroke patients and to determine the clinically acceptable limits of variability in CT perfusion results.

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Pascal Jabbour, Michael Fehlings, Alexander R. Vaccaro, and James S. Harrop

In this paper the authors review spine trauma and spinal cord injury (SCI) in the geriatric population. The information in this study was compiled through a literature review of clinical presentation and management of SCI in the elderly population. This was done to define, identify, and specify treatment algorithms and management strategies in this unique patient population.

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Joshua H. Weinberg, Ahmad Sweid, Kalyan Sajja, M. Reid Gooch, Nabeel Herial, Stavropoula Tjoumakaris, Robert H. Rosenwasser, and Pascal Jabbour

OBJECTIVE

The objective of this study was to demonstrate the feasibility and safety of CorPath GRX robotic-assisted (RA) transradial (TR) carotid artery stenting (CAS) compared with manual TR CAS.

METHODS

The authors conducted a retrospective analysis of a prospectively maintained database and identified 13 consecutive patients who underwent TR CAS from June 2019 through February 2020. Patients were divided into 2 groups: RA (6 patients) and manual (7 patients).

RESULTS

Among 6 patients in the RA group with a mean age of 70.0 ± 7.2 years, technical success was achieved in all 6 (100%) procedures; there were no technical or access-site complications and no catheter exchanges. Transfemoral conversion was required in 1 (16.7%) case due to a tortuous aortic arch. There were no perioperative complications, including myocardial infarction, stroke, and mortality. The mean procedure duration was significantly longer in the RA group (85.0 ± 14.3 minutes [95% CI 69.9–100.0] vs 61.2 ± 17.5 minutes [95% CI 45.0–77.4], p = 0.0231). There was no significant difference in baseline characteristics, fluoroscopy time, contrast dose, radiation exposure, catheter exchanges, technical success, transfemoral conversion, technical or access-site complications, myocardial infarction, stroke, other complications, or mortality.

CONCLUSIONS

The authors’ results suggest that RA TR CAS is feasible, safe, and effective. Neurovascular-specific engineering and software modifications are needed prior to complete remote control. Remote control has important implications regarding patient access to lifesaving procedures for conditions such as stroke and aneurysm rupture as well as operative precision. Future clinical investigations among larger cohorts are needed to demonstrate reliable performance and patient benefit.

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Badih Daou, Christine Hammer, Nohra Chalouhi, Robert M. Starke, Pascal Jabbour, Robert H. Rosenwasser, and Stavropoula Tjoumakaris

OBJECTIVE

Dissection of the carotid and vertebral arteries can result in the development of aneurysmal dilations. These dissecting pseudoaneurysms can enlarge and cause symptoms. The objective of this study is to provide insight into the progression of dissecting pseudoaneurysms and the treatments required to manage them.

METHODS

A review of the electronic medical records was conducted to detect patients with carotid and vertebral artery dissection. An imaging review was conducted to identify patients with dissecting pseudoaneurysms. One hundred twelve patients with 120 dissecting pseudoaneurysms were identified. Univariate and multivariate analyses were conducted to assess the factors associated with undergoing further interventions other than medical treatment, pseudoaneurysm enlargement, pseudoaneurysms resulting in ischemic and nonischemic symptoms, and clinical outcome.

RESULTS

Overall, 18.3% of pseudoaneurysms were intracranial and 81.7% were extracranial, and the average size was 7.3 mm. The mean follow-up time was 29.3 months; 3.3% of patients had a recurrent transient ischemic attack, no patients had a recurrent stroke, and 14.2% of patients had recurrence of nonischemic symptoms (headache, neck pain, Horner syndrome, or cranial nerve palsy). Follow-up imaging demonstrated that 13.8% of pseudoaneurysms had enlarged, 30.2% had healed, and 56% had remained stable. In total, 20.8% of patients had an intervention other than medical treatment. Interventions included stenting, coiling, flow diversion, and clipping. Predictors of intervention included increasing size, size > 10 mm, location in the C2 (petrous) segment of the internal carotid artery (ICA), younger age, hyperlipidemia, pseudoaneurysm enlargement, and any symptom development. Significant predictors of enlargement included smoking, history of trauma, C2 location, hyperlipidemia, and larger initial pseudoaneurysm size. Predictors of pseudoaneurysm resulting in recurrent ischemic and nonischemic symptoms included increasing size and location in the petrous segment of the ICA. Smoking was a predictor of unfavorable outcome.

CONCLUSIONS

Dissecting pseudoaneurysms have a benign course and most will not cause symptoms or enlarge on follow-up. Medical treatment can be a sufficient, initial treatment for dissecting pseudoaneurysms.