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Anterior cervical plates: a historical perspective

Roham Moftakhar and Gregory R. Trost

The development of anterior cervical plates (ACPs) represents a rapidly changing aspect of spine surgery. This paper focuses on a historical overview of ACPs. The authors discuss the disadvantages of earlier generations of plates and demonstrate how current plates have been designed to overcome the presumed shortcomings of their predecessors.

This historical review begins with the earliest plates—unrestricted backout plates—and moves on to newer plates—restricted backout plates and their different subcategories.

Virtually all modern ACPs work equally well in cervical stabilization; however, there are differences in design that warrant future studies to understand the long-term performances of different plates.

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Retrosigmoid approach for resection of cerebellopontine angle meningioma and decompression of the trigeminal nerve

Lee A. Tan, Carter S. Gerard, Sumeet K. Ahuja, and Roham Moftakhar

Cerebellopontine angle (CPA) lesions account for up to 10% of all intracranial tumors. The most common CPA lesions are vestibular schwannomas (70–80%), meningiomas (10–15%) and epidermoid cysts (5%). CPA tumors are estimated to be the secondary cause for up to 9.9% patients with trigeminal neuralgia. We demonstrate a case of medically refractory trigeminal neuralgia caused by a CPA meningioma that was successfully treated via retrosigmoid approach. The patient had immediate and dramatic symptomatic improvement after surgery. Detailed surgical techniques of retrosigmoid craniotomy and tumor dissection are presented in high definition video with narration.

The video can be found here: http://youtu.be/55j9QCQEsH8.

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Ventriculoperitoneal shunt with a rare twist: small-bowel ischemia and necrosis secondary to knotting of peritoneal catheter

Case report

Lee A. Tan, Manish K. Kasliwal, Roham Moftakhar, and Lorenzo F. Munoz

Small-bowel ischemia and necrosis due to knotting of the peritoneal catheter is an extremely rare complication related to a ventriculoperitoneal shunt (VPS). A 3-month-old girl, with a history of Chiari II malformation and myelomeningocele (MM) after undergoing right occipital VPS insertion and MM repair at birth, presented to the emergency department with a high-grade fever. Examination of a CSF sample obtained via shunt tap raised suspicion for the presence of infection. Antibiotic therapy was initiated, and subsequently the VPS was removed and an external ventricular drain was placed. Intraoperatively, as attempts at pulling the distal catheter from the scalp incision were met with resistance, the distal catheter was cut and left in the abdomen while the remainder of the shunt system was successfully removed. While the patient was awaiting definitive shunt revision surgery to replace the VPS, she developed abdominal distension due to small-bowel obstruction. An emergency exploratory laparotomy revealed a knot in the distal catheter looping around and strangulating the distal ileum, causing small-bowel ischemia and necrosis in addition to the obstruction. A small-bowel resection with ileostomy was performed, with subsequent placement of ventriculoatrial shunt for treatment of hydrocephalus. The authors report this exceedingly rare clinical scenario to highlight the fact that any retained distal catheter must be carefully managed with immediate abdominal exploration to remove the distal catheter to avoid bowel necrosis as pulling of a knotted peritoneal catheter may strangulate the bowel and cause ischemia, with significant clinical morbidity and possible mortality.

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Utility of computed tomography perfusion in detection of cerebral vasospasm in patients with subarachnoid hemorrhage

Roham Moftakhar, Howard A. Rowley, Aquilla Turk, David B. Niemann, Beverly Aagaard Kienitz, Jamie Van Gomple, and Mustafa K. Başkaya

Object

Digital subtraction (DS) angiography is the gold standard for detecting cerebral vasospasm after subarachnoid hemorrhage (SAH). Computed tomography (CT) perfusion is a recently developed modality for the evaluation of cerebral hemodynamics. This study was conducted to evaluate the potential of using CT perfusion to detect vasospasm in patients with SAH.

Methods

Fourteen patients between the ages of 41 and 66 years with aneurysmal SAH underwent 23 CT perfusion scans for suspected vasospasm. All patients underwent DS angiography within 12 hours of the CT perfusion scans. The presence of vasospasm on CT perfusion images was determined based on qualitative reading using color maps of mean transit time, cerebral blood flow, and cerebral blood volume as criteria. The presence or absence of vasospasm as retrospectively determined using CT perfusion was compared with DS angiography findings.

Of the 23 CT perfusion scans performed, 21 (91%) were concordant with angiography findings in predicting the presence or absence of vasospasm. In 15 of 23 scans, the presence of vasospasm was detected on CT perfusion scans and confirmed on DS angiography studies. In two cases, vasospasm was revealed on DS angiography but was not confirmed on CT perfusion. The degree of agreement between CT perfusion and DS angiography for detection of vasospasm was high (κ = 0.8, p < 0.0001).

Conclusions

Computed tomography perfusion is an accurate, reliable, and noninvasive method to detect the presence or absence of vasospasm. It can be used as a tool to help guide the decision to pursue DS angiography with the intent to treat vasospasm.

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Endovascular transarterial embolization of cerebral arteriovenous malformation with ethylene-vinyl alcohol copolymer

Lee A. Tan, Andrew K. Johnson, Kiffon M. Keigher, Roham Moftakhar, and Demetrius K. Lopes

Cerebral arteriovenous malformations (AVMs) have an estimated 2–4% annual risk of hemorrhage. Treatment options for AVMs include microsurgical resection, stereotactic radiosurgery, and endovascular embolization. As endovascular technology and techniques continue to advance and mature, endovascular embolization is becoming an increasingly vital component of AVM treatment not only as a presurgical treatment to reduce microsurgical risks, but also as a stand-alone curative method in some cases. This case illustrates the successful and curative transarterial embolization of a right frontal AVM in a 17-year-old boy with ethylene-vinyl alcohol copolymer (Onyx).

The video can be found here: http://youtu.be/L4hE1MvCZCY.

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Y-stent-assisted coil embolization of cerebral aneurysms

Lee A. Tan, Andrew K. Johnson, Kiffon M. Keigher, Roham Moftakhar, and Demetrius K. Lopes

Y-stent–assisted coiling is a technique used by neuroendovascular surgeons to treat complex, wide-necked, bifurcation aneurysms in locations such as basilar tip and middle cerebral artery bifurcation. Several recent studies have demonstrated low complication rate and favorable clinical and angiographic outcomes. The Y-stent technique is illustrated here in detail and the intraoperative nuances are also discussed to minimize potential complications associated with technique.

The video can be found here: http://youtu.be/77pEmqx_fyQ.

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Intraaneurysmal balloon assistance for navigation across a wide-necked aneurysm

Technical note

Stacey Quintero Wolfe, Hamad Farhat, Roham Moftakhar, Mohamed Samy Elhammady, and Mohammad Ali Aziz-Sultan

Endovascular obliteration of wide-necked aneurysms may be precluded by the inability to navigate across the aneurysm neck. The authors present a technique in which a Hyperform balloon is inflated within the aneurysm and used as a contact surface to “bounce” the remodeling balloon across the aneurysm neck. They have successfully used this technique in 3 patients to efficiently overcome vessel tortuosity, aneurysmal dead space, and balloon prolapse, allowing for obliteration of large, wide-necked aneurysms.

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The Pipeline Embolization Device for the treatment of posterior circulation fusiform aneurysms: lessons learned at a single institution

Clinical article

Stephan A. Munich, Lee A. Tan, Kiffon M. Keigher, Michael Chen, Roham Moftakhar, and Demetrius K. Lopes

Object

Vertebrobasilar fusiform aneurysms (VFAs) are rare lesions characterized by abnormal dilation and tortuosity of the vertebral and/or basilar arteries. Untreated, these aneurysms have a tendency to progress, often resulting in neurological symptoms or rupture leading to subarachnoid hemorrhage. The microsurgical treatment of these lesions can be difficult due to their location and the circumferential involvement of the arteries. These features make microsurgical treatment prone to high morbidity. The Pipeline Embolization Device (PED) has gained popularity for the treatment of aneurysms of the internal carotid artery. Its use in the posterior circulation has been limited, likely due to a fear of perforating artery occlusion.

Methods

The authors retrospectively reviewed their database of patients treated with the PED and identified 12 patients who had VFAs. The clinical features, complications, and outcomes of these patients were analyzed.

Results

At an average follow-up of 11 months, the mean modified Rankin Scale score was 1.9. Complete aneurysm occlusion was seen in 90% of the patients with radiographic follow-up. Three patients suffered new neurological deficits postoperatively. One of these patients died, while the remaining 2 demonstrated significant clinical improvement at follow-up.

Conclusions

With attention to the anatomy of perforating arteries, staged contralateral vertebral artery sacrifice, and adequate platelet inhibition, PED may be an effective treatment option—alone or in a hybrid construct with stents of less coverage for VFAs—with an acceptable complication rate.

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Onyx embolization of carotid-cavernous fistulas

Clinical article

Mohamed Samy Elhammady, Stacey Quintero Wolfe, Hamad Farhat, Roham Moftakhar, and Mohammad Ali Aziz-Sultan

Object

The authors conducted a study to determine the safety and efficacy of embolization of carotid-cavernous fistulas (CCFs) with the ethylene vinyl alcohol copolymer, Onyx.

Methods

They prospectively collected data in all patients with CCFs who underwent Onyx-based embolization at their institution over a 3-year period. The type of fistula, route of embolization, viscosity of Onyx, additional use of coils, extent of embolization, procedural complications, and clinical follow-up were recorded.

Results

A total of 12 patients (5 men and 7 women who were age 24–88 years) underwent embolization in which Onyx was used. There were 1 Barrow Type A, 1 Type B, 3 Type C, and 7 Type D fistulas. Embolization was performed via a transvenous route in 8 cases and a transarterial route in 4 cases. Onyx 34 was used in all but 2 cases: a direct Type A fistula embolized with Onyx 500 and an indirect Type C fistula embolized with Onyx 18. Adjuvant embolization with framing coils was performed in 7 cases. All procedures were completed in a single session. Immediate fistula obliteration was achieved in all cases. Clinical resolution of presenting symptoms occurred in 100% of the patients by 2 months. Neurological complications occurred in 3 patients. One patient developed a complete cranial nerve (CN) VII palsy that has not resolved. Two patients developed transient neuropathies—1 a Horner syndrome and partial CN VI palsy, and 1 a complete CN III and partial CN V palsy. Radiographic follow-up (mean 16 months, range 4–35 months) was available in 6 patients with complete resolution of the lesion in all.

Conclusions

Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.

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Transarterial embolization of a scalp hemangioma presenting with Kasabach-Merritt syndrome

Case report

Stacey Quintero Wolfe, Hamad Farhat, Mohamed Samy Elhammady, Roham Moftakhar, and Mohammad Ali Aziz-Sultan

A 2-month-old infant presented with an enlarging scalp hemangioma and consumptive coagulopathy. The patient became severely thrombocytopenic despite medical treatment. Transarterial embolization with Onyx was performed with significant reduction in the size of the tumor and complete resolution of the thrombocytopenia within 12 hours. Onyx embolization appears to be an excellent treatment option for hemangiomas presenting with Kasabach-Merritt syndrome that are unresponsive to standard medical therapy.