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Dheeraj Gandhi, Sameer A. Ansari, B. Gregory Thompson, and Cormac Maher

Traumatic injuries of the posterior communicating artery are distinctly rare. We report an unusual case of traumatic tear of the posterior communicating artery with fistulous communication to the adjacent, retroclival venous plexus. The fistula, and an accompanying large venous aneurysm, was completely occluded via transvenous embolization. The patency of the posterior communicating artery was preserved.

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Maryam Soltanolkotabi, Samantha E. Schoeneman, Tord D. Alden, Michael C. Hurley, Sameer A. Ansari, Arthur J. DiPatri Jr., Tadanori Tomita, and Ali Shaibani

Object

The authors undertook this study to assess the safety and efficacy of Onyx embolization in the treatment of intracranial arteriovenous malformations (AVMs) in pediatric patients.

Methods

All pediatric Onyx embolization of intracranial AVM cases performed consecutively at a single children's hospital over a 5-year period were collected and evaluated.

Results

Twenty-five patients (mean age 10.5 years) underwent a total of 38 procedures. An aggregate of 56 pedicles were embolized (mean 1.47 per session). The Spetzler-Martin grade was determined in all cases. Onyx embolization resulted in complete obliteration of the AVM in 3 cases (12%) and partial obliteration in 22 cases (88%). A total of 23 patients underwent surgical treatment. The mean preoperative AVM devascularization in these cases was 72%. One patient was treated with radiosurgery following Onyx embolization. Overall, 10 complications occurred in a total of 38 procedures (26.3%). None of the complications resulted in permanent neurological morbidity. The rate of transient neurological complications was 10.5% (4 of 38 procedures) and the rate of transient nonneurological complications was 5.3% (2 of 38 procedures). The remaining 4 complications were clinically silent (rate of 10.5%). There were no procedure-related deaths in this study population. There was no significant difference in patients with and without complications in terms of demographic characteristics, AVM grade, or embolization features (p ≥ 0.2). Deep venous drainage was associated with higher complication rates (p = 0.03).

Conclusions

Onyx utilization is feasible for preoperative or primary embolization in the treatment of pediatric intracranial AVMs; however, the spectrum of complications encountered is broad, and attention must be paid to the technical nuances of and indications for its use to avoid many potential dangerous effects. Although the overall complication rates were higher than expected, all were either clinically silent or had only transient clinical effects. Thus, this experience suggests that Onyx embolization can be performed safely with a low rate of permanent morbidity in pediatric patients harboring these difficult lesions.

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Maryam Soltanolkotabi, Shahram Rahimi, Michael C. Hurley, Robin M. Bowman, Eric J. Russell, Sameer A. Ansari, and Ali Shaibani

The authors report on the case of a 7-year-old boy who presented with a reduced level of activity, macrocephaly, prominent scalp veins, and decreased left-sided visual acuity. Imaging workup demonstrated generalized cerebral volume loss, bilateral chronic subdural hematomas, absent left sigmoid sinus, hypoplastic left transverse sinus, and severe focal weblike stenosis of the right sigmoid sinus. Right sigmoid sinus angioplasty and stent insertion was performed, with an immediate reduction in the transduced intracranial venous pressure gradient across the stenosis (from 22 to 3 mm Hg). Postprocedural diminution of prominent scalp and forehead veins and spinal venous collateral vessels was followed by a progressive improvement in visual acuity and physical activity over a 1-year follow-up period, supporting the efficacy of angioplasty and stent insertion in intracranial venous outflow obstruction.

There are multiple potential causes of intracranial venous hypertension in children. Development of dural sinus stenosis in infancy may be one such cause, mimicking the clinical presentation of other causes such as vein of Galen malformations. This condition can be ameliorated by early endovascular revascularization.

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Nathan A. Shlobin, Eytan Raz, Maksim Shapiro, Jeffrey R. Clark, Steven C. Hoffman, Ali Shaibani, Michael C. Hurley, Sameer A. Ansari, Babak S. Jahromi, Nader S. Dahdaleh, and Matthew B. Potts

OBJECTIVE

Spinal cord infarction due to interruption of the spinal vascular supply during anterior thoracolumbar surgery is a rare but devastating complication. Here, the authors sought to summarize the data on this complication in terms of its incidence, risk factors, and operative considerations. They also sought to summarize the relevant spinal vascular anatomy.

METHODS

They performed a systematic literature review of the PubMed, Scopus, and Embase databases to identify reports of spinal cord vascular injury related to anterior thoracolumbar spine procedures as well as operative adjuncts and considerations related to management of the segmental artery ligation during such anterior procedures. Titles and abstracts were screened, and studies meeting inclusion criteria were reviewed in full.

RESULTS

Of 1200 articles identified on the initial screening, 16 met the inclusion criteria and consisted of 2 prospective cohort studies, 10 retrospective cohort studies, and 4 case reports. Four studies reported on the incidence of spinal cord ischemia with anterior thoracolumbar surgery, which ranged from 0% to 0.75%. Eight studies presented patient-level data for 13 cases of spinal cord ischemia after anterior thoracolumbar spine surgery. Proposed risk factors for vasculogenic spinal injury with anterior thoracolumbar surgery included hyperkyphosis, prior spinal deformity surgery, combined anterior-posterior procedures, left-sided approaches, operating on the concavity side of a scoliotic curve, and intra- or postoperative hypotension. In addition, eight studies analyzed operative considerations to reduce spinal cord ischemic complications in anterior thoracolumbar surgery, including intraoperative neuromonitoring and preoperative spinal angiography.

CONCLUSIONS

While spinal cord infarction related to anterior thoracolumbar surgery is rare, it warrants proper consideration in the pre-, intra-, and postoperative periods. The spine surgeon must be aware of the relevant risk factors as well as the pre- and intraoperative adjuncts that can minimize these risks. Most importantly, an understanding of the relevant spinal vascular anatomy is critical to minimizing the risks associated with anterior thoracolumbar spine surgery.

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Tahaamin Shokuhfar, Michael C. Hurley, Anas Al-Smadi, Sameer A. Ansari, Matthew B. Potts, Babak S. Jahromi, Tord D. Alden, and Ali Shaibani

OBJECTIVE

The aim of this paper was assess the efficacy and safety of using the MynxGrip arterial closure device in pediatric neuroendovascular procedures where the use of closure devices remains off-label despite their validation and widespread use in adults.

METHODS

A retrospective review of all pediatric patients who underwent diagnostic or interventional neuroendovascular procedures at the authors’ institution was performed. MynxGrip use was predicated by an adequate depth of subcutaneous tissue and common femoral artery (CFA) diameter. Patients remained on supine bedrest for 2 hours after diagnostic procedures and for 3 hours after therapeutic procedures. Patient demographics, procedural details, hemostasis status, and complications were recorded.

RESULTS

Over 36 months, 83 MynxGrip devices were deployed in 53 patients (23 male and 30 female patients; mean age 14 years) who underwent neuroendovascular procedures. The right-side CFA was the main point of access for most procedures. The mean CFA diameter was 6.24 mm and ranged from 4 mm to 8.5 mm. Diagnostic angiography comprised 46% of the procedures. A single device failure occurred without any sequelae; the device was extracted, and hemostasis was achieved by manual compression with the placement of a Safeguard compression device. No other immediate or delayed major complications were recorded.

CONCLUSIONS

MynxGrip can be used safely in the pediatric population for effective hemostasis and has the advantage of earlier mobilization.

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Aravind G. Kalluri, Madhav Sukumaran, Pouya Nazari, Pedram Golnari, Sameer A. Ansari, Michael C. Hurley, Ali Shaibani, Babak S. Jahromi, and Matthew B. Potts

OBJECTIVE

The carotid cave is a unique intradural region located along the medial aspect of the internal carotid artery. Small carotid cave aneurysms confined within this space are bound by the carotid sulcus of the sphenoid bone and are thought to have a low risk of rupture or growth. However, there is a lack of data on the natural history of this subset of aneurysms.

METHODS

The authors present a retrospective case series of 290 small (≤ 4 mm) carotid cave aneurysms evaluated and managed at their institution between January 2000 and June 2017.

RESULTS

No patient presented with a subarachnoid hemorrhage attributable to a carotid cave aneurysm, and there were no instances of aneurysm rupture or growth during 911.0 aneurysm-years of clinical follow-up or 726.3 aneurysm-years of imaging follow-up, respectively.

CONCLUSIONS

This series demonstrates the benign nature of small carotid cave aneurysms.

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Ramez N. Abdalla, Tahaamin Shokuhfar, Michael C. Hurley, Sameer A. Ansari, Babak S. Jahromi, Matthew B. Potts, H. Hunt Batjer, and Ali Shaibani

Spinal pial arteriovenous fistulas (spAVFs) are believed to be congenital lesions, and the development of a de novo spAVF has not been previously described. A 49-year-old female with a childhood history of vascular malformation–induced right lower-extremity hypertrophy presented in 2004 with progressive pain in her right posterior thigh and outer foot. Workup revealed 3 separate type IV spAVFs, which were treated by combined embolization and resection, with final conventional angiography showing no residual spinal vascular lesion in 2005. Ten years later, the patient returned with new right lower-extremity weakness, perineal pain, and left plantar foot numbness. Repeat spinal angiography demonstrated 2 de novo intertwined conus medullaris spAVFs.

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Pedram Golnari, Pouya Nazari, Roxanna M. Garcia, Hannah Weiss, Ali Shaibani, Michael C. Hurley, Sameer A. Ansari, Matthew B. Potts, and Babak S. Jahromi

OBJECTIVE

Adoption of endovascular treatment (EVT) and other advances in aneurysm care have shifted practice patterns of cerebral aneurysm treatment over the past 2 decades in the US. The objective of this study was to determine whether resulting trends in volumes, outcomes, and complications have matured in general practice or continue to evolve.

METHODS

Data were obtained from the National Inpatient Sample from 1993 to 2015. ICD-9 codes were used to estimate annual volumes, outcomes, and complications following treatment of ruptured and unruptured aneurysms. Univariate and multivariate analyses were used to estimate risk ratios for complications and outcomes. Trends in time were assessed utilizing annual percentage change (APC).

RESULTS

The authors found a nearly 5-fold increase in annual admissions with diagnoses of unruptured aneurysms, whereas SAH volume increased less than 50%. Clipping ruptured aneurysms steadily declined (APC −0.86%, p = 0.69 until 1999, then −6.22%, p < 0.001 thereafter), whereas clipping unruptured aneurysms slightly increased (APC 2.02%, p < 0.001). EVT tripled in 2002–2004 and steadily increased thereafter (APC 7.22%, p < 0.001 and 5.85%, p = 0.01 for unruptured and ruptured aneurysms, respectively). Despite a 3-fold increase in both diagnosis and treatment of unruptured aneurysms, the incidence of SAH remained steady at 12 per 100,000 persons per year (APC 0.04%, p = 0.83). In contrast, SAH severity increased over time, as did patient age and comorbidities (all p < 0.001). SAH led to nonroutine discharge more frequently over time after both EVT and clipping (APC 1.24% and 1.10%, respectively), although mortality decreased during the same time (APC −2.48% and −1.44%, respectively). Complications were more frequent after clipping than EVT, but this differential risk diminished during the study period and was less perceptible in ruptured aneurysms. The proportion of patients discharged home after treatment of unruptured aneurysms was significantly lower (p < 0.001) after clipping (69.3%–79.5%) than EVT (88.3%–93.3%); both proportions changed minimally since 1998 (APC −0.39%, p = 0.02, and APC −0.11%, p = 0.14, respectively).

CONCLUSIONS

EVT volume markedly increased for ruptured and unruptured aneurysms from 1993 to 2015, whereas clipping decreased for ruptured and slightly increased for unruptured aneurysms. The incidence of SAH remained unchanged despite increased diagnosis and treatment of unruptured aneurysms. In ruptured aneurysms, SAH severity has increased over time, as have age, comorbidities, and nonroutine discharges. In contrast, routine discharge after treatment of unruptured aneurysms remains largely unchanged since 1998 and remains lower with clipping.