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Conduits for cerebrovascular bypass and lessons learned from the cardiovascular experience

James K. Liu, Peter Kan, S. V. Karwande, and William T. Couldwell

Direct cerebral revascularization is an important procedure in the treatment of certain complex aneurysms and skull base tumors when acute sacrifice of the internal carotid artery is required. It likely remains an appropriate treatment in a small subgroup of patients with cerebral ischemia refractory to maximal medical management. Similar to cardiovascular surgery, the choice of a graft conduit is critical for a successful outcome. The standard conduits are interposition vein grafts (usually the greater saphenous vein), free arterial grafts (radial artery), and pedicled arterial grafts (superficial temporal artery). The goal of this review is to summarize the conduits commonly used in cerebral revascularization with emphasis on their patency rates and flow characteristics. Comparisons are made with similar data available in the cardiovascular literature.

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Simple closure following transsphenoidal surgery

Technical note

William T. Couldwell, Peter Kan, and Martin H. Weiss

✓ The most common nonendocrine complication after transsphenoidal surgery is cerebrospinal fluid (CSF) leak. Many neurosurgeons have advocated the routine reconstruction of the floor of the sella turcica using autologous fat, muscle, fascia, and either cartilage or bone after transsphenoidal surgery to prevent postoperative CSF fistulas. However, the use of autologous grafting requires a second incision, prolongs operative time, and adds to the patient's postoperative discomfort. In addition, the presence of sellar packing may interfere with the interpretation of postoperative images. To avoid these disadvantages, the authors suggest that routine sellar reconstruction or closure after transsphenoidal surgery is unnecessary unless an intraoperative CSF leak is encountered. The incidence of postoperative CSF leakage in the patients reported on in this series is no higher than that reported by others, and no other complications such as pneu-matocele have been encountered in approximately 2700 patients in whom no intraoperative CSF leak was encountered. The authors conclude that routine closure of the floor of the sella turcica or sphenoid is unnecessary in the absence of intraoperative CSF leak.

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Utility of CT perfusion scanning in patient selection for acute stroke intervention: experience at University at Buffalo Neurosurgery–Millard Fillmore Gates Circle Hospital

Peter T. Kan, Kenneth V. Snyder, Parham Yashar, Adnan H. Siddiqui, L. Nelson Hopkins, and Elad I. Levy

Computed tomography perfusion scanning generates physiological flow parameters of the brain parenchyma, allowing differentiation of ischemic penumbra and core infarct. Perfusion maps, along with the National Institutes of Health Stroke Scale score, are used as the bases for endovascular stroke intervention at the authors' institute, regardless of the time interval from stroke onset. With case examples, the authors illustrate their perfusion-based imaging guidelines in patient selection for endovascular treatment in the setting of acute stroke.

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Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases

Evan Joyce, Michael T. Bounajem, Jonathan Scoville, Ajith J. Thomas, Christopher S. Ogilvy, Howard A. Riina, Omar Tanweer, Elad I. Levy, Alejandro M. Spiotta, Bradley A. Gross, Brian T. Jankowitz, C. Michael Cawley, Alexander A. Khalessi, Aditya S. Pandey, Andrew J. Ringer, Ricardo Hanel, Rafael A. Ortiz, David Langer, Michael R. Levitt, Mandy Binning, Philipp Taussky, Peter Kan, and Ramesh Grandhi

OBJECTIVE

The incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients.

METHODS

In a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65–79 years) and advanced elderly (age > 80 years) patients.

RESULTS

MMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively.

CONCLUSIONS

MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.

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Abstracts of the 2017 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves Las Vegas, Nevada • March 8–11, 2017