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Cover Journal of Neurosurgery

Pineal cysts and other pineal region malignancies: determining factors predictive of hydrocephalus and malignancy

Robert M. Starke, Justin M. Cappuzzo, Nicholas J. Erickson, and Jonathan H. Sherman

OBJECTIVE

Cystic lesions of the pineal gland are most often uncomplicated benign lesions with typical MRI characteristics. The authors aimed to study pineal lesion characteristics on MRI to better distinguish benign pineal cysts from other pineal region malignancies as well as to determine which characteristics were predictive of the latter malignancies. They also aimed to study risk factors predictive of hydrocephalus or malignancy in patients harboring these lesions.

METHODS

The authors performed a retrospective review of a prospectively compiled database documenting the outcomes of patients with suspected pineal cysts on MRI who had presented in the period from 1998 to 2004. Inherent patient and lesion characteristics were assessed in a univariate logistic regression analysis to predict the following dependent variables: development of hydrocephalus, biopsy-confirmed malignancy, and intervention. Possible inherent patient and lesion characteristics included age, sex, T1 and T2 MRI signal pattern, contrast enhancement pattern, presence of cyst, presence of blood, complexity of lesion, presence of calcification, and duration of follow-up. Inherent patient and lesion characteristics that were predictive in the univariate analysis (p < 0.15) were included in the multivariable logistic regression analysis.

RESULTS

Of the 79 patients with benign-appearing pineal cysts, 26 (33%) were male and 53 (67%) were female, with a median age of 38 years (range 9–86 years). The median cyst radius was 5 mm (range 1–20 mm). Two patients (2.5%) had evidence of calcifications, 7 (9%) had multicystic lesions, and 25 (32%) had some evidence of contrast enhancement.

The median follow-up interval was 3 years (range 0.5–13 years). Seven patients (9%) had an increase in the size of their lesion over time. Eight patients (10%) had a hemorrhage, and 11 patients (14%) developed hydrocephalus. Nine (11%) received ventriculoperitoneal shunts for the development of hydrocephalus, and 12 patients (16%) were found to have malignancies following biopsy or resection. In the multivariate analysis, contrast enhancement on MRI (OR 1.6, 95% CI 2.86–74.74, p = 0.013) and hemorrhage (OR 26.9, 95% CI 3.4–212.7, p = 0.022) were predictive of hydrocephalus. Increasing lesion size and hydrocephalus were near perfect predictors of malignancy and thus were removed from multivariate analysis. In addition, contrast enhancement on MRI (OR 8.8, 95% CI 2.0–38.6, p = 0.004) and hemorrhage (OR 6.8, 95% CI 1.1–40.5, p = 0.036) were predictive of malignancy.

CONCLUSIONS

Although cystic abnormalities of the pineal gland are often benign lesions, they are frequently monitored over time, as other pineal region pathologies may appear similarly on MRI. Patients with growing lesions, contrast enhancement, and hemorrhage on MRI are more likely to develop hydrocephalus and have malignant pathology on histological examination and should therefore be followed up with serial MRI with a lower threshold for neurosurgical intervention.

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Cover Journal of Neurosurgery

Evolution of the patient-first approach: a dual-trained, single-neurosurgeon experience with 2002 consecutive intracranial aneurysm treatments

Muhammad Waqas, Andre Monteiro, Justin M. Cappuzzo, Vincent M. Tutino, and Elad I. Levy

OBJECTIVE

The paradigm for intracranial aneurysm (IA) treatment is shifting toward a hybrid approach involving open and endovascular techniques. The authors chronicled the evolution of IA treatment by retrospectively examining a large series of IA cases treated by a single dual-trained neurosurgeon, focusing on evolving technology relative to the choice of treatment options, perioperative morbidity, and mortality.

METHODS

The aneurysm database at the authors’ institution was searched to identify consecutive patients treated with endovascular or open microsurgical approaches by one neurosurgeon during an 18-year time span. Patients were included regardless of IA rupture status, location or morphology, or treatment modality. Data collected were baseline clinical characteristics, aneurysm size, treatment modality, operative complications, in-hospital mortality, and retreatment rate.

RESULTS

A total of 1858 patients with 2002 IA treatments were included in the study. Three-hundred fifty IAs (17.5%) were ruptured. Open microsurgery was performed in 504 aneurysms (25.2%) and endovascular surgery in 1498 (74.8%). Endovascular IA treatments trended toward a growing use of flow diversion during the last 11 years. In-hospital mortality was 1.7% overall, including 7.0% in ruptured and 0.5% in unruptured cases. The overall complication rate was 3.3%, including 3.4% for microsurgical cases and 3.3% for endovascular cases. The rate of retreatment was 3.6% after clipping and 10.7% for endovascular treatment.

CONCLUSIONS

This study demonstrates complementary use of open and endovascular approaches for IA treatment. By customizing treatment to the patient, comparable rates of procedural complications, mortality, and retreatment were achieved for both endovascular and microsurgical approaches.

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Cover Journal of Neurosurgery: Case Lessons

First reported single-surgeon transpalpebral hybrid approach for indirect cavernous carotid fistula: illustrative case

Justin M. Cappuzzo, Ammad A. Baig, William Metcalf-Doetsch, Muhammad Waqas, Andre Monteiro, and Elad I. Levy

BACKGROUND

Failure to reach the cavernous sinus after multiple transvenous attempts, although rare, can be challenging for neurointerventionists. The authors sought to demonstrate technical considerations and nuances of the independent performance of a novel hybrid surgical and endovascular transpalpebral approach through the superior ophthalmic vein (SOV) for direct coil embolization of an indirect carotid cavernous fistula (CCF), and they review salient literature regarding the transpalpebral approach.

OBSERVATIONS

An illustrative case, including patient history and presentation, was reviewed. PubMed, MEDLINE, and Embase databases were searched for articles published between January 1, 2000, and September 30, 2021, that reported ≥1 patient with a CCF treated endovascularly via the SOV approach. Data extracted included sample size, treatment modality, surgical technique, performing surgeon specialty, and procedure outcome. The authors’ case illustration demonstrates the technique for the hybrid transpalpebral approach. For the review, 273 unique articles were identified; 14 containing 74 treated patients fulfilled the inclusion criteria. Oculoplastic surgery was the most commonly involved specialty (5 of 14 studies), followed by ophthalmology (3 of 14). Coiling alone was the treatment of choice in 12 studies, with adjunctive use of Onyx (Medtronic) in 2.

LESSONS

The authors’ technical case description, video, illustrations, and review provide endovascular neurosurgeons with a systematic guide to conduct the procedure independently.

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Cover Journal of Neurosurgery: Pediatrics

Comparison of posterior fossa volumes and clinical outcomes after decompression of Chiari malformation Type I

Siri Sahib S. Khalsa, Alan Siu, Tiffani A. DeFreitas, Justin M. Cappuzzo, John S. Myseros, Suresh N. Magge, Chima O. Oluigbo, and Robert F. Keating

OBJECTIVE

Previous studies have indicated an association of Chiari malformation Type I (CM-I) and a small posterior fossa. Most of these studies have been limited by 2D quantitative methods, and more recent studies utilizing 3D methodologies are time-intensive with manual segmentation. The authors sought to develop a more automated tool to calculate the 3D posterior fossa volume, and correlate its changes after decompression with surgical outcomes.

METHODS

A semiautomated segmentation program was developed, and used to compare the pre- and postoperative volumes of the posterior cranial fossa (PCF) and the CSF spaces (cisterna magna, prepontine cistern, and fourth ventricle) in a cohort of pediatric patients with CM-I. Volume changes were correlated with postoperative symptomatic improvements in headache, syrinx, tonsillar descent, cervicomedullary kinking, and overall surgical success.

RESULTS

Forty-two pediatric patients were included in this study. The mean percentage increase in PCF volume was significantly greater in patients who showed clinical improvement versus no improvement in headache (5.89% vs 1.54%, p < 0.05) and tonsillar descent (6.52% vs 2.57%, p < 0.05). Overall clinical success was associated with a larger postoperative PCF volume increase (p < 0.05). These clinical improvements were also significantly associated with a larger increase in the volume of the cisterna magna (p < 0.05). The increase in the caudal portion of the posterior fossa volume was also larger in patients who showed improvement in syrinx (6.63% vs 2.58%, p < 0.05) and cervicomedullary kinking (9.24% vs 3.79%, p < 0.05).

CONCLUSIONS

A greater increase in the postoperative PCF volume, and specifically an increase in the cisterna magna volume, was associated with a greater likelihood of clinical improvements in headache and tonsillar descent in patients with CM-I. Larger increases in the caudal portion of the posterior fossa volume were also associated with a greater likelihood of improvement in syrinx and cervicomedullary kinking.

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Cover Neurosurgical Focus: Video

FRED flow diversion with LVIS protection of large posterior communicating artery aneurysm: the "FRELVIS" technique

Steven B. Housley, Justin M. Cappuzzo, Muhammad Waqas, Andre Monteiro, Elad I. Levy, and Adnan H. Siddiqui

Treatment of wide-necked posterior communicating artery (PCoA) aneurysms is extremely challenging, especially in fetal posterior cerebral artery (PCA) configurations. This technical video demonstrates the nuances of an innovative use of flow diversion to treat a recurrent wide-necked PCoA aneurysm. This middle-aged patient presented with recurrence of a previously ruptured, coil-embolized PCoA aneurysm. Initial attempts at Comaneci-assisted coiling were unsuccessful because the coil herniated into the middle cerebral artery (MCA). Therefore, a low-profile visualized intraluminal support (LVIS) was placed in the fetal PCA across the aneurysm ostium and a flow diverter was placed in the internal carotid artery and MCA to constitute a Y-construct.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2262

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Cover Neurosurgical Focus

Transverse venous stenting for the treatment of idiopathic intracranial hypertension, or pseudotumor cerebri

Justin M. Cappuzzo, Ryan M. Hess, John F. Morrison, Jason M. Davies, Kenneth V. Snyder, Elad I. Levy, and Adnan H. Siddiqui

OBJECTIVE

Idiopathic intracranial hypertension (IIH) is a commonly occurring disease, particularly among young women of child-bearing age. The underlying pathophysiology for this disease has remained largely unclear; however, the recent literature suggests that focal outflow obstruction of the transverse sinus may be the cause. The purpose of this study was to report one group’s early experience with transverse venous sinus stenting in the treatment of IIH and assess its effectiveness.

METHODS

The authors performed a retrospective chart review to identify patients who had undergone stenting of an outflow-obstructed transverse venous sinus for the treatment of IIH at Gates Vascular Institute between January 2015 and November 2017. Patient demographic data of interest included age, sex, BMI, and history of smoking, hypertension, obstructive sleep apnea, hormonal contraceptive use, and acetazolamide therapy. Each patient’s presenting signs and symptoms and whether those symptoms improved with treatment were reviewed. The average opening lumbar puncture (LP) pressure preprocedure, average pressure gradient across the obstructed segment prior to stenting, treatment failure rate (need for shunt placement), and mean follow-up period were calculated.

RESULTS

Of the 18 patients who had undergone transverse venous stenting for IIH, 16 (88.9%) were women. The mean age of all the patients was 38.3 years (median 38 years). Mean BMI was 34.2 kg/m2 (median 33.9 kg/m2). Presenting symptoms were headache (16 patients [88.9%]), visual disturbances (13 patients [72.2%]), papilledema (8 patients [44.4%]), tinnitus (3 patients [16.7%]), and auditory bruit (3 patients [16.7%]). The mean opening LP pressure pre-procedure was 35.6 cm H2O (median 32 cm H2O). The mean pressure gradient measured proximally and distally to the area of focal obstruction within the transverse sinus was 16.5 cm H2O (median 15 cm H2O). Postprocedurally, 14 patients (77.8%) continued to have headaches; 6 (33.3%) continued to have visual disturbances. No patients continued to have auditory bruit (0%) or papilledema (0%). One patient (5.6%) had new-onset tinnitus postprocedure. Overall improvement of symptoms was noted in 16 patients (88.9%) postprocedure, with 1 patient (5.6%) requiring shunt placement and 2 other patients (11.1%) requiring postprocedural LP to monitor intracranial pressure to determine candidacy for further surgical interventions to treat residual symptoms. The mean duration of follow-up was 194.2 days.

CONCLUSIONS

Transverse sinus stenting is a rapidly developing technique that has shown good effectiveness and safety in the literature. Authors of the present study found that stenting a flow-obstructed transverse sinus in patients with IIH was a safe and effective way to treat the condition.

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Cover Neurosurgical Focus

Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

Muhammad Waqas, Cathleen C. Kuo, Rimal H. Dossani, Andre Monteiro, Ammad A. Baig, Modhi Alkhaldi, Justin M. Cappuzzo, Elad I. Levy, and Adnan H. Siddiqui

OBJECTIVE

While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs.

METHODS

PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3–4, and posterior cerebral artery P2–4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment.

RESULTS

Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23–5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75–8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66–4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone.

CONCLUSIONS

The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.

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Cover Neurosurgical Focus

Comparison of effectiveness and outcomes among different thrombectomy techniques in acute basilar artery occlusion: a dual-center experience

Andre Monteiro, Gustavo M. Cortez, Muhammad Waqas, Hamid H. Rai, Ammad A. Baig, Rimal H. Dossani, Justin M. Cappuzzo, Faisal Almayman, Amin Aghaebrahim, Jason M. Davies, Eric Sauvageau, Kenneth V. Snyder, Ricardo A. Hanel, Elad I. Levy, and Adnan H. Siddiqui

OBJECTIVE

Acute basilar artery occlusion (BAO) is a rare large-vessel occlusion associated with high morbidity and mortality. Modern thrombectomy with stent retrievers and large-bore aspiration catheters is highly effective in achieving recanalization, but a direct comparison of different techniques for acute BAO has not been performed. Therefore, the authors sought to compare the technical effectiveness and clinical outcomes of stent retriever–assisted aspiration (SRA), aspiration alone (AA), and a stent retriever with or without manual aspiration (SR) for treatment of patients presenting with acute BAO and to evaluate predictors of clinical outcome in their cohort.

METHODS

A retrospective analysis of databases of large-vessel occlusion treated with endovascular intervention at two US endovascular neurosurgery centers was conducted. Patients ≥ 18 years of age with acute BAO treated between January 2013 and December 2020 with stent retrievers or large-bore aspiration catheters were included in the study. Demographic information, procedural details, angiographic results, and clinical outcomes were extracted for analysis.

RESULTS

Eighty-three patients (median age 67 years [IQR 58–76 years]) were included in the study; 33 patients (39.8%) were female. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 10–21). Intravenous alteplase was administered to 26 patients (31.3%). The median time from symptom onset to groin or wrist puncture was 256 minutes (IQR 157.5–363.0 minutes). Overall, successful recanalization was achieved in 74 patients (89.2%). The SRA technique had a significantly higher rate of modified first-pass effect (mFPE; 55% vs 31.8%, p = 0.032) but not true first-pass effect (FPE; 45% vs 34.9%, p = 0.346) than non-SRA techniques. Good outcome (modified Rankin Scale [mRS] score 0–2) was not significantly different among the three techniques. Poor outcome (mRS score 3–6) was associated with a higher median admission NIHSS score (12.5 vs 19, p = 0.007), a higher rate of adjunctive therapy usage (9% vs 0%, p < 0.001), and a higher rate of intraprocedural complications (10.7% vs 14.5%, p = 0.006). The admission NIHSS score significantly predicted good outcome (OR 0.98, 95% CI 0.97–0.099; p = 0.032). Incomplete recanalization after thrombectomy significantly predicted mortality (OR 1.68, 95% CI 1.18–2.39; p = 0.005).

CONCLUSIONS

The evaluated techniques resulted in high recanalization rates. The SRA technique was associated with a higher rate of mFPE than AA and SR, but the clinical outcomes were similar. A lower admission NIHSS score predicted a better prognosis for patients, whereas incomplete recanalization after thrombectomy predicted mortality.

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Cover Journal of Neurosurgery

Not a trifecta: complementary use of carotid artery revascularization techniques in the era of hybrid neurosurgery

Bennett R. Levy, Muhammad Waqas, Andre Monteiro, Justin M. Cappuzzo, Ammad A. Baig, Wasiq I. Khawar, Jason M. Davies, Kenneth V. Snyder, Adnan H. Siddiqui, Howard A. Riina, and Elad I. Levy

OBJECTIVE

Carotid stenosis is currently treated by carotid endarterectomy (CEA), carotid artery stenting (CAS), or transcarotid artery revascularization (TCAR). This study sought to add to the literature by providing real-world data comparing the safety and effectiveness associated with the performance of these carotid revascularization techniques by dual-trained neurosurgeons.

METHODS

The authors performed a retrospective review of carotid stenosis databases at two US centers. Patients treated by CEA, transfemoral CAS, or TCAR for atherosclerotic carotid artery disease were included. Clinical outcomes were compared at 30 days after the procedure.

RESULTS

Seven hundred eighty patients were included (583 with CAS, 165 with CEA, and 32 with TCAR). Overall, 486 patients (62.3%) were men, and 393 (50.4%) had left-sided carotid stenosis. Most patients (n = 617, 79.1%) had symptomatic disease. Among the three treatment groups, there were no statistically significant differences with respect to 30-day ischemic events (CAS 3.8%, CEA 1.8%, TCAR 6.3%; p = 0.267) or 30-day mortality rates (CAS 3.6%, CEA 2.4%, TCAR 3.1%; p = 0.857). Male sex had significantly lower odds of 30-day transient ischemic attack (TIA) or stroke in both univariable (p = 0.024) and multivariable (p = 0.023) regression models. Increasing age had significantly higher odds of 30-day mortality on univariable (p = 0.006) and multivariable (p = 0.003) regression. Patients with the occurrence of 30-day TIA or stroke also had significantly higher odds of 30-day mortality on univariable (p < 0.001) and multivariable (p < 0.001) regression.

CONCLUSIONS

This real-world experience reflects the current practice of hybrid neurosurgery at two high-volume tertiary care centers and suggests that all three treatment modalities have comparable safety and effectiveness if patients are properly selected.

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Cover Journal of Neurosurgery

Oral Presentations 2016 AANS Annual Scientific Meeting Chicago, IL • April 30–May 4, 2016

Published online April 1, 2016; DOI: 10.3171/2016.4.JNS.AANS2016abstracts