The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in ...the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
ObjectivesTo investigate the impact of the COVID-19 pandemic as well as concomitant COVID-19 itself on stroke care, focusing on middle cerebral artery (MCA) territory infarctions.DesignRegistry-based ...study.SettingWe used the National Inpatient Sample (NIS) database, which covers a wide range of hospitals within the USA.ParticipantsThe NIS was queried for patients with MCA strokes between 2016 and 2020. In total, 35 231 patients were included.Outcome measuresOutcome measures were postprocedural complications, length of stays (LOSs), in-hospital mortality and non-routine discharge. Propensity score matching using all available baseline variables was performed to reduce confounders when comparing patients with and without concomitant COVID-19.ResultsMechanical thrombectomy (MT) was performed in 48.4%, intravenous thrombolysis (IVT) in 38.2%, and both MT and IVT (MT+IVT) in 13.4% of patients. A gradual increase in the use of MT and an opposite decrease in the use of IVT (p<0.001) was detected during the study period. Overall, 25.0% of all patients were admitted for MCA strokes during the pandemic period (2020), of these 209 (2.4%) were concomitantly diagnosed with COVID-19. Patients with MCA strokes and concomitant COVID-19 were significantly younger (64.9 vs 70.0; p<0.001), had significantly worse NIH Stroke Severity scores, and worse outcomes in terms of LOS (12.3 vs 8.2; p<0.001), in-hospital mortality (26.3% vs 9.8%; p<0.001) and non-routine discharge (84.2% vs 76.9%; p=0.013), as compared with those without COVID-19. After matching, only in-hospital mortality rates remained significantly higher in patients with COVID-19 (26.7% vs 8.5%; p<0.001). Additionally, patients with COVID-19 had higher rates of thromboembolic (12.3% vs 7.6%; p=0.035) and respiratory (11.3% vs 6.6%; p=0.029) complications.ConclusionsAmong patients with MCA stroke, those with concomitant COVID-19 were significantly younger and had higher stroke severity scores. They were more likely to experience thromboembolic and respiratory complications and in-hospital mortality compared with matched controls.
A case of pipeline migration in the cervical carotid Jabbour, Pascal; Atallah, Elias; Chalouhi, Nohra ...
Journal of clinical neuroscience,
January 2019, 2019-Jan, 2019-01-00, 20190101, Volume:
59
Journal Article
Peer reviewed
•Pipeline shortening and migration can be disabling and potentially lead to fatality.•Every case of Pipeline migration must have a customized management plan.•A high expertise is required when ...deploying pipeline in off-label locations.
Since its emergence in 2011, the pipeline flow diversion (PFD) has gained recognition in the treatment of certain intracranial aneurysms. However, early or delayed pipeline migration (PM) and micro-catheter/guidewire retention have been infrequently reported. We report a case of PM and shortening in the treatment of a left cervical internal carotid artery (LICA) aneurysm. A middle-aged African-American patient presents for an off-label PFD treatment of an incidental 21 × 23 mm aneurysm at the sub-petrous segment of the left ICA. While the patient remained completely neuro-intact, a 6 months follow-up angiogram revealed a persisting filling of the cervical aneurysm with a foreshortening of the pipeline by 1/3 of its original 30 mm size and proximal migration into the aneurysmal sac. We opted to watch the aneurysm within 6 months especially that the aneurysm was extra-cranial and because of the potential risks involved in trying to re-access the device.
Odor-guided behaviors, including homing, predator avoidance, or food and mate searching, are ubiquitous in animals. It is only recently that the neural substrate underlying olfactomotor behaviors in ...vertebrates was uncovered in lampreys. It consists of a neural pathway extending from the medial part of the olfactory bulb (medOB) to locomotor control centers in the brainstem via a single relay in the caudal diencephalon. This hardwired olfactomotor pathway is present throughout life and may be responsible for the olfactory-induced motor behaviors seen at all life stages. We investigated modulatory mechanisms acting on this pathway by conducting anatomical (tract tracing and immunohistochemistry) and physiological (intracellular recordings and calcium imaging) experiments on lamprey brain preparations. We show that the GABAergic circuitry of the olfactory bulb (OB) acts as a gatekeeper of this hardwired sensorimotor pathway. We also demonstrate the presence of a novel olfactomotor pathway that originates in the non-medOB and consists of a projection to the lateral pallium (LPal) that, in turn, projects to the caudal diencephalon and to the mesencephalic locomotor region (MLR). Our results indicate that olfactory inputs can induce behavioral responses by activating brain locomotor centers via two distinct pathways that are strongly modulated by GABA in the OB. The existence of segregated olfactory subsystems in lampreys suggests that the organization of the olfactory system in functional clusters may be a common ancestral trait of vertebrates.
It is widely recognized that animals respond to odors by generating or modulating specific motor behaviors. These reactions are important for daily activities, reproduction, and survival. In the sea ...lamprey, mating occurs after ovulated females are attracted to spawning sites by male sex pheromones. The ubiquity and reliability of olfactory-motor behavioral responses in vertebrates suggest tight coupling between the olfactory system and brain areas controlling movements. However, the circuitry and the underlying cellular neural mechanisms remain largely unknown. Using lamprey brain preparations, and electrophysiology, calcium imaging, and tract tracing experiments, we describe the neural substrate responsible for transforming an olfactory input into a locomotor output. We found that olfactory stimulation with naturally occurring odors and pheromones induced large excitatory responses in reticulospinal cells, the command neurons for locomotion. We have also identified the anatomy and physiology of this circuit. The olfactory input was relayed in the medial part of the olfactory bulb, in the posterior tuberculum, in the mesencephalic locomotor region, to finally reach reticulospinal cells in the hindbrain. Activation of this olfactory-motor pathway generated rhythmic ventral root discharges and swimming movements. Our study bridges the gap between behavior and cellular neural mechanisms in vertebrates, identifying a specific subsystem within the CNS, dedicated to producing motor responses to olfactory inputs.
Ventriculoperitoneal (VP) shunts represent a surgical option for patients affected by increased intracranial hypertension when medical management fails or is contraindicated. Complications following ...implantation include shunt obstruction, infection, over and under drainage, migration or disconnection of the tube, formation of a pseudocyst, and allergy to the silicone tube. We report the case of a 31-year-old woman who presented to the emergency room with nausea and generalized malaise, found to have the distal segment of the VP catheter perforating her gastric wall into the stomach lumen which required surgical intervention. In this report, we describe a rare complication associated with the implantation of ventriculoperitoneal shunt (VPS) catheters and the subsequent management plan.
The craniocervical junction is a rare location for spinal dural arteriovenous fistulas (dAVFs). Typically, fistulas at this location present with findings related to intracranial cortical venous ...reflux or cervical myelopathy. We present a case of craniocervical junction dAVF with isolated clinical and radiographic findings of thoracolumbar myelopathy.
A 54-year-old man presented with subacute onset of lower extremity weakness, paresthesias, and gait dysfunction. Routine spine magnetic resonance imaging demonstrated edema of the conus medullaris and distal thoracic spinal cord and prominent dorsal venous flow voids, suggestive of a thoracolumbar dAVF. Spinal angiography performed at an outside institution failed to demonstrate a fistula. Noninvasive spinal angiographic imaging with time-resolved magnetic resonance angiography (TR-MRA) performed at our institution was able to demonstrate presence of the fistula at the craniocervical junction. Subsequent cerebral angiography identified feeding vessels arising from the posterior meningeal artery and ascending pharyngeal artery on the right side. The fistula was successfully embolized with onyx embolic material, with rapid resolution of his clinical symptoms.
Isolated lower extremity myelopathic symptoms are a rarely reported finding in patients harboring craniocervical junction dAVFs. At our institution, noninvasive imaging with TR-MRA is routinely used to aid localization of dAVFs. This results in decreased contrast dose and radiation exposure, and inclusion of the cervical spine should be performed when thoracolumbar imaging fails to identify a dAVF prior to proceeding to invasive angiography.
Clopidogrel/aspirin antiplatelet therapy routinely is administered 7–10 days before pipeline aneurysm treatment. Our study assessed the safety and efficacy of a 600-mg loading dose of clopidogrel 24 ...hours before Pipeline Embolization Device (PED) treatment.
We performed a retrospective cohort study involving patients treated with pipeline from October 2010 to May 2016. A total of 39.7% (n = 158) of patients were dispensed a loading dose of 650 mg of aspirin plus at least 600 mg of clopidogrel 24 hours preceding PED deployment; 60.3% (n = 240) received 81–325 mg of aspirin daily for 10 days with 75 mg of clopidogrel daily preprocedurally. The mean follow-up was 15.8 months (standard deviation SD 12.4 months). modified Rankin Scale (mRS) was registered before the discharge and at each follow-up visit. To control confounding, we used multivariable logistic regression and propensity score conditioning.
Of 398 patients, the proportion of female patients was ≈16.5% (41/240) in both groups and shared the same mean of age ≈56.46 years. Similarly, ≈12.2% (mean = 0.09; SD = 0.30) had a subarachnoid hemorrhage. A total of 92% (mean = 0.29; SD = 0.70) from the pretreatment group and 85.7% (mean = 0.44; SD = 0.91) of the bolus group had a mRS ≤2. In a multivariate analysis, bolus did not affect the mRS score, P = 0.24. Seven patients had a long-term recurrence, 2 (0.83%; mean = 0.01; SD = 0.10) from the pretreatment group. In a multivariable logistic regression, bolus was not associated with a long-term recurrence rate (odds ratio OR 1.91; 95% confidence interval CI 0.27–13.50; P = 0.52) neither with thromboembolic accidents (OR 0.99; 95% CI 0.96–1.03; P = 0.83) nor with hemorrhagic events (OR 1.00; 95% CI 0.97–1.03; P = 0.99). Three patients died: 1 who received a bolus had an acute subarachnoid hemorrhage. The mean mortality rate was parallel in both groups ≈0.25 (SD = 0.16). Bolus was not associated with mortality (OR 1.11; 95% CI 0.26–4.65; P = 0.89). The same associations were present in propensity score–adjusted models.
In a cohort receiving PED, a 600-mg loading dose of clopidogrel should be safe and efficacious in those off the standard protocol or showing <30% platelet inhibition before treatment.
We report the case of a 62-year-old man who presented with a progressive myelopathy secondary to spinal cord compression from an odontoid process fracture and subaxial central canal stenosis. The ...patient underwent a C1-T2 posterior decompression and instrumented fusion (PCDF) and did well immediately postoperatively. However, on POD1, he developed a right hypoglossal nerve (HN) palsy attributed to direct mechanical compression or injury from the C1 lateral mass screw (LMS), which improved following a revision and screw replacement. While HN injury is a known complication of high anterior and anterolateral cervical spine approaches as well as transcondylar screw fixation, this case aims to expand on the limited reports available regarding hypoglossal nerve injury following placement of bicortical C1 LMS. Furthermore, the use of fluoroscopic guidance in addition to anatomic landmarks and triggered electromyography of the tongue are offered as potential solutions to prevent HN injury intraoperatively.
OBJECTIVE
There is currently a lack of consensus on the utility of intraoperative neuromonitoring (IONM) for decompression of Chiari type I malformation (CM-I). Commonly used monitoring modalities ...include somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), and brainstem auditory evoked potentials (BAEPs). The purpose of this study was to evaluate the utility of IONM in preventing neurological injury for CM-I decompression.
METHODS
The authors conducted a retrospective study of a population of adult patients (ages 17–76 years) diagnosed with CM-I between 2013 and 2021. IONM modalities included SSEPs, MEPs, and/or BAEPs. Prepositioning baseline signals and operative alerts of significant signal attenuation were recorded.
RESULTS
Ninety-three patients (average age 38.4 ± 14.6 years) underwent a suboccipital craniectomy for CM-I decompression. Eighty-two (88.2%) of 93 patients underwent C1 laminectomy, 8 (8.6%) underwent C1 and C2 laminectomy, and 4 (4.3%) underwent suboccipital craniectomy with concomitant cervical decompression and fusion in the setting of degenerative cervical spondylosis. Radiographically, the average cerebellar tonsillar ectopia/descent was 1.1 ± 0.5 cm and 53 (57.0%) of 93 patients presented with a syrinx. The average number of vertebral levels traversed by the syrinx was 5.3 ± 3.5, and the average maximum width of the syrinx was 5.8 ± 3.3 mm. There was one instance (1/93, 1.1%) of an MEP alert, which resolved spontaneously after 10 minutes in a patient who had concomitant stenosis due to pannus formation at C1–2. No patient developed a permanent neurological complication.
CONCLUSIONS
There were no permanent complications related to intraoperative neurological injury. Transient fluctuations in IONM signals can be detected without clinical significance. The authors suggest that CM-I suboccipital decompression surgery may be performed safely without IONM. The use of IONM in patients with additional occipitocervical pathology should be left as an option to the performing surgeon on a case-by-case basis.
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