Long-term catheter angiography after aneurysm coil therapy: results of 209 patients and predictors of delayed recurrence and retreatment.

OBJECT: Aneurysm recurrence after coil therapy remains a major shortcoming in the endovascular management of cerebral aneurysms. The need for long-term imaging follow-up was recently investigated. This study assessed the diagnostic yield of long-term digital subtraction angiography (DSA) follow-up and determined predictors of delayed aneurysm recurrence and retreatment. METHODS: Inclusion criteria were as follows: 1) available short-term and long-term (> 36 months) follow-up DSA images, and 2) no or only minor aneurysm recurrence (not requiring further intervention, i.e., < 20%) documented on short-term follow-up DSA images. RESULTS: Of 209 patients included in the study, 88 (42%) presented with subarachnoid hemorrhage. On shortterm follow-up DSA images, 158 (75%) aneurysms showed no recurrence, and 51 (25%) showed minor recurrence (< 20%, not retreated). On long-term follow-up DSA images, 124 (59%) aneurysms showed no recurrence, and 85 (41%) aneurysms showed recurrence, of which 55 (26%) required retreatment. In multivariate analysis, the predictors of recurrence on long-term follow-up DSA images were as follows: 1) larger aneurysm size (p = 0.001), 2) male sex (p = 0.006), 3) conventional coil therapy (p = 0.05), 4) aneurysm location (p = 0.01), and 5) a minor recurrence on short-term follow-up DSA images (p = 0.007). Ruptured aneurysm status was not a predictive factor. The sensitivity of short-term follow-up DSA studies was only 40.0% for detecting delayed aneurysm recurrence and 45.5% for detecting delayed recurrence requiring further treatment. CONCLUSIONS: The results of this study highlight the importance of long-term angiographic follow-up after coil therapy for ruptured and unruptured intracranial aneurysms. Predictors of delayed recurrence and retreatment include large aneurysms, recurrence on short-term follow-up DSA images (even minor), male sex, and conventional coil therapy.

Aneurysmal subarachnoid hemorrhage in patients under 35-years-old: a single-center experience.

OBJECTIVE: Aneurysmal subarachnoid hemorrhage (SAH) is relatively uncommon in young adults. There is a paucity of data pertaining to the management of aneurysmal SAH in young patients, especially with endovascular therapy. METHODS: We reviewed all SAH patients under the age of 35 years treated at Jefferson Hospital for Neuroscience, Philadelphia, USA, from 2004 to 2009. RESULTS: A total of 40 patients (15 males and 25 females) under the age of 35 were treated for aneurysmal SAH. The average patient age was 30 years (17-35 yo); 25 (62.5%) were smokers. Seventeen patients presented with a Hunt and Hess Grade I or II (42.5%), 20 with a Grade III (50%), and 3 with a Grade IV (7.5%). Thirty-two aneurysms (80%) were located in the anterior circulation and 8 (20%) in the posterior circulation. Thirty-five patients (87.5%) were treated with coil embolization versus 5 with craniotomy and clipping. The endovascular and microsurgical occlusion rates were 90.6% and 100%, respectively. There were no procedural complications with endovascular therapy. Of 35 patients undergoing endovascular treatment, 24 (68.6%) had excellent outcomes at time of discharge with a Glasgow outcome scale of 5. There were no deaths in the series. No patient experienced a rehemorrhage after endovascular treatment. CONCLUSION: Smoking, female sex, and anterior circulation aneurysms are highly prevalent in young adults with SAH. Endovascular treatment resulted in an overall favorable outcome with no rehemorrhages in patients under the age of 35 years. Our results suggest that endovascular therapy is a reasonable treatment for young patients with SAH.

Rapid and progressive venous thrombosis after occlusion of high-flow arteriovenous fistula.

BACKGROUND: Cerebral venous thrombosis developing after surgical or endovascular obliteration of arteriovenous fistula (AVF) is a rare but devastating complication that has not been adequately reported. CASE DESCRIPTION: Two patients presenting with AVF (1 pial, 1 dural) and large venous pouches were successfully treated by surgical and endovascular means and were neurologically intact postoperatively. Rapid neurologic deterioration was seen on postoperative day 5 in the first patient and postoperative day 2 in the second patient. Both patients had massive cerebral venous thromboses on brain imaging and surgical exploration. One patient died and the other was severely disabled. CONCLUSION: Rapid occlusion of a high-flow AVF resulting in significant venous stasis can precipitate thrombosis of the venous system distal to the fistulous point. In the presence of large venous pouches and significant venous stasis, strict therapeutic anticoagulation may be required to prevent cerebral venous thrombosis. Therapeutic anticoagulation, though feasible following endovascular treatment, may prove particularly challenging after open surgical interventions given the risk of hemorrhagic complications.

An extreme case of the syndrome of the trephined requiring the use of a novel titanium plate.

INTRODUCTION: Patients with large cranial defects can manifest a secondary neurological deterioration known as the "syndrome of the trephined." CASE REPORT: This is the case of a 66-year-old female with a left-sided acute subdural hematoma, treated with decompressive craniectomy. Six months later, a cranioplasty was performed. However, it was complicated by an infection requiring removal of the bone plate. A week later, the patient became comatose; her craniectomy flap was sunken. After ruling out all other possible disorders, we suspected an extreme syndrome of the trephined. The patient's neurological status drastically improved after she was placed on a Trendelenburg position regiment. A second cranioplasty was performed only 3 months after the infection using a novel custom designed titanium mesh, the least porous material used in synthetic bone flaps, to decrease the risk of infection. The patient had an excellent recovery; at her 6-month follow-up she was neurologically intact, cosmetically satisfied, and free of infection. CONCLUSIONS: The treatment of extreme cases of syndrome of the trephined in the setting of a recent infection can be challenging; successful treatment can be achieved by using a custom titanium plate.

Thoracic myelopathy due to an intramedullary herniated nucleus pulposus: first case report and review of the literature.

BACKGROUND AND IMPORTANCE: Herniation of intervertebral discs is relatively common. Migration usually occurs in the ventral epidural space; very rarely discs migrate in the subdural space. No cases of intradural intramedullary disc have been reported in humans. CLINICAL PRESENTATION: A case of a herniated intervertebral disc directly into the spinal cord parenchyma is presented. The patient presented with 2 weeks of progressive bilateral lower extremity numbness and weakness, saddle hypoesthesia, urinary dysfunction and gait disturbance. Spine magnetic resonance imaging (MRI) with gadolinium revealed a solitary well-defined intramedullary lesion (T7-T8 level) with ring enhancement and focal cord expansion with significant surrounding edema. Metastatic workup and neural axis imaging was negative. A thoracic laminectomy and myelotomy was performed; the lesion was pearlescent and well circumscribed. It was densely adherent to the ventral pia and gross totally removed. Pathology was consistent with nucleus pulposus. CONCLUSION: Intradural intramedullary migration of a herniated intervertebral disc is extremely rare but should be considered in the differential. It may present in a variety of clinical scenarios, including thoracic myelopathy, and mimic intramedullary spinal cord tumor.

Temporary endovascular bypass: rescue technique during mechanical thrombolysis.

BACKGROUND: The goal of mechanical thrombolysis is to re-establish blood flow to a completely occluded artery in patients who fail intravenous thrombolytic therapy or who are outside the therapeutic window. OBJECTIVE: We present our single-institution experience with the use of temporary, partial deployment of a self-expanding intracranial stent as a rescue technique for the treatment of acute stroke. The use of the Enterprise stent represents an off-label use of a humanitarian device exemption device. METHODS: We performed a retrospective review of a prospective database of acute stroke patients treated with intra-arterial techniques at the Thomas Jefferson University Comprehensive Stroke Center from July 2009 to July 2010. RESULTS: Seven patients were included, and we obtained a 100% recanalization rate to Thrombolysis in Myocardial Infarction grade 2 and 3 with a 28% asymptomatic hemorrhagic transformation. No device-related complications were encountered. CONCLUSION: Temporary, partial deployment of a self-expanding intracranial stent as a rescue procedure is feasible, effective, and safe in the setting of endovascular intervention for acute stroke, although our experience is limited. This technique was used only as a rescue procedure when more established procedures failed.

Bilateral footdrop after treatment of an anterior communicating artery aneurysm: a case report and review of the literature.

BACKGROUND AND IMPORTANCE: Footdrop designates weakness of the ankle as well as toes dorsiflexion. Peripheral causes of unilateral footdrop are well established. Bilateral footdrop originating from pathologies in the central nervous system are rare and include a number of unexplored etiologies. CLINICAL PRESENTATION: A case of bilateral footdrop is presented. The patient presented with a grade IV subarachnoid hemorrhage with intraventricular extension. He was treated with coil embolization of an anterior communicating artery aneurysm. Postoperatively, he was found to have weakness of both ankle and toe dorsiflexion. Findings on magnetic resonance imaging of the cervical, thoracic, and lumbar spine were negative for abnormal cord signal, cord infarction, and compressive lesion. Magnetic resonance imaging of the brain revealed parasagittal bifrontal and right greater than left convexity foci of acute infarction. CONCLUSION: Central causes of acute footdrop are rare. However, they should be considered in the differential diagnosis, particularly in the presence of upper motor neuron signs on physical examination.

Dorsal epidural intervertebral disk herniation with atypical radiographic findings: case report and literature review.

BACKGROUND/OBJECTIVE: Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac. DESIGN: Case report. FINDINGS: A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment. CONCLUSIONS: Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.

Potential financial impact of restriction in "never event" and periprocedural hospital-acquired condition reimbursement at a tertiary neurosurgical center: a single-institution prospective study.

OBJECT: The Centers for Medicare and Medicaid Services (CMS) have moved to limit hospital augmentation of diagnosis-related group billing for "never events" (adverse events that are serious, largely preventable, and of concern to the public and health care providers for the purpose of public accountability) and certain hospital-acquired conditions (HACs). Similar restrictions may be applied to physician billing. The financial impact of these restrictions may fall on academic medical centers, which commonly have populations of complex patients with a higher risk of HACs. The authors sought to quantify the potential financial impact of restrictions in never events and periprocedural HAC billing on a tertiary neurosurgery facility. METHODS: Operative cases treated between January 2008 and June 2008 were reviewed after searching a prospectively maintained database of perioperative complications. The authors assessed cases in which there was a 6-month lag time to allow for completion of hospital and physician billing. They speculated that other payers would soon adopt the present CMS restrictions and that procedure-related HACs would be expanded to cover common neurosurgery procedures. To evaluate the impact on physician billing and to directly contrast physician and hospital billing impact, the authors focused on periprocedural HACs, as opposed to entire admission HACs. Billing records were compiled and a comparison was made between individual event data and simultaneous cumulative net revenue and net receipts. The authors assessed the impact of the present regulations, expansion of CMS restrictions to other payers, and expansion to rehospitalization and entire hospitalization case billing due to HACs and never events. RESULTS: A total of 1289 procedures were completed during the examined period. Twenty-five procedures (2%) involved patients in whom HACs developed; all were wound infections. Twenty-nine secondary procedures were required for this cohort. Length of stay was significantly higher in patients with HACs than in those without (11.6 +/- 11.5 vs 5.9 +/- 7.0 days, respectively). Fifteen patients required readmission due to HACs. Following present never event and HAC restrictions, hospital and physician billing was minimally affected (never event billing as percent total receipts was 0.007% for hospitals and 0% for physicians). Nonpayment for rehospitalization and reoperation for HACs by CMS and private payers yielded greater financial impact (CMS only, percentage of total receipts: 0.14% hospital, 0.2% physician; all payers: 1.56% hospital, 3.0% physician). Eliminating reimbursement for index procedures yielded profound reductions (CMS only as percentage of total receipts: 0.62% hospital, 0.8% physician; all payers: 5.73% hospital, 8.9% physician). CONCLUSIONS: The authors found potentially significant reductions in physician and facility billing. The expansion of never event and HACs reimbursement nonpayment may have a substantial financial impact on tertiary care facilities. The elimination of never events and reduction in HACs in current medical practices are worthy goals. However, overzealous application of HACs restrictions may remove from tertiary centers the incentive to treat high-risk patients.

Human lung cell growth is not stimulated by lead ions after lead chromate-induced genotoxicity.

Chromate compounds are known human lung carcinogens. Water solubility is an important factor in the carcinogenicity of these compounds with the most potent carcinogenic compounds being water-insoluble or 'particulate'. Previously we have shown that particulate chromates dissolve extracellularly releasing chromium (Cr) and lead (Pb) ions and only the Cr ions induce genotoxicity. Pb ions have been considered to have epigenetic effects and it is thought that these may enhance the carcinogenic activity of lead chromate, perhaps by stimulating Cr-damaged cells to divide. However, this possibility has not been directly tested. Accordingly, we investigated the ability of Pb ions to stimulate human lung cells and possibly force lead chromate-damaged cells to grow. We found that at concentrations of lead chromate that induced damage, human lung cells exhibited cell cycle arrest and growth inhibition that were very similar to those observed for sodium chromate. Moreover, we found that soluble Pb ions were not growth stimulatory to human lung cells and in fact induced progressive mitotic arrest. These data indicate that lead chromate-generated Cr ions cause growth inhibition and cell cycle arrest and that Pb does not induce epigenetic effects that stimulate chromate-damaged cells to grow.