Medicine and Health Sciences Commons^™

Management Of Head And Neck Pseudoaneurysms: A Review Of 33 Consecutive Cases., Eliza Anderson, Nohra Chalouhi, Md, Aaron Dumont, Stavropoula Tjoumakaris, Mario Zanaty, Robert H. Rosenwasswer Md, Robert M Starke, Pascal Jabbour Md

Department of Neurosurgery Faculty Papers

Background. Endosaccular coiling, vessel occlusion, stenting, stent-assisted coiling, and flow diversion are all endovascular treatment options for pseudoaneurysms (PAs) of the head and neck. We explore different clinical situations in which these were selected for PA management at a single institution. Methods. Over a period of ten years, 33 patients presented to our hospital with PAs of the head and neck. Their outcomes and procedural complications are discussed. Results. We observed a complication rate of 18.2% (6 of 33), consisting predominantly of infarcts following vessel occlusion. As measured by the modified Rankin Scale, 25 (75.8%) patients had achieved favorable outcomes …

Predictors Of Infections Following Cranioplasty: A Retrospective Review Of A Large Single Center Study., Mario Zanaty, Nohra Chalouhi, Md, Robert M Starke, Rohan Chitale, Md, Shannon Hann, Md, Cory D Bovenzi, Mark P Saigh, Eric W Schwartz, Emily S I Kunkel, Alexandra S Efthimiadis-Budike, Pascal Jabbour Md, Richard Dalyai, Robert H. Rosenwasswer Md, Stavropoula Tjoumakaris

Department of Neurosurgery Faculty Papers

Introduction. The variables that predispose to postcranioplasty infections are poorly described in the literature. We formulated a multivariate model that predicts the risk of infection in patients undergoing cranioplasty. Method. Retrospective review of all patients who underwent cranioplasty following craniectomy from January, 2000, to December, 2011. Tested predictors were age, sex, diabetic status, hypertensive status, reason for craniectomy, urgency status of craniectomy, location of cranioplasty, reoperation for hematoma, hydrocephalus postcranioplasty, and material type. A multivariate logistic regression analysis was performed. Results. Three hundred forty-eight patients met the study criteria. Infection rate was 26.43% (92/348). Of these cases with infection, 56.52% …

Cerebral Arteriovenous Malformations: Evaluation And Management., Norman Ajiboye, Nohra Chalouhi, Md, Robert M Starke, Mario Zanaty, Rodney Bell, Md

Department of Neurosurgery Faculty Papers

There has been increased detection of incidental AVMs as result of the frequent use of advanced imaging techniques. The natural history of AVM is poorly understood and its management is controversial. This review provides an overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management of AVMs. The authors discussed the imaging techniques available for detecting AVMs with regard to the advantages and disadvantages of each imaging modality. Furthermore, this review paper discusses the factors that must be considered for the most appropriate management strategy (based on the current evidence in the literature) and the risks and benefits …

Evaluating Initial Spine Trauma Response: Injury Time To Trauma Center In Pa, Usa., James Harrop, Md, George M. Ghobrial, Md, Rohan Chitale, Md, Kelly Krespan, Laura Odorizzi, Tristan Fried, Mitchell Maltenfort, Phd, Murray Cohen, Md, Alex R. Vaccaro, Md

Department of Neurosurgery Faculty Papers

Historical perceptions regarding the severity of traumatic spinal cord injury has led to considerable disparity in triage to tertiary care centers. This article retrospectively reviews a large regional trauma database to analyze whether the diagnosis of spinal trauma affected patient transfer timing and patterns. The Pennsylvania Trauma database was retrospectively reviewed. All acute trauma patient entries for level I and II centers were categorized for diagnosis, mechanism, and location of injury, analyzing transportation modality and its influence on time of arrival. A total of 1162 trauma patients were identified (1014 blunt injuries, 135 penetrating injuries and 12 other) with a …

Cortical Injury Modulates The Pain Pathway Partially Through Inducible Nitric Oxide Synthase, Bv Daiutolo, Cm Macolino, Al Tyburski, Mb Elliot

Department of Neurosurgery Faculty Papers

Introduction

Headache is a highly prevalent symptom in all severities of traumatic brain injury (TBI), and it is one of the most common symptoms of post-traumatic headache. Post-traumatic headache (PTH) remains the most common chronic pain syndrome within the TBI patient population¹. Mild and moderate forms of TBI are more prevalent than severe forms, but it is currently believed that PTH occurrence is not related to the severity of TBI¹. Despite being a common symptom following injury, little is known about the pathogenesis of post-traumatic headache. This is partly due to a lack in preclinical animal …

Inflammation In The Pain Pathway In A Model Of Mild Closed Head Injury: Implications For Post-Concussion Headache, Cm Macolino, Bv Daiutolo, Al Tyburski, Mb Elliot

Department of Neurosurgery Faculty Papers

Introduction

Headache is a hallmark feature of post-concussion syndrome. Post-concussion headache (PCH) is highly prevalent in the military with as high as 97.8% reporting having headaches¹ occurring in up to 85% of athletes following ^2-4 concussion or mTBI. In the Military and sports, return to duty or play guidelines state that a soldier/player should be asymptomatic before returning to physical activity⁴. However, headache following concussion is commonly dismissed.

PCH can be a new headache resulting from head trauma or worsening of pre-existing headache disorder. Incidence rates for concussion will continue to grow along with the increasing awareness …

Advances In Neurovascular Treatments., Robert M Starke, Stephen J Monteith, Nohra Chalouhi, Dale Ding, Ricky Medel, David Hasan, Aaron S Dumont

Department of Neurosurgery Faculty Papers

No abstract provided.

Cervical Spondylotic Myelopathy In The Young Adult: A Review Of The Literature And Clinical Diagnostic Criteria In An Uncommon Demographic, Peter S Amenta, Md, George M. Ghobrial, Md, Kelly Krespan, Phi Nguyen, Mohammad Ali, Md, James Harrop, Md

Department of Neurosurgery Faculty Papers

Background: Cervical spondylotic myelopathy (CSM) is typically encountered in the elderly population. Significant inconsistencies currently exist regarding the definition of the disorder, the true incidence of CSM in younger populations, and the established diagnostic criteria.

Objective: To highlight the lack of standardization in the definition and diagnosis of CSM.

Methods: A PubMed literature search was conducted spanning the years 2001 to 2011. The search was limited by the following terms: 1) English language, 2) Adults (19-44 years old), and 3) “cervical spondylotic myelopathy.” Each article was reviewed to determine if the presence of the definition of CSM existed in the …

Critical Role Of Tnf-Α In Cerebral Aneurysm Formation And Progression To Rupture., Robert M Starke, Nohra Chalouhi, Md, Pascal Jabbour Md, Stavropoula Tjoumakaris, L. Fernando Gonzalez, Robert H. Rosenwasswer Md, Kosuke Wada, Kenji Shimada, David M Hasan, Nigel H Greig, Gary K Owens, Aaron Dumont

Department of Neurosurgery Faculty Papers

BACKGROUND: Alterations in TNF-α expression have been associated with cerebral aneurysms, but a direct role in formation, progression, and rupture has not been established.

METHODS: Cerebral aneurysms were induced through hypertension and a single stereotactic injection of elastase into the basal cistern in mice. To test the role of TNF-α in aneurysm formation, aneurysms were induced in TNF-α knockout mice and mice pretreated with the synthesized TNF-α inhibitor 3,6'dithiothalidomide (DTH). To assess the role of TNF-α in aneurysm progression and rupture, DTH was started 6 days after aneurysm induction. TNF-α expression was assessed through real-time PCR and immunofluorescence staining.

RESULTS: …

Cortical Injury Modulates The Pain Pathway Partially Through Inducible Nitric Oxide Synthase, Bv Daiutolo, Cm Macolino, Al Tyburski, Mb Elliot

Department of Neurosurgery Faculty Papers

Introduction

Headache is a highly prevalent symptom in all severities of traumatic brain injury (TBI), and it is one of the most common symptoms of post-traumatic headache. Post-traumatic headache (PTH) remains the most common chronic pain syndrome within the TBI patient population¹. Mild and moderate forms of TBI are more prevalent than severe forms, but it is currently believed that PTH occurrence is not related to the severity of TBI¹. Despite being a common symptom following injury, little is known about the pathogenesis of post-traumatic headache. This is partly due to a lack in preclinical animal …

Variability Of Patient Spine Education By Internet Search Engine., George M. Ghobrial, Md, Angud Mehdi, Mitchell Maltenfort, Phd, Ashwini D Sharan, Md, James Harrop, Md

Department of Neurosurgery Faculty Papers

BACKGROUND: Patients are increasingly reliant upon the Internet as a primary source of medical information. The educational experience varies by search engine, search term, and changes daily. There are no tools for critical evaluation of spinal surgery websites.

PURPOSE: To highlight the variability between common search engines for the same search terms. To detect bias, by prevalence of specific kinds of websites for certain spinal disorders. Demonstrate a simple scoring system of spinal disorder website for patient use, to maximize the quality of information exposed to the patient.

STUDY DESIGN: Ten common search terms were used to query three of …

Therapeutic Implications Of Estrogen For Cerebral Vasospasm And Delayed Cerebral Ischemia Induced By Aneurysmal Subarachnoid Hemorrhage., Dale Ding, Robert M Starke, Aaron S Dumont, Gary K Owens, David M Hasan, Nohra Chalouhi, Md, Ricky Medel, Chih-Lung Lin

Department of Neurosurgery Faculty Papers

Cerebral vasospasm (CV) remains the leading cause of delayed morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). However, increasing evidence supports etiologies of delayed cerebral ischemia (DCI) other than CV. Estrogen, specifically 17 β -estradiol (E2), has potential therapeutic implications for ameliorating the delayed neurological deterioration which follows aneurysmal SAH. We review the causes of CV and DCI and examine the evidence for E2-mediated vasodilation and neuroprotection. E2 potentiates vasodilation by activating endothelial nitric oxide synthase (eNOS), preventing increased inducible NOS (iNOS) activity caused by SAH, and decreasing endothelin-1 production. E2 provides neuroprotection by increasing thioredoxin expression, decreasing c-Jun N-terminal …

Flow-Diversion Panacea Or Poison?, Mario Zanaty, Nohra Chalouhi, Md, Stavropoula I. Tjoumakaris, Robert H. Rosenwasswer Md, L. Fernando Gonzalez, Pascal Jabbour Md

Department of Neurosurgery Faculty Papers

Endovascular therapy is now the treatment of choice for intracranial aneurysms (IAs) for its efficacy and safety profile. The use of flow diversion (FD) has recently expanded to cover many types of IAs in various locations. Some institutions even attempt FD as first line treatment for unruptured IAs. The most widely used devices are the pipeline embolization device (PED), the SILK flow diverter (SFD), the flow redirection endoluminal device (FRED), and Surpass. Many questions were raised regarding the long-term complications, the optimal regimen of dual antiplatelet therapy, and the durability of treatment effect. We reviewed the literature to address these …

A Prospective, Multicenter, Phase I Matched-Comparison Group Trial Of Safety, Pharmacokinetics, And Preliminary Efficacy Of Riluzole In Patients With Traumatic Spinal Cord Injury., Robert G Grossman, Michael G Fehlings, Ralph F Frankowski, Keith D Burau, Diana S L Chow, Charles Tator, Angela Teng, Elizabeth G Toups, James Harrop, Bizhan Aarabi, Christopher I Shaffrey, Michele M Johnson, Susan J Harkema, Maxwell Boakye, James D Guest, Jefferson R Wilson

Department of Neurosurgery Faculty Papers

A prospective, multicenter phase I trial was undertaken by the North American Clinical Trials Network (NACTN) to investigate the pharmacokinetics and safety of, as well as obtain pilot data on, the effects of riluzole on neurological outcome in acute spinal cord injury (SCI). Thirty-six patients, with ASIA impairment grades A-C (28 cervical and 8 thoracic) were enrolled at 6 NACTN sites between April 2010 and June 2011. Patients received 50 mg of riluzole PO/NG twice-daily, within 12 h of SCI, for 14 days. Peak and trough plasma concentrations were quantified on days 3 and 14. Peak plasma concentration (Cmax) and …

Stereotactic Radiosurgery With Neoadjuvant Embolization Of Larger Arteriovenous Malformations: An Institutional Experience, Richard Dalyai, Thana Theofanis, Robert Starke, Nohra El-Chalouhi, Md, George M. Ghobrial Md, Pascal Jabbour, Md, Aaron Dumont, L. Fernando Gonzalez, David Gordon, Robert Rosenwasser, Stavropoula Tjoumakaris

Department of Neurosurgery Faculty Papers

Objective. This study investigates the safety and efficacy of a multimodality approach combining staged endovascular embolizations with subsequent SRS for the management of larger AVMs. Methods. Ninety-five patients with larger AVMs were treated with staged endovascular embolization followed by SRS between 1996 and 2011. Results. The median volume of AVM in this series was 28 cm³ and 47 patients (48%) were Spetzler-Martin grade IV or V. Twenty-seven patients initially presented with hemorrhage. Sixty-one patients underwent multiple embolizations while a single SRS session was performed in 64 patients. The median follow-up after SRS session was 32 months (range 9-136 months). …

Update On Intra-Arterial Chemotherapy For Retinoblastoma., Mario Zanaty, Guilherme Barros, Nohra Chalouhi, Md, Robert M Starke, Philip Manasseh, Stavropoula I. Tjoumakaris, Carol L Shields, David Hasan, Ketan Bulsara, Robert H. Rosenwasswer Md, Pascal Jabbour Md

Department of Neurosurgery Faculty Papers

The tools for managing retinoblastoma have been increasing in the past decade. While globe-salvage still relies heavily on intravenous chemotherapy, tumors in advanced stage that failed chemotherapy are now referred for intra-arterial chemotherapy (IAC) to avoid enucleation. However, IAC still has many obstacles to overcome. We present an update on the indications, complications, limitations, success, and technical aspects of IAC. Given its safety and high efficacy, it is expected that IAC will replace conventional strategies and will become a first-line option even for tumors that are amenable for other strategies.

Extending The Indications Of Flow Diversion To Small, Unruptured, Saccular Aneurysms Of The Anterior Circulation., Nohra Chalouhi, Md, Robert M Starke, Steven Yang, Cory D Bovenzi, Stavropoula Tjoumakaris, David Hasan, L. Fernando Gonzalez, Robert H. Rosenwasswer Md, Pascal Jabbour Md

Department of Neurosurgery Faculty Papers

BACKGROUND AND PURPOSE: Flow diverters are currently indicated for treatment of large and complex intracranial aneurysms. The purpose of this study was to determine whether the indications of flow diversion can be safely extended to unruptured, small, saccular aneurysms (<10 >mm) of the anterior circulation.

METHODS: Forty patients treated with the pipeline embolization device (PED) were matched in a 1:4 fashion with 160 patients treated with stent-assisted coiling based on patient age, sex, aneurysm location, and aneurysm size. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared.

RESULTS: The rate of periprocedural complications was 5% in the PED …