Cerebral aneurysms.
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Aneurysm, Ruptured↗
Biomedical subjects
Jonathan L Brisman
Publications and source records attributed to Jonathan L Brisman.
Successful emergent angioplasty of neurosarcoid vasculitis presenting with strokes.
BACKGROUND: Sarcoidosis is a systemic disease with neurologic involvement in approximately 5% of cases. Ischemic events related to neurosarcoid vasculitis are rare. We report the successful treatment of symptomatic neurosarcoid vasculitis with angioplasty. CASE DESCRIPTION: A 41-year-old African American with a diagnosis of neurosarcoid presented with aphasia and right-sided weakness. He was treated medically with antiplatelet agents, heparinization, and hypertensive therapy. Despite this treatment, he experienced clinical worsening and radiographic extension of his infarcts. He underwent successful angioplasty of a severe focal stenosis of the left middle cerebral artery. After the procedure, he experienced marked improvement in his symptoms and at follow-up continues to improve. CONCLUSIONS: We report the angiographic demonstration of neurosarcoidosis with large vessel changes and resultant strokes and its successful treatment with balloon angioplasty.
Adult↗
Neurointerventional treatment of vasospasm.
OBJECTIVES: To review the historical development and current status of endovascular techniques used in the treatment of symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. METHODS: This article summarizes the relevant literature on neurointerventional therapy for vasospasm, namely instillation of intraarterial medication (papaverine, nicardipine, verapamil) and transluminal balloon angioplasty. The authors synthesize the available literature with their own experience using the various endovascular modalities to treat vasospasm at high volume cerebrovascular centers. TECHNIQUE: Indications for the use of neurointerventional therapy as well as a summary of the technique for transluminal angioplasty to treat vasospasm as employed by the authors is described. DISCUSSION: Neurointerventional treatment of vasospasm following aneurysmal hemorrhage has been proven to be a safe and successful technique for those patients suffering symptomatic vasospasm refractory to medical management. The techniques contunue to undergo refinement as endovascular technology advances. We currently favor the use of balloon angioplasty over intraarterial antispasmotics due to the increased durability and long-lasting effects of the former and lower risk profile.
Angioplasty, Balloon↗
Cystic dilation of the conus ventriculus terminalis presenting as an acute cauda equina syndrome relieved by decompression and cyst drainage: case report.
OBJECTIVE AND IMPORTANCE: The ventriculus terminalis of the conus, or "fifth ventricle" refers to the ependymal-lined space in the middle of the conus that is present in childhood and whose persistence into adulthood is rare. A number of cases of cystic dilatation of the ventriculus terminalis have been described in adulthood. Patients tend to present with either pain alone or gradually progressive conus or cauda equina syndromes with varying degrees of recovery after cyst drainage. Presentation with an acute cauda equina syndrome and its successful surgical management has not been previously reported. CLINICAL PRESENTATION: A 57-year-old woman experienced back pain and bilateral sciatica ascribed to diabetic neuropathy for 2 years. Over a 24-hour period she developed bilateral lower extremity weakness, saddle anesthesia, and bowel and bladder incontinence. Lumbosacral magnetic resonance imaging demonstrated a large cystic dilatation of the ventriculus terminalis. INTERVENTION: She was taken for emergency surgical decompression and cyst drainage. Immediately after surgery, she experienced significant increase in lower extremity strength and has since regained continence. CONCLUSION: Cystic dilation of the ventriculus terminalis should be part of the differential diagnosis for a cauda equina syndrome; surgical decompression with simple cyst drainage can result in excellent clinical results.
Decompression, Surgical↗
Transarterial embolization of vein of Galen malformations: the use of magnetic resonance imaging noninvasive optimal vessel analysis to quantify shunt reduction. Report of two cases.
In patients with vein of Galen malformations, high-flow shunting decreases cerebral perfusion. By reducing or eliminating these shunts, transarterial embolization can improve cerebral perfusion and clinical outcomes. Quantifying pre- and postembolization shunt blood flow may help determine the optimal timing and efficacy of embolization and may provide prognostic information. The authors used magnetic resonance imaging noninvasive optimal vessel analysis as a novel modality to measure volumetric blood flow through vein of Galen malformation shunts in a neonate and an infant before and after transarterial embolization.
Brain↗
Breast adenocarcinoma metastatic to epidural cervical spine meningioma: case report and review of the literature.
While several cases of cancer metastatic to cranial meningiomas have been reported, metastasis to spinal meningioma has been reported only once, and a mechanism for such metastases has not been investigated. We report a case of breast carcinoma metastatic to an epidural cervical meningioma, summarize the literature on metastases to central nervous system meningiomas, and suggest a possible mechanism. Our patient, a 55-year-old woman, presented with difficulty walking, back pain, and quadriparesis. Magnetic resonance imaging revealed an enhancing C3-4 epidural lesion and an L4 compression fracture. Because of concern that the fracture and epidural lesion might represent metastases, we performed a metastatic work-up, which revealed a right breast mass. The patient underwent C3-C4 laminectomies and an epidural lesion was encountered. Intraoperative frozen section revealed mixed meningioma and breast adenocarcinoma. A gross total resection was achieved and the patient subsequently received spinal irradiation and hormonal therapy. Whereas a literature review revealed numerous reports of metastases to cranial meningiomas, this represents only the second reported case of such pathology in the spine. Mechanisms of this unusual process likely include meningiomas' vascularity, meningiomas' slow growth providing nutrient availability, and perhaps, as suggested by our analysis, E-cadherin expression by both meningiomas and breast cancer. Metastasis to meningioma must be considered in an epidural spinal lesion in all patients with a known malignancy, with surgical aggressiveness tailored to the intraoperative pathologic diagnosis.
Adenocarcinoma↗
Hyperacute neuropathological findings after proton beam radiosurgery of the rat hippocampus.
OBJECTIVE: To study the hyperacute histological and immunohistochemical effects of stereotactic proton beam irradiation of the rat hippocampus. METHODS: Nine rats underwent proton beam radiosurgery of one hippocampus with nominal doses of cobalt-2, -12, and -60 Gray equivalents (n = 3 each). Control animals (n = 3) were not irradiated. Animals were killed 5 hours after irradiation and brain sections were stained for Nissl, silver degeneration, deoxyribonucleic acid (DNA) fragmentation (DNAF), and the activated form of two mitogen-activated protein kinases (MAPKs), phospho-Erk1/2 (P-Erk1/2) and p38. Stained cells in the hippocampus expressing DNAF and/or P-Erk1/2 were counted. Confocal microscopy with double immunofluorescent staining was used to examine cellular colocalization of DNAF and P-Erk1/2. RESULTS: Both DNAF and P-Erk1/2 showed quantitative dose-dependent increases in staining in the targeted hippocampus compared with the contralateral side and controls. This finding was restricted to the subgranular proliferative zone of the hippocampus. Both markers also were up-regulated on the contralateral side when compared with controls in a dose-dependent fashion. Simultaneous staining for DNAF and P-Erk1/2 was found in fewer than half of all cells. p38 was unchanged compared with controls. Although Nissl staining appeared normal, silver stain confirmed dose-dependent cellular degeneration. CONCLUSION: DNAF, a marker of cell death, was present in rat hippocampi within 5 hours of delivery of cobalt-2 Gray equivalents stereotactically focused irradiation, suggesting that even low-dose radiosurgery has hyperacute neurotoxic effects. Activated mitogen-activated protein kinase was incompletely colocalized with DNAF, suggesting that activation of this cascade is neither necessary nor sufficient to initiate acute cell death after irradiation.
Animals↗
Aneurysmal rupture during coiling: low incidence and good outcomes at a single large volume center.
OBJECTIVE: To study the incidence and clinical outcomes of intraoperative aneurysm rupture (IOR) during endovascular coil embolization at a single large volume center and to review the literature on this subject to determine whether IOR rupture rate and mortality correlate with volume of aneurysms treated at a given center and years since the institution of Guglielmi detachable coils as a treatment modality. METHODS: We reviewed the aneurysm database at the Center for Endovascular Surgery since its inception (1997-2003) and reviewed 600 consecutively treated intracranial aneurysms in which coiling was attempted. All patients who sustained an IOR were studied. Procedural and follow-up angiograms as well as clinical outcomes were retrospectively reviewed. A literature review was conducted. RESULTS: Six patients (1.0%) experienced IOR (1.4% in acutely ruptured lesions, 0% in unruptured). All six had presented with diffuse subarachnoid hemorrhage (Fisher Grade 3) and in good clinical grade (Hunt & Hess Grades 1-3). One patient was rendered permanently disabled secondary to delay in controlling the IOR. All others were neurologically unchanged. A review of the literature revealed a trend in correlation between volume of aneurysms treated and IOR rate; no statistically significant correlation was found between volume of aneurysms treated or years since the introduction of GDC technology and IOR rates or mortality. CONCLUSION: IOR remains a serious risk of endosaccular coiling of intracranial aneurysms, with aneurysms presenting with subarachnoid hemorrhage at greater risk for this complication. This risk can be minimized with very low associated morbidity and mortality (incidence 1%, 17% morbidity, 0% mortality at our institution).
Adult↗
Multiple cerebral aneurysms in a neonate: occlusion and rupture.
Aneurysmal subarachnoid hemorrhage in a neonate is exceedingly uncommon. The authors report the case of a neonate with a large anterior communicating artery aneurysm, accessory left middle cerebral artery aneurysm, and left internal carotid artery (ICA) fusiform aneurysm. The neonate suffered from occlusion of the left ICA and aneurysm rupture. The large aneurysm was treated with detachable coils and the patient made a significant recovery. Of the 15 case reports of cerebral aneurysms in neonates that have been published, none has contained a description of multiple aneurysms or a discussion of endovascular treatment.
Aneurysm, Ruptured↗
Pediatric nonvertebral paraspinal arteriovenous fistulas along the segmental nerve: clinical, imaging, and therapeutic considerations.
OBJECT: The authors characterize the clinical presentation and imaging features of paraspinal nonvertebral arteriovenous fistulas (AVFs) along the segmental nerve and describe their endovascular treatment. METHODS: The authors undertook a retrospective review of medical records, imaging, and treatment of patients with endovascular problems spanning the period from 1985 to 2003. Five pediatric patients (2-3 years of age) received diagnoses of nonvertebral paraspinal AVFs along the segmental nerve. All patients presented with an incidentally discovered continuous murmur over the paraspinal or parasternal regions. All patients were neurologically intact; two patients had cardiomegaly. The AVF was found in the midthoracic level in four patients and at L-3 in one patient. All AVFs were high-flow single-hole fistulas at the neural foramen with venous drainage into paraspinal and epidural veins but without intradural reflux. All fistulas were endovascularly occluded in the same session as diagnostic angiography took place. The fistula was completely occluded, with detachable coils in one case and with N-butyl-cyanoacrylate (NBCA) in four cases. Before NBCA injection, the flow through the fistula was decreased either by placing coils distal to the fistula or by inflating a balloon proximally. No signs of recanalization appeared on short-term follow-up magnetic resonance imaging in all patients. All patients remained neurologically intact at the last available follow-up session (mean 6 years). CONCLUSIONS: Nonvertebral paraspinal AVFs along the segmental nerve are specific disease entities seen in children presenting with bruit and cardiomegaly. Endovascular embolization should be the treatment of choice for this rare disease.
Angiography↗
Treatment options for wide-necked intracranial aneurysms using a self-expandable hydrophilic coil and a self-expandable stent combination.
The endovascular treatment of wide-necked intracranial aneurysms is evolving. We report our initial experience in treating seven wide-neck intracranial aneurysms by using a new self-expanding stent, the Neuroform, in combination with a new generation of coils that incorporate a self-expandable hydrophilic lining, the HydroCoil.
Adult↗
MRI changes in the rat hippocampus following proton radiosurgery.
PURPOSE: To define radiographic dose-response relationships for proton radiosurgery using a rat brain model. METHODS AND MATERIALS: A group of 23 rats was treated with Bragg peak proton beam irradiation involving the right hippocampus. Single doses of 5, 12, 20, 30, 60, 90 and 130 cobalt gray equivalents (CGE) were delivered to groups of 3 animals using single fraction technique. One extra animal was included at the 130- and 30-CGE doses. Animals were imaged using a standard 1.5-tesla GE Signa MRI. A 3-inch surface coil was employed to obtain T1-weighted sagittal images (TR 600 and TE 30) and dual echo T2-weighted coronal images (TR 3,000 and TE 30/90). Animals were imaged at 1.5, 3, 4.5, 6 and 9 months. Volumetric analysis with custom software was done to evaluate areas of increased signal on T2-weighted images, and signal change versus time curves were generated. Gadolinium-enhanced T1-weighted imaging was also done at the 9-month time point to further evaluate tissue injury. The development of hydrocephalus was also examined. RESULTS: Peak tissue injury was greater and occurred earlier with higher versus lower doses of radiation. Statistically significant differences were seen between the 130- and 90-CGE animals and between the 90- and 60-CGE animals (p < 0.0016) using ANOVA. Signal changes can be seen in at least 1 of the animals at 20 CGE. The largest volume of tissue enhancement at 9 months was seen in animals at 60 CGE, which may represent an intermediate zone of tissue injury and gliosis compared with greater tissue loss at higher doses and less injury at lower doses. Hydrocephalus developed first in the untreated hemisphere in 130- and 90-CGE animals as a result of mass effect while it occurred at a later time in the treated hemisphere in lower-dose animals. CONCLUSIONS: Following single-dose proton radiosurgery of rat hippocampus, serial MRIs show T2 signal changes in animals ranging from 130 down to 20 CGE as well as the development of hydrocephalus. Dose-effect relationships using proton radiosurgery in rats will be a helpful step in guiding further studies on radiation injury to brain tissue.
Animals↗
Subarachnoid hematoma, hydrocephalus, and aseptic meningitis resulting from a high cervical myelogram.
Despite its reduced use since the advent of magnetic resonance imaging, the high cervical myelogram remains a common diagnostic test in the evaluation of patients whose symptoms suggest cervical stenosis. We report a case of subarachnoid hematoma, hydrocephalus, and aseptic meningitis after a high cervical myelogram. A 52-year-old woman presented with headache, slurred speech, worsened neck pain and stiffness, and diffuse extremity weakness leading to gait instability beginning several hours after a cervical myelogram. Computed tomography (CT) scan revealed a C1-C2 hematoma below the dura, blood in the fourth and lateral ventricles, and hydrocephalus. An external ventricular drain was placed, and cerebrospinal fluid profile was consistent with aseptic meningitis. A suboccipital craniectomy and C1-C2 laminectomies were performed, followed by a C1-C2 durotomy, which revealed a large subarachnoid blood clot in the region of the cisterna magna extending down to the upper aspect of C2, which was evacuated by incising the arachnoid. In the midline at C1, an active source of intramedullary arterial bleeding on the dorsal surface of the spinal cord was coagulated. Spinal subarachnoid hematoma is a rare complication of high cervical myelogram. The extension of blood into the ventricular system with associated hydrocephalus has never been previously reported after myelography. Thus, severe persistent pain after cervical myelography should be evaluated by CT scans of the brain and cervical spine.
Cervical Vertebrae↗
Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage.
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Cerebrospinal Fluid Shunts↗
Sinus pericranii involving the torcular sinus in a patient with Hunter's syndrome and trigonocephaly: case report and review of the literature.
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Adult↗
Intentional partial coil occlusion followed by delayed clip application to wide-necked middle cerebral artery aneurysms in patients presenting with severe vasospasm. Report of two cases.
The treatment of ruptured cerebral aneurysms in patients presenting with vasospasm remains a particular challenge. The authors treated two patients harboring Hunt and Hess Grade 1 subarachnoid hemorrhages from middle cerebral artery (MCA) aneurysms associated with severe local angiographically demonstrated yet asymptomatic vasospasm on presentation. Because both aneurysms had wide necks and were located at the MCA bifurcation, they were believed to be anatomically suitable for microsurgical clip application. Severe M, vasospasm was believed to be a relative contraindication to open surgery, however. An intentionally staged endovascular and microsurgical treatment strategy was planned in each patient. Partial coil occlusion of the aneurysmal dome was performed to prevent the lesion from rebleeding and was followed by balloon angioplasty of the spastic vessel. Early treatment of the severe spasm appeared to prevent significant delayed neurological ischemic deficit. Following resolution of the vasospasm, definitive clipping of the aneurysms was performed on Day 13 post embolization. One patient had a good clinical recovery and was discharged without neurological deficit. The other patient's hospital course was complicated by the occurrence of a postoperative posterior temporal infarct requiring partial temporal lobectomy, although she eventually had a good recovery with only a small visual field deficit. Based on data obtained in these two patients, one can infer that ruptured wide-necked MCA aneurysms associated with severe local vasospasm may best be treated using a staged combined treatment plan. Delayed clip application might be performed more safely 4 to 6 weeks postocclusion, or later, than at 2 weeks.
Adult↗
Thrombus formation during intracranial aneurysm coil placement: treatment with intra-arterial abciximab.
BACKGROUND AND PURPOSE: The management of thrombus formation during coil placement in an intracranial aneurysm is important in minimizing periprocedural morbidity and mortality. We report on seven cases in which the primary treatment for thrombus formation during such coil placement was intra-arterial abciximab infusion. METHODS: Clinical and radiologic records of 100 consecutive patients who underwent coil placement in intracranial aneurysms at our institution during a 1-year period were reviewed. We identified seven cases (four ruptured aneurysms, three unruptured aneurysms) in which thrombus formation occurred during the procedure. RESULTS: Intra-arterial abciximab infusion, up to 5 mg, completely dissolved the thrombus in four of seven patients and almost completely dissolved it in two. In one patient with distal emboli, recanalization was not achieved. In two patients, an intravenous bolus of abciximab without 12-hour infusion was also given adjunctively. In one patient, leakage of contrast material occurred; this was related to the intra-arterial infusion. Clinically, no new neurologic deficits were directly related to the intra-arterial abciximab infusion. Six patients had good clinical outcome, and one patient died. CONCLUSION: Relatively low-dose, intra-arterial abciximab infusion can immediately dissolve an acute thrombus that forms during intracranial aneurysm coil placement. Although neither the optimal dose of intra-arterial abciximab nor the need to supplement the intra-arterial infusion with intravenous administration was established, we preliminarily found that low-dose intra-arterial abciximab infusion may be relatively effective and safe in this setting, even in patients with acute subarachnoid hemorrhage.
Abciximab↗
Received wisdom vs evidence in stroke prevention: carotid stenting will soon replace endarterectomy for all patients requiring such revascularization.
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Carotid Arteries↗