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Joseph M Zabramski

Publications and source records attributed to Joseph M Zabramski.

At least 19 recordsLinked to original sources
PubMed2006

The history of neurosurgical procedures for moyamoya disease.

Almost 50 years of research on moyamoya disease (1957-2006) has led to the development of a variety of surgical and medical options for its management in affected patients. Some of these options have been abandoned, others have served as the basis for the development of better procedures, and many are still in use today. Investigators studying moyamoya disease during this period have concluded that the best treatment is planned after studying each patient's presenting symptoms and angiographic pattern. The surgical procedures proposed for the treatment of moyamoya disease can be classified into three categories: direct arterial bypasses, indirect arterial bypasses, and other methods. Direct bypass methods that have been proposed are vein grafts and extracranial-intracranial anastomosis (superficial temporal artery-middle cerebral artery [STA-MCA] anastomosis and occipital artery-MCA anastomosis). Indirect techniques that have been proposed are the following: 1) encephaloduroarteriosynangiosis; 2) encephalomyosynangiosis; 3) encephalomyoarteriosynangiosis; 4) multiple cranial bur holes; and 5) transplantation of omentum. Other options such as cervical carotid sympathectomy and superior cervical ganglionectomy have also been proposed. In this paper the authors describe the history of the development of surgical techniques for treating moyamoya disease.

Europe↗
PubMed2006

Analysis of pain resolution after surgical resection of intramedullary spinal cord cavernous malformations.

OBJECTIVE: To determine the short- and long-term effects of surgical resection of intramedullary spinal cavernous malformations on preoperative pain. METHODS: Between 1988 and 2003, 53 intramedullary spinal cavernous malformations were surgically managed. A retrospective analysis of this cohort revealed 23 (43%) patients who presented with pain as a clinically relevant feature. Long-term evaluation of pain outcomes was available in 21 patients. Pain outcomes were characterized as improved, unchanged, or worse compared with preoperative and immediate postoperative status. RESULTS: Seven patients presented with radiculopathy, 12 with central pain, and four with both. Immediately after surgery, pain symptoms improved in 18 (78%) patients, were unchanged in 5 (22%), and were worse in none compared with the patients' preoperative status (n = 23). During the follow-up period, 11 (52%) patients improved, nine (43%) remained at their preoperative baseline, and one (5%) was worse compared with their preoperative levels of pain. The difference in postoperative and long-term pain status was statistically significant (P = 0.031). CONCLUSION: The surgical efficacy for improving pain related to intramedullary spinal cavernous malformations may be worse than implied in the literature. Although pain relief immediately after surgery is good, we found that recurrence is common and that only approximately 50% of patients report long-term benefit. Despite the significant limitations of this retrospective study, these data may serve as a guide when counseling patients preoperatively to help them to maintain realistic expectations about outcomes.

Adolescent↗
PubMed2006

Comparative analysis of anterior petrosectomy and transcavernous approaches to retrosellar and upper clival basilar artery aneurysms.

OBJECTIVE: To compare two techniques, transcavernous approach (TcA) and anterior petrosectomy (AP), used to manage retrosellar and upper clival basilar artery (BA) aneurysms. METHODS: AP and TcA were carried out on nine sides of cadaver heads. With use of a computerized tracking system, the area of surgical exposure in the ventral surface of the brain stem, the superficial area of exposure, and the linear exposure of the BA were evaluated. The angles of approach in the horizontal and vertical axes were measured using a robotic microscope. The caudal extent of exposure was determined by an aneurysm clip applied to proximal BA, and the distance between the clip and the floor of the sella was quantified after performing TcA. RESULTS: TcA (1127.3 +/- 438.4 mm2) provided a greater superficial exposure than AP (697.7 +/- 219.1 mm2) (P = 0.01). There were no statistical differences in the deep working exposure (P = 0.303) between TcA (206.9 +/- 40.7 mm2) and AP (260.2 +/- 137.1 mm2). The linear exposure of the BA was greater for AP (22.7 +/- 6.2 mm2) than for the TcA (12.8 +/- 2.9 mm2) (P = 0.004). The caudal extent of exposure averaged 6.1 mm from the floor of the sella. No differences were found in horizontal angles (P = 0.596); however, vertical angles were significantly greater for the TcA than AP (15.2 +/- 3.4) (P = 0.004). CONCLUSION: From an anatomic standpoint, the TcA offers more advantages than the AP, when approaching retrosellar BA aneurysms, except for those cases in which proximal control is the principal issue and the neck of the aneurysm is located more than 6.0 mm below the floor of the sella.

Analysis of Variance↗
PubMed2006

Long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms.

OBJECTIVE: This is the largest contemporary series examining long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms. METHODS: The presentation, location and shape of aneurysm, wrapping technique, outcome at discharge and last follow-up, and change in aneurysm at last angiographic follow-up were reviewed retrospectively in 74 patients with wrapped or clip-wrapped aneurysms. Patients in whom wrapping was used in conjunction with primary clipping were excluded. RESULTS: Of the 74 patients, 11 were lost to follow-up. The mean age of the remaining 63 patients (16 males, 47 females) was 56.5 years (range, 13-89 yr). Fifty-one aneurysms were located in the anterior circulation, and 17 were located in the posterior circulation. Fourteen patients presented with a ruptured aneurysm. Seventeen aneurysms were fusiform. Seven aneurysms were clip-wrapped, and 61 were wrapped with cotton. At discharge the Glasgow Outcome Scale (GOS) score was 5 in 54 patients and 4 in 5 patients. Two patients died from their presenting hemorrhage, and one from a medical comorbidity. The mean clinical follow-up was 44.1 months (range, 1-120 mo). One patient under clinical follow-up experienced subarachnoid hemorrhage. The mean angiographic follow-up of 34 patients was 41.8 months (range, 3-120 mo). During this follow-up period, no patient's aneurysm changed in size or configuration. CONCLUSION: Wrapping or clip-wrapping of unclippable intracranial aneurysms is safe and seems to confer protection against aneurysmal growth or subarachnoid hemorrhage.

Adolescent↗
PubMed2006

Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling.

OBJECTIVE: Recovery of posterior communicating artery aneurysm-induced oculomotor nerve palsy (ONP) after aneurysm coiling has been reported. However, the coil mass may compromise recovery of the nerve. Therefore, we compared the outcome of coiling and clipping for this indication. METHODS: We retrospectively compared the outcomes of ONP in 13 patients, six of whom underwent endovascular coiling and seven of whom underwent surgical clipping. RESULTS: Six of the seven surgical patients with ONP recovered completely, compared with two of the six patients in the endovascular group. Of the patients with more than 1 year of follow-up, all six surgical patients recovered completely, compared with two of four endovascular patients (P = 0.05). In addition, preoperative complete or partial ONP also was associated with degree of resolution by survival analysis (P = 0.03). All patients with partial ONP in the surgical group and two of three patients in the endovascular group recovered without residual deficits, whereas three of the four patients with complete ONP in the clipping group and none in the coiling group recovered completely. Regardless of the treatment method, time to complete resolution of ONP was 6 months in both groups. CONCLUSION: Clipping posterior communicating artery aneurysms was associated with a higher probability of complete recovery from ONP than coiling. Degree of preoperative ONP also affected recovery. If patients can tolerate surgery, it should be considered the treatment of choice.

Adult↗
PubMed2006

The pterional-transsylvian approach: an analytical study.

OBJECTIVE: Splitting of the sylvian fissure (SF) improves exposure with the pterional (PT) approach. Traditionally, the choice of whether or not to split the SF and how far to open it has depended on the neurosurgeon's experience and preference rather than on quantifiable data. We undertook this study to evaluate the effects of progressive splitting of the SF on surgical exposure with the PT approach. METHODS: A PT craniotomy was performed on nine sides of cadaver heads. Splitting the SF was divided into four steps: 1) dissection of the basal cisterns, 2) dissection of the sphenoidal compartment, 3) dissection of the operculoinsular compartment to the anterior ascendant ramus, and 4) dissection progressing 2.0 cm distal to the anterior ascendant ramus. The degree of the retraction and the relative position of the brain retractors were kept constant. After each step, we used a computerized tracking system to measure the area of surgical exposure of the circle of Willis, the angles of approach to the carotid bifurcation, and the distance between the frontal lobe and skull base. RESULTS: Exposure of the circle of Willis, angles of approach to the carotid bifurcation, and linear distance between the frontal lobe and skull base all increased significantly as splitting of the SF progressed from Steps 1 to 2 and from Steps 2 to 3. There was no significant difference between Steps 3 and 4. CONCLUSION: Exposure of the basal cisterns and circle of Willis by the PT approach is optimized when dissection of the SF reaches the anterior ascendant ramus. Further splitting of the SF provides no additional gain.

Cadaver↗
PubMed2006

Anatomical and quantitative description of the transcavernous approach to interpeduncular and prepontine cisterns. Technical note.

OBJECT: The management of wide-necked, giant, or unsuccessfully coil-treated basilar apex aneurysms requires a wide exposure, for both working area and linear visualization of the basilar artery (BA). Cranial-based approaches, such as the transcavernous approach, have been proposed to deal with such aneurysms; whether abbreviated forms of this approach might provide similar exposure remains controversial. The authors examine this issue quantitatively. METHODS: Four alcohol-preserved cadaveric heads injected with pigmented silicone were prepared for bilateral dissection. After completing an orbitozygomatic craniotomy, the surgeons worked in a reverse direction, performing the transcavernous approach in five steps: 1) posterior clinoidectomy; 2) cavernous sinus opening; 3) anterior clinoidectomy; 4) cutting of the distal dural ring; and 5) cutting of the proximal dural ring. Performing the complete transcavernous approach significantly increased the working area and linear exposure of the BA compared with abbreviated forms of the approach (p < 0.05). Opening the roof of the cavernous sinus significantly increased the working area compared with posterior clinoidectomy alone (p = 0.014); however, additional gains in exposure required completing the transcavernous approach. Resection of the anterior clinoid process combined with opening of only the distal dural ring did not significantly increase the working area or linear exposure of the BA. CONCLUSIONS: The complete transcavernous approach significantly increases the working area and linear exposure of the BA compared with the more conservative forms of approach.

Basilar Artery↗
PubMed2006

Surgical management of arteriovenous malformations in children.

OBJECT: Children compose 3 to 20% of the patients with arteriovenous malformations (AVMs); however, AVMs are responsible for 30 to 50% of intracranial hemorrhages in children. METHODS: The medical records of 82 children with 84 AVMs treated surgically between 1983 and 2005 were reviewed. Fifty-two patients (63%) presented with hemorrhage, 13.4% presented with seizures, and AVMs in 12% were found incidentally. Patients with brainstem lesions presented at a significantly younger age (p = 0.002) than those harboring lesions in other locations. Frontal lobe lesions were significantly smaller than those in other locations, and thalamic lesions were significantly larger (p = 0.012 and 0.005, respectively). Most patients with Spetzler-Martin Grades I to III lesions underwent craniotomy only. Half of the patients with Grade IV and V lesions underwent embolization, craniotomy, and radiosurgery. The mean follow-up period was 43 months. Postoperatively, the initial obliteration rate was 65%, with a long-term obliteration rate of 90%. The perioperative mortality rate was 3.7%. Altogether, 81% of patients had excellent outcomes, and patients with Grade I lesions had the best outcomes. Of the 52 patients who presented with hemorrhage, 17% had fair or poor outcomes. The recurrence rate was 5.6%. CONCLUSIONS: Children with AVMs may be more prone than adults to present with a hemorrhage and to experience recurrence of the lesion after treatment. The authors favor resection for most AVMs in children and use embolization as a preoperative strategy for Grades II to V lesions treated surgically. Prehemorrhagic Grade IV and V lesions may best be treated conservatively and observed carefully for the development of symptoms. Long-term follow up of all patients is essential.

Cerebral Hemorrhage↗
PubMed2005

Tandem practice model: a model for physician-nurse practitioner collaboration in a specialty practice, neurosurgery.

PURPOSE: To describe the benefits of a physician-nurse practitioner (NP) collaborative practice model, specifically that of a tandem practice model, using a neurosurgeon and a primary care NP in the clinic and inpatient setting. DATA SOURCES: Selected journal articles from Medline and CINAHL, and anecdotal clinical experience. CONCLUSIONS: This collaborative practice model, in which the physician and NP deliver patient care in tandem, is beneficial to patients and their families because they receive comprehensive care that is patient oriented and holistic. Further, the model benefits multiple disciplines across the healthcare continuum by providing efficient communication of patient needs, accessibility of the specialty team, and timely implementation of patient interventions. The collaboration of the physician specialist and primary care NP provides a holistic approach to the care of diverse and challenging patient populations. IMPLICATIONS FOR PRACTICE: Patients seen in a specialty practice, particularly that of neurosurgery, often have little understanding of their problem and may be frightened or confused because of their perceptions of the unknown. Providing care to such specialized patient populations in a constantly changing healthcare environment may prove demanding to the specialist. The introduction of a primary care NP into such specialty settings offers patients, their families, consultants, and staff members an additional resource for evaluation, intervention, education, and communication, improving the continuity and comprehensiveness of care to challenging patient populations. This model is an option for physician specialists interested in augmenting their practice and provides further resources for meeting the holistic needs of selected patient populations regardless of the setting.

Attitude of Health Personnel↗
PubMed2005

Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex.

OBJECTIVE: To compare the angles of approach and area of exposure to the anterior communicating artery (AComA) complex associated with pterional (PT), orbitopterional (OPT), and orbitozygomatic (OZ) craniotomies before and after gyrus rectus resection. METHODS: PT, OPT, and OZ craniotomies were performed on both sides of four heads, and the angles of approach and area of exposure to the AComA complex were measured before and after resection of the gyrus rectus. RESULTS: The vertical angle of approach increased significantly among the PT and OPT (P = 0.001), PT and OZ (P = 0.001), and OPT and OZ approaches (P = 0.005). The horizontal angle of approach was significantly larger between the PT to OPT (P = 0.001) and PT to OZ (P = 0.001) approaches but not between the OPT and OZ approaches (P = 0.757). After gyrus rectus resection, the vertical and horizontal angles of approach increased significantly for the PT approach but not for the OPT and OZ approaches. The area of exposure to the AComA complex increased progressively from the PT to OPT to OZ approach but did not reach statistical significance (P = 0.124). Resection of the gyrus rectus resulted in significant relative gains in the area of exposure for the PT (P = 0.01) and OPT (P = 0.04) approaches but not for the OZ approach (P = 0.88). CONCLUSION: The vertical and horizontal angles of approach to the AComA complex are significantly larger for the OPT and OZ approaches compared with the PT approach. Use of the OZ approach may decrease the need for frontal lobe retraction and resection of the gyrus rectus.

Anterior Cerebral Artery↗
PubMed2005

Microsurgical anatomy of the transcallosal anterior interforniceal approach to the third ventricle.

OBJECTIVE: We explored relevant regional microanatomy as it relates to the challenging anterior interforniceal (AIF) approach for removing hypothalamic hamartomas. METHODS: Five silicone-injected cadaveric heads were dissected by use of frameless stereotactic navigation to reveal microanatomy and extent of exposure through the transcallosal AIF approach. Distances between trajectories to the coronal suture and the genu of the corpus callosum (CC) and between the posterior border of the anterior commissure to the lower end of the rostrum of the CC and posterior border of the foramen of Monro were measured. RESULTS: The AIF approach provided adequate access to the anterior third ventricle and related structures (i.e., hypothalamus, infundibular recess, and mamillary bodies) through the corridor bounded by the anterior commissure anteriorly and the choroid plexus at the foramen of Monro posteriorly. The mean distances from the posterior trajectory to the coronal suture and the genu of the CC were 44.8 mm (range, 43.8-46.2 mm) and 14.88 mm (14.1-15.7 mm), respectively. The mean distance from the anterior trajectory posterior to the coronal suture was 4.66 mm (0-8.9 mm), and 32.6 mm (30.5-33.9 mm) to the genu of the CC. The mean length of callosotomy was 17.52 mm (16.2-19.1 mm). The mean distance between the posterior border of the anterior commissure and the lower end of the rostrum of the CC was 5.22 mm (4.6-5.6 mm), and 10.52 mm (9.7-11.5 mm) to the posterior border of the foramen of Monro. CONCLUSION: The technically safe AIF approach permitted limited interforniceal splitting, no major deep vein manipulation, and adequate visualization of the hypothalamus, infundibular recess, and mamillary bodies.

Cadaver↗
PubMed2005

Microsurgical anatomy and quantitative analysis of the transtemporal-transchoroidal fissure approach to the ambient cistern.

OBJECTIVE: Surgical approaches to ambient cistern lesions are complex. We investigated the microanatomy of the transtemporal-transchoroidal fissure approach to the ambient cistern with emphasis on exposure of the posterior cerebral artery. METHODS: Dissections were performed bilaterally in five silicone-injected cadaveric heads. Critical anatomic distances, specifically with reference to the P2 segment of posterior cerebral artery in relation to the inferior choroidal point and P2-P3 junction, were measured with digital calipers. Other landmarks (temporal lobe tip, points from the temporal base to the choroidal fissure) were included for quantitative analysis. RESULTS: The transtemporal-transchoroidal fissure approach provided adequate exposure of the ambient cistern, minimized temporal lobe retraction, and allowed assessment of regional microanatomy. The mean distance from the temporal base to the choroidal fissure measured 18.09 mm (range, 16.9-21.9 mm). The distances from the choroidal fissure to P2 varied at the coronal plane of the inferior choroidal point (mean, 6.96 mm; range, 3.6-12.0 mm) and the P2-P3 junction (mean, 6.02 mm; range, 4.3-6.9 mm), respectively. CONCLUSION: The transtemporal-transchoroidal fissure approach provides a corridor to the ambient cistern and P2-P3 junction while minimizing temporal lobe retraction and avoiding interruption of temporal lobe venous drainage. Because of widely variable vascular anatomy, access to posterior cerebral artery lesions using this approach requires preoperative imaging to identify the specific location of the P2-P3 junction.

Arachnoid↗
PubMed2005

Spontaneous spinal subarachnoid hemorrhage secondary to spinal aneurysms: diagnosis and treatment paradigm.

INTRODUCTION: Isolated spinal aneurysms are rare; only a few have been reported. To the best of our knowledge, this series represents the largest experience with four ruptured spinal aneurysms, all of which were treated surgically. METHODS: Clinical information from the hospital charts and diagnostic images of four patients with the diagnosis of spinal aneurysms were reviewed from the senior authors' (RFS, JMZ) office database, surgical reports, and radiological imaging database. Follow-up examinations were performed by phone interview, when possible, and by chart review. RESULTS: Between 1997 and 2004, four patients with ruptured spinal aneurysms underwent surgical treatment. All aneurysms were located within the spinal canal and manifested with spinal subarachnoid hemorrhage. No collagen disease, aortic coartaction, arteriovenous fistula, or arteriovenous malformations were identified in these patients. CONCLUSION: Subarachnoid hemorrhage within the spinal cord can be caused by ruptured aneurysms. Spinal aneurysms are rare, but should be considered within the differential diagnosis of patients with intracranial subarachnoid hemorrhage when cranial angiography is negative. Magnetic resonance imaging and selective spinal angiography are useful for workup, but definitive diagnosis may require surgical exploration.

Adult↗
PubMed2005

Microvascular decompression after gamma knife surgery for trigeminal neuralgia: intraoperative findings and treatment outcomes.

OBJECT: The authors sought to determine whether the results of trigeminal microvascular decompression (MVD) are influenced by prior gamma knife surgery (GKS). METHODS: Gamma knife surgery is an established procedure for treating medically intractable trigeminal neuralgia but failures do occur. The authors assessed six patients (two men and four women; mean age 52 years) who experienced pain recurrence after GKS and elected to undergo trigeminal MVD via retrosigmoid craniotomy. Three patients underwent a single GKS to a maximal dose of 80 Gy, whereas three others underwent a second GKS to total of 120 to 135 Gy. At surgery, none of the six patients demonstrated excess arachnoid thickening, grossly apparent changes in the nerve itself, or any other tissue alterations that made successful mobilization of a blood vessel from the trigeminal root entry zone technically more difficult. A single individual had a small atherosclerotic plaque in the superior cerebellar artery near its contact point with the trigeminal nerve. Follow up at a mean of 25.4 months (range 7.5-42 months) indicated that five patients were pain free. One patient had improved but still relied on medications for pain control. CONCLUSIONS: In the authors' experience, trigeminal MVD can be performed without added difficulty in patients who have previously undergone GKS. The success rates seem similar to those normally associated with MVD. Patients who elect the less invasive option of GKS can be assured that trigeminal MVD remains a viable alternative at a later date if further surgery is required.

Adult↗
PubMed2005

Incidence of superficial sylvian vein compromise and postoperative effects on CT imaging after surgical clipping of middle cerebral artery aneurysms.

BACKGROUND AND PURPOSE: Dissection and retraction of the sylvian fissure can cause venous insufficiency and may be an important contributor to postoperative edema or hemorrhage after clipping of a middle cerebral artery (MCA) aneurysm. The incidence of changes in the superficial middle cerebral vein (SMCV) and adjacent veins and whether such changes increase the amount of edema or hemorrhage on postoperative CT is the focus of this study. METHODS: Pre- and postoperative angiograms of 100 consecutive patients with MCA aneurysms treated by craniotomy and clipping were compared to determine the postoperative incidence of changes involving the SMCV. CTs from the normal and abnormal postoperative venous groups were compared to determine the amount of edema or presence of parenchymal hemorrhage. RESULTS: Postoperatively, 31 (31%) SMCVs were altered, 20 to a minor or moderate degree. Eleven cases were pronounced. In 9 (9%) cases, the SMCV was completely obscured or failed to fill on postoperative angiography. More edema (observer 1, P < .0002; observer 2, P < .0006) and small brain parenchymal hemorrhages (observer 1, P < .00003; observer 2, P < .00001) were found on the postoperative CT images of the group whose SMCVs were altered than those that were unchanged. CONCLUSIONS: Neurosurgeons and neuroradiologists should be attentive to changes in the SMCV and adjacent venous structures to optimize outcomes of procedures involving the sylvian fissure.

Brain Edema↗
PubMed2005

Subarachnoid hemorrhage due to isolated spinal artery aneurysm in four patients.

Spinal artery aneurysms are usually found with arteriovenous malformations or other entities that increase hemodynamic stress. Isolated spinal artery aneurysms are rare. Four patients who presented with the acute onset of lower back pain underwent MR imaging, which revealed spinal subarachnoid hemorrhage. In all patients, work-up yielded a diagnosis of isolated spinal aneurysm, and operative treatment was successful. In the appropriate clinical setting, spinal aneurysm should be considered as a possible cause of spinal subarachnoid hemorrhage.

Adult↗
PubMed2004

Combined endovascular and microsurgical management of giant and complex unruptured aneurysms.

OBJECT: The purpose of this study was to assess the efficacy and describe the technical features of combined endovascular and microsurgical treatments for complex and giant unruptured intracranial aneurysms. METHODS: A prospectively maintained database was reviewed to identify all patients with unruptured intracranial aneurysms who were treated with combined techniques. Twenty-one lesions were treated in as many patients: six lesions involved the posterior cerebral artery (PCA); seven the cavernous portion of the internal carotid artery (ICA); two the basilar apex; two the basilar trunk; and one each the anterior communicating artery, anterior cerebral artery, petrous ICA, and cervical ICA. Aneurysms were treated with combined extracranial-intracranial bypass procedures and parent-vessel occlusion, flow redirection, or arterial transposition. Aneurysm occlusion was achieved in 20 patients. In the remaining patient the aneurysm recurred, requiring stent-assisted repeated coil placement. Three patients suffered permanent neurological deficits related to treatment, and three died, two of whom had basilar trunk aneurysms. CONCLUSIONS: Certain complex aneurysms may be treated optimally by combining endovascular and surgical procedures. A low incidence of complications follows treatment of anterior circulation aneurysms. Treatment of complex posterior circulation aneurysms is associated with a higher incidence of complications, although this likely reflects the more complex nature of these lesions. The risks of this combined treatment strategy are likely lower than the risks associated with the natural history of this subset of aneurysms.

Adult↗