Biomedical subjects

Robert D Ecker

Publications and source records attributed to Robert D Ecker.

At least 19 recordsLinked to original sources

PubMed2007

Same-segment and adjacent-segment disease following posterior cervical foraminotomy.

OBJECT: The cervical foraminotomy was pioneered in the 1940s to address radicular symptoms via a posterior approach, but the long-term outcome has not been adequately studied. METHODS: The authors retrospectively analyzed data obtained from 303 patients (188 male and 115 female, mean age 49.2 years) who had consecutively undergone a single-level posterior foraminotomy for cervical radiculopathy between 1972 and 1992. The median follow-up duration was 7.1 years. The major end point studied was the development of symptomatic adjacent- or same-segment disease. Incidence rates per 1000 person-years were calculated, and the natural history of the disease was predicted using Kaplan-Meier survivorship analysis. In 15 (4.9%) of 303 patients, symptomatic adjacent-segment disease developed, yielding a rate of 6.4/1000 person-years at risk. This included nine (2.9%) of 303 patients requiring reoperation, yielding a rate of 3.8/1000 person-years. Kaplan-Meier survivorship analysis suggested a relatively stable annual 0.7% rate for developing adjacent-segment disease, with a 10-year rate of 6.7%. Ten patients developed same-segment disease, yielding a risk rate of 3.9/1000 person-years. Kaplan-Meier survivorship analysis demonstrated a 5- and 10-year risk rate of developing same-segment disease of 3.2 and 5.0%, respectively. CONCLUSIONS: Although additional study is needed, analysis of the present data suggests that posterior foraminotomy is associated with a low rate of same- and adjacent-segment disease.

Female↗

PubMed2006

Reversal of a 30-h fixed deficit with carotid angioplasty and stenting: technical note.

We describe the case of an 82-year-old man with a fixed neurological deficit of 30 h duration. A left hemispheric perfusion deficit was found on perfusion/diffusion imaging studies in conjunction with an ipsilateral carotid stenosis documented by cerebral angiography. Carotid angioplasty with stent placement was performed and resulted in dramatic clinical improvement. Carotid stenosis can cause acute hemodynamic hypoperfusion with a symptomatic reversible clinical deficit.

Aged, 80 and over↗

PubMed2006

Intravascular ultrasound identification of intraluminal embolic plaque material during carotid angioplasty with stenting.

INTRODUCTION: Carotid angioplasty with stenting (CAS) has evolved as a viable method for treating patients at high risk for carotid endarterectomy. Strokes complicating CAS are most commonly caused by the liberation and distal embolization of embolic material from plaque during the procedure. METHODS: CAS with distal embolic protection (DEP) was performed using the assistance of intravascular ultrasound (IVUS) in a 68-year-old man with asymptomatic carotid artery stenosis. Evaluation of the plaque pretreatment was performed using virtual histology software. IVUS evaluation was also performed after prestent angioplasty, stenting, and poststent angioplasty. RESULTS: Initial degree of angiographic stenosis was 78.9%. Final degree of stenosis was 15.7%. By IVUS, stenosis by minimum lumen diameter and minimum lumen area were 75.6% and 93.4% pretreatment, respectively, and 42.2% and 47.1% posttreatment, respectively. An intraluminal lesion was noted in the distal aspect of the stent after poststent angioplasty but before DEP device removal. Ultrasonographic characteristics of the intraluminal defect were consistent with ruptured plaque material. Angiographic runs failed to demonstrate the lesion. A repeat IVUS run performed approximately 10 min later failed to depict the lesion, suggesting that distal embolization had occurred. Embolic material was noticed in the DEP device after removal. The patient did not experience any ischemic neurological symptoms. CONCLUSIONS: IVUS can identify intraluminal plaque material, which may be a precursor for embolism and delayed ischemic events after CAS. IVUS may allow for treatment before distal embolization of plaque material. Virtual histology IVUS software may help to identify carotid lesions at higher risk for significant embolization during CAS.

Aged↗

PubMed2006

Acute M2 bifurcation stenting for cerebral infarction: lessons learned from the heart: technical case report.

OBJECTIVE AND IMPORTANCE: Acute ischemic stroke is the third leading cause of death in the United States. For patients with NIHSS scores >10 and evaluated within 6 hours, intra-arterial thrombolysis is the treatment of choice. The Merci retriever (Concentric Medical Inc., Mountain View, CA) and IV TPA are currently the only FDA-approved treatments for acute ischemic stroke. For patients who do not meet the criteria for TPA administration and/or in whom the Merci device fails, options are limited. Intracranial stenting for acute ischemic stroke after failed thrombolysis is now possible because of improved delivery systems and appropriately sized stents. CLINICAL PRESENTATION: A 26-year-old woman presented with an NIHSS score of 11 (right-sided hemiparesis and mixed aphasia) 4 hours from the time of symptom onset. CT perfusion demonstrated increased time to peak in the entire left hemisphere; conventional angiography demonstrated a left M1 occlusion. INTERVENTION: After crossing the occlusion with a microcatheter, reteplase (2 units) was administered into the clot. Mechanical thrombolysis was then attempted, without restoration of flow. Two 3 x 12-mm coronary stents were placed from the M1 into the superior and inferior divisions, respectively, with complete restoration of flow (TIMI 3). Within 72 hours, the patient had an NIHSS score of 1, with a small infarction in the external capsule. CONCLUSION: Novel stroke interventions need to be developed for patients with acute ischemic stroke in whom traditional interventions fail. We present (to our knowledge) the first case of successful revascularization of an acute M1 occlusion accomplished with placement of two coronary stents.

Adult↗

PubMed2006

Stent-assisted intracranial recanalization for acute stroke: early results.

OBJECTIVE: In patients who are not candidates for intravenous tissue plasminogen activator, intra-arterial (IA) therapy is an alternative. Current recanalization rates are 50 to 60% for IA thrombolysis. Stent-assisted recanalization in the setting of acute stroke after failed thrombolysis may improve recanalization rates. METHODS: A retrospective analysis was performed of 19 patients treated at two institutions between July 2001 and March, 2005 with intracranial stenting of a vessel resistant to standard thrombolytic techniques. Demographics, clinical, and radiographic presentation and outcomes were studied. RESULTS: Thirteen men and six women with a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 16 (range, 15-22) were included. Eight lesions were located at the internal carotid artery terminus, seven in the M1/M2 segment, and four in the basilar artery. Average time-to-treatment was 210 +/- 160 minutes. Overall recanalization rate (Thrombolysis in Cerebral Infarction Grade 2 or 3) was 79%. There were six deaths: five due to progression of stroke and withdrawal of care at the family's request and one as the result of a delayed carotid injury after tracheostomy. One postoperative asymptomatic intracranial hemorrhage occurred without adverse affect on outcome. Median discharge NIHSS score of surviving patients was 5 (range, 2.5-11.5). Lesions at the internal carotid artery terminus (P < 0.009), older age (P < 0.003), and higher baseline NIHSS score (P < 0.009) were significant negative outcome predictors, as measured by >3 modified Rankin scale score at discharge. CONCLUSION: Stent-assisted recanalization for acute stroke resulting from intracranial thrombotic occlusion is associated with a high recanalization rate and low intracranial hemorrhage rate. These initial results suggest that stenting may be an option for recalcitrant cerebral arterial occlusions.

Adult↗

PubMed2006

Current concepts in the management of intracranial atherosclerotic disease.

Medically refractory, symptomatic intracranial atherosclerotic disease has a poor prognosis. Based on the results of the Warfarin-Aspirin Symptomatic Intracranial Disease study, the risk of ipsilateral stroke at 1.8 years is between 13 and 14% in patients with symptomatic intracranial atherosclerosis. Synergistic advances in intracranial angioplasty and stenting, modern neuroimaging techniques, and periprocedural and postprocedural antithrombotic regimens are creating new models for the diagnosis and successful endovascular treatment of intracranial stenosis. In this article, the most recent clinical developments and concepts for the diagnosis and endovascular treatment of intracranial atherosclerotic disease are discussed.

Angioplasty↗

PubMed2006

Workforce needs for endovascular neurosurgery.

During the past decade, endovascular techniques and clinical experience have matured to the point that all or a significant part of the treatment of acute ischemic stroke, cerebral aneurysms, brachiocephalic occlusive disease, and arteriovenous fistulae or malformations is performed in angiography suites by neuroradiologists, vascular surgeons, peripheral interventionists, cardiologists, neurologists, and neurosurgeons worldwide. With improvements in technology and lower morbidity rates, the scope of endovascular techniques will only increase. Currently, in the United States alone, this amounts to a volume of more than 500,000 patients annually. Neurosurgeons currently provide only a small portion of the care of these patients. The workforce needs for endovascular surgeons in neurosurgery will be determined by the patients, the willingness of neurosurgeons to embrace endovascular techniques, and the broad scope of cerebrovascular disorders that can be treated.

Career Mobility↗

PubMed2005

Toward clinical equipoise: the current case for carotid angioplasty and stent placement.

Recent advances in carotid artery (CA) stent placement procedures have propelled this technology into the forefront of treatment options for both symptomatic and asymptomatic patients with CA stenosis. Until recently, endarterectomy was the only surgical option for patients with CA occlusive disease. For high-risk surgical candidates, periprocedural stroke rates remained unacceptable and were significantly higher than those associated with the natural history of the disease. Advances in stent technology and improvements in antiplatelet and antithrombotic regimens, in conjunction with distal protection devices, have significantly lowered the risk of periprocedural complications for high-risk surgical candidates requiring CA revascularization. In this paper the authors review data gleaned from the important recent CA stent trials and address questions concerning the safety, efficacy, and durability of stent-assisted angioplasty for extracranial CA occlusive disease. Additionally, they review the role of noninvasive imaging modalities for the diagnosis and surveillance of CA disease in these high-risk patients.

Angioplasty↗

PubMed2005

Endovascular management of carotid artery disease after radiation therapy and radical neck dissection.

OBJECT: More patients with head and neck cancers who undergo radical neck dissection and adjuvant radiation are experiencing prolonged survival times. Because of their improved survival, patients are living long enough to suffer the delayed effects of radiation therapy. Radiation-induced carotid artery (CA) stenosis in patients with or without radical neck dissection often requires extensive exposure and vessel reconstruction. The aim of this study was to evaluate the efficacy of endovascular treatment as an alternative therapy for radiation-induced CA stenosis. METHODS: Coinciding with the improved longevity of these patients, CA angioplasty and stent placement has become a definitive treatment strategy for this particularly challenging group of individuals. Long lesions are easily addressed with multiple telescoped stents. The tendency toward early restenosis can now be addressed with cutting balloon angioplasty. A review of the authors' institutional database yielded five patients (four men and one woman) with a history of radiation treatment ipsilateral to their CA stenosis. Three of five patients were symptomatic, and the interval between radiation therapy and endovascular treatment ranged from 1 to 47 years (mean 16.6 years). Four of the five patients were treated using distal embolic protection devices, and all patients underwent balloon dilation after stent placement. CONCLUSIONS: As advancements are made in the technology and techniques for CA angioplasty and stent placement, the safety and durability of treatments in patients with radiation-induced atherosclerotic disease will improve.

Aged↗

PubMed2005

Recent advances in endoluminal revascularization for intracranial atherosclerotic disease.

More than 750,000 strokes occur annually in the United States. Of these, 8-10% are due to intracranial atherosclerosis. Less than 50% of patients with strokes from intracranial atherosclerosis will have a transient ischemic attack. For those patients with symptomatic intracranial atherosclerosis, the prognosis is poor; and the recent Warfarin-Aspirin Symptomatic Intracranial Stenosis (WASID) trial results have demonstrated the high risk of warfarin without clear benefit. Intracranial angioplasty and stenting is emerging as a viable and effective treatment alternative for patients with symptomatic intracranial stenosis. Advances in stent design, endovascular wires, and catheters and balloons are allowing endovascular surgeons to safely treat intracranial atherosclerosis. Wider clinical experience has led to refinement of patient selection and endoluminal techniques. Drug eluting-stents have the promise of decreasing the risk of restenosis. In this review, the most recent clinical, laboratory, and technical details for the treatment of intracranial angioplasty and stenting are discussed.

Endarterectomy↗

PubMed2005

Diagnosis and treatment of vertebral column metastases.

The vertebral column is recognized as the most common site for bony metastases in patients with systemic malignancy. Patients with metastatic spinal tumors may present with pain, neurologic deficit, or both. Some tumors are asymptomatic and are detected during screening examinations. Treatment options include medical therapy, surgery, and radiation. However, diversity of patient condition, tumor pathology, and anatomical extent of disease complicate broad generalizations for treatment. Historically, surgery was considered the most appropriate initial therapy in patients with spinal metastasis with the goal of eradication of gross disease. However, such an aggressive approach has not been practical for many patients. Now, operative intervention is often palliative, with pain control and maintenance of function and stability the major goals. Surgery is reserved for neurologic compromise, radiation failure, spinal instability, or uncertain diagnosis. Recent literature has revealed that surgical outcomes have improved with advances in surgical technique, including refinement of anterior, lateral, posterolateral, and various approaches to the anterior spine, where most metastatic disease is located. We review these surgical approaches for which a team of surgeons often is needed, including neurosurgeons and orthopedic, general, vascular, and thoracic surgeons. Overall, a multimodality approach is useful in caring for these patients. It is important that clinicians are aware of the various therapeutic options and their indications. The optimal treatment of individual patients with spinal metastases should include consideration of their neurologic status, anatomical extent of disease, general health, age, and qualilty of life.

Back Pain↗

PubMed2005

Perforation of external carotid artery branch arteries during endoluminal carotid revascularization procedures: consequences and management.

The purpose of this article is to describe several inadvertent perforations of external carotid artery branches that occurred in our laboratory during planned carotid artery stenting procedures. When known, the mechanism of the perforation is described. The treatment of these complications is discussed, along with a more general discussion of potential embolic materials. Perforation of branch arteries within the external carotid artery territory during planned carotid revascularization is an uncommon but potentially life-threatening complication. This complication can occur as a result of wire or catheter placement into these vessels. Early recognition of the perforation, prompt treatment of the bleeding, and control of the patient's airway are necessary to avoid a potentially catastrophic outcome.

Aged↗

PubMed2004

Natural history of unruptured intracranial aneurysms.

Since the publication of the retrospective part of the International Study of Unruptured Intracranial Aneurysms (ISUIA) in 1998, there has been a significant focus in the neurosurgical literature on the natural history of these lesions. The prospective data from the second part of the ISUIA, which was published in 2003, provided further evidence that small, asymptomatic intracranial aneurysms may have a more benign course than previously believed. With the data from the ISUIA as a reference point, in this paper the authors strive to provide a source of practical clinical data to aid cerebrovascular physicians in the initial decision to treat or observe a patient with a small, asymptomatic intracranial aneurysm. The issues covered will include previous rupture, symptoms other than rupture, aneurysm size, site, and aspect ratio. It is the authors' goal to provide a useful practical framework on the relevant clinical issues as an aid to practitioners treating patients who present with intracranial aneurysms.

Humans↗

PubMed2004

Does famotidine induce thrombocytopenia in neurosurgical patients?

The incidence of thrombocytopenia in neurosurgical patients prescribed famotidine is unknown. Using hospital records of neurosurgery patients treated between July 2001 and July 2002, a retrospective cohort study was performed comparing platelet counts in patients treated with famotidine with a similar group of patients who were not prescribed an H2 antagonist. Patients were excluded if: 1) platelets were less than 150,000 prior to famotidine administration; 2) pre-drug and post-drug platelets were not drawn; 3) they were concurrently taking a potential thrombocytopenic inducing drug; or 4) disseminated intravascular coagulation, thrombocytopenic purpura, or any other confounding hematologic disorder developed. Seventeen of 50 (34%) patients on famotidine developed thrombocytopenia compared with 11 of 98 (11.2%) of those untreated (P = 0.002). In this retrospective study, neurosurgical patients on famotidine developed thrombocytopenia statistically significantly more often than those untreated. Although no clinically significant sequelae developed as a result of the thrombocytopenia, if these findings are confirmed by a prospective study, proton pump inhibitors and sucralfate, with their similar efficacy, may be a better choice for gastrointestinal prophylaxis in neurosurgical patients.

Adult↗

PubMed2004

Recurrent subependymoma treated with radiosurgery.

PURPOSE: Subependymomas are rare, slow-growing intracranial neoplasms of the subependymal matrix. We document a successful case of radiosurgical treatment of a multiply recurrent subependymoma. MATERIALS AND METHODS: A nineteen-year-old male developed a recurrent fourth ventricular subependymoma after 6 resections, fractionated radiation therapy (50.4 Gy) and chemotherapy. In addition, a lesion consistent with a cavernous malformation (CM) was noted adjacent to the tumor within the previously irradiated region. RESULTS: Stereotactic radiosurgery was performed covering both the subependymoma and the presumed CM. Fifty-four months after radiosurgery, both lesions had decreased in size and the patient remained neurologically unchanged. CONCLUSIONS: Subependymoma may be added to the list of primary glial neoplasms that have been successfully managed with stereotactic radiosurgery. Also, we add a case of presumed CM following radiation therapy to the literature.

Adult↗

PubMed2004

Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy.

OBJECT: Definitive data characterizing the safety and efficacy of carotid angioplasty with stent placement (CAS) for symptomatic, occlusive carotid artery (CA) disease require further refinements and standardization of techniques as well as large prospective studies on a par with the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Despite the absence of such data, many surgeons have performed angioplasty and stent placement in patients with clinical or anatomical features known to add significant perioperative risk and capable of disqualifying the patients from participation in NASCET: There exists no cost analysis comparing high-risk endarterectomy with percutaneous angioplasty and stent insertion. METHODS: Forty-five patients (29 men and 16 women) with high-risk, symptomatic CA stenosis have been treated with CAS at the authors' institution since 1996. Indications for this procedure included symptomatic recurrent stenosis following CA endarterectomy (CEA), active coronary disease, high CA bifurcation, and severe medical comorbidities. A longstanding CEA computer database was screened for control patients with similar risk factors; 391 patients (276 men and 115 women) were identified. Actual cost data, duration of hospital stay, and relevant clinical data from the time of treatment until hospital discharge were collected in each patient. The median total cost of CAS was dollar 10,628, whereas that for CEA was dollar 10,148 (p = 0.495). CONCLUSIONS: In patients with high-risk, NASCET-ineligible CA stenosis there was no overall statistically significant cost difference between CEA and CAS. Given that there may not be a cost advantage for either procedure, procedural risk, efficacy, and durability should be key factors in determining the optimal treatment strategy.

Aged↗

PubMed2003

Durability of carotid endarterectomy.

BACKGROUND AND PURPOSE: We sought to determine the incidence of recurrent stenosis after carotid endarterectomy. METHODS: One thousand consecutive carotid endarterectomy patients were followed prospectively. The surgery was performed in a standard fashion. Cerebral protection was provided with intraoperative electroencephalographic monitoring and selective shunting. All arteriotomies were repaired with a patch graft. Each patient was seen 3 months after surgery and then yearly, with a duplex ultrasound obtained at each visit. Evidence for new ischemic events or recurrent stenosis of >or=70% was recorded. RESULTS: The 30-day combined minor and major stroke and death rate was 1.9%. At 7.1-year follow-up, 0.1% of patients had recurrent stenosis >or=70%, the majority of which were asymptomatic. CONCLUSIONS: Carotid endarterectomy is a low-risk procedure for the treatment of carotid occlusive disease, with excellent long-term durability. Although less invasive, carotid angioplasty must demonstrate equal robustness in long-term follow-up before it is considered a routine alternative to surgery.

Aged↗

PubMed2003

Delayed ischemic deficit after resection of a large intracranial dermoid: case report and review of the literature.

OBJECTIVE AND IMPORTANCE: A unique case of delayed ischemic deficit after resection of a large intracranial dermoid is presented. CLINICAL PRESENTATION: A 23-year-old woman, 36 hours after the uneventful gross total resection of a large intracranial dermoid cyst, slowly developed a progressive mixed aphasia and right hemiparesis. Magnetic resonance imaging and magnetic resonance angiography revealed small infarcts of the left putamen and temporal-occipital junction and a vasospastic tapering of the left M1 segment. INTERVENTION: Angiography confirmed severe vasospastic tapering of the left M1 and M2 segments. Endovascular treatment successfully restored flow in the left superior division. However, the initial attempt at low-pressure dilation of the inferior division led to vessel rupture. Seven months after reoperation for emergent trapping of the M1 segment, the patient made an excellent recovery, with only mild right-hand incoordination. CONCLUSION: Ruptured dermoid cysts are a risk for early and delayed cerebral ischemia, and endovascular treatment of dermoid-encased vessels may carry a higher risk for rupture.

Adult↗