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Jonathan J Russin - One of the best experts on this subject based on the ideXlab platform.
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rescue Cerebral Revascularization in patients with progressive steno occlusive ischemia of the anterior intracranial circulation
World Neurosurgery, 2020Co-Authors: Jeffrey A Steinberg, Kristine Ravina, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:BACKGROUND: Despite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from Cerebral Revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease. METHODS: A retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle Cerebral artery over a 4-year period (July 2014-July 2018). Surgical and clinical outcomes were recorded. RESULTS: Seventeen patients (average age 62 +/- 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle Cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 +/- 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 +/- 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score >/=4, and 13 (85%) achieved a modified Rankin Scale score
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rescue Cerebral Revascularization in patients with progressive steno occlusive ischemia of the anterior intracranial circulation
World Neurosurgery, 2020Co-Authors: Jeffrey A Steinberg, Kristine Ravina, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:Background Despite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from Cerebral Revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease. Methods A retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle Cerebral artery over a 4-year period (July 2014–July 2018). Surgical and clinical outcomes were recorded. Results Seventeen patients (average age 62 ± 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle Cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 ± 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 ± 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score ≥4, and 13 (85%) achieved a modified Rankin Scale score ≤2. Conclusions Bypass for steno-occlusive disease of the anterior intracranial circulation is a potentially effective treatment for patients with progressive and/or refractory ischemic symptoms, although the complication rate is significant. Optimal patient selection criteria and timing of surgery remain open questions.
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role of botulinum neurotoxin a in Cerebral Revascularization graft vasospasm prevention current state of knowledge
Neurosurgical Focus, 2019Co-Authors: Kristine Ravina, Joseph N Carey, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:: Graft stenosis and occlusion remain formidable complications in Cerebral Revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in Revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for Cerebral Revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.
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ec ic bypass for Cerebral Revascularization following skull base tumor resection current practices and innovations
Journal of Surgical Oncology, 2018Co-Authors: Erik M Wolfswinkel, Mark J Landau, Kristine Ravina, Niels Kokot, Jonathan J Russin, Joseph N CareyAbstract:: Complex skull base tumors can involve critical vessels of the head and neck. To achieve a gross total resection, vessel sacrifice may be necessary. In cases where vessel sacrifice will cause symptomatic Cerebral ischemia, surgical Revascularization is required. The purpose of this paper is to review Cerebral Revascularization for skull base tumors, the indications for these procedures, outcomes, advances, and future directions.
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combined direct and indirect Cerebral Revascularization using local and flow through flaps
Journal of Reconstructive Microsurgery, 2017Co-Authors: Beina Azadgoli, Erik M Wolfswinkel, Jonathan J Russin, Hyuma A Leland, Joshua Bakhsheshian, Joseph N CareyAbstract:Background Extracranial–intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for Cerebral Revascularization as an additional tool to provide direct and indirect Revascularization and/or soft tissue coverage. Methods A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect Revascularization and/or soft tissue reconstruction were performed. Results Indications for arterial bypass included intracranial aneurysm ( n = 2) and moyamoya disease ( n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect Cerebral Revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle Cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized. Conclusion Local and flow-through flaps can improve combined direct and indirect Revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures. Level of Evidence The level of evidence is IV.
Robert F. Spetzler - One of the best experts on this subject based on the ideXlab platform.
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Comprar Color Atlas of Cerebral Revascularization: Anatomy, Techniques, Clinical Cases. Anatomy, Techniques, Clinical Cases | Robert F. Spetzler | 9781604068221 | Thieme
2020Co-Authors: Robert F. Spetzler, Peter Nakaji, Albert L RhotonAbstract:Tienda online donde Comprar Color Atlas of Cerebral Revascularization: Anatomy, Techniques, Clinical Cases. Anatomy, Techniques, Clinical Cases al precio 210,00 € de Robert F. Spetzler | Peter Nakaji | Albert L. Rhoton, Jr MD, tienda de Libros de Medicina, Libros de Neurologia - Neurocirugia
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Cerebral Revascularization for moyamoya syndrome associated with sickle cell disease a systematic review of the literature on the role of extracranial intracranial bypass in treating neurologic manifestations of pediatric patients with sickle cell di
World Neurosurgery, 2020Co-Authors: Danielle Terrell, Amey R Savardekar, Stephen Garrett Whipple, Rimal H Dossani, Robert F. SpetzlerAbstract:Moyamoya syndrome (MMS) in patients with sickle cell disease (SCD) accentuates the risk of recurrent strokes. Chronic transfusion therapy (CTT) is an excellent option for preventing recurrent strokes in most patients with SCD. In SCD with MMS, CTT may fail as a long-term solution. Cerebral Revascularization, in the form of extracranial-intracranial bypass, has been shown to prevent recurrent strokes in this cohort. We review the evolution of this paradigm shift in the management of SCD-associated MMS. A systematic review, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, was conducted. Our primary objectives were 1) to study the evolution of Cerebral Revascularization techniques in management of MMS in SCD and 2) to analyze the impact of neurosurgical intervention in this high-risk population. Four patients with SCD-associated MMS, who underwent indirect Cerebral Revascularization at our institute were retrospectively reviewed. A summary of 13 articles chronicling the advent and subsequent evolution of Cerebral Revascularization as a viable treatment strategy for stroke prevention in SCD-associated MMS is presented. The literature review suggests that early detection and surgical intervention (in addition to CTT) could significantly reduce stroke recurrence and improve neurocognitive outcome. Our short series of 4 patients also had a good outcome and no recurrence of strokes postoperatively. The literature emphasizes the use of a traditional standardized protocol for early identification (transcranial Dopplers, selective magnetic resonance angiography, and CTT). Early treatment and screening that involves early magnetic resonance angiography and referral to neurosurgery for Revascularization may be considered for this high-risk population.
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indications and results of direct Cerebral Revascularization in the modern era
World Neurosurgery, 2015Co-Authors: Yashar M S Kalani, Robert F. Spetzler, Leonardo Rangelcastilla, Wyatt L Ramey, Peter Nakaji, Felipe C Albuquerque, Cameron G Mcdougall, Joseph M ZabramskiAbstract:Background There has been a progressive decrease in the indications for Cerebral Revascularization during the past 30 years, particularly with the advance of endovascular techniques. Our objective was to define indications for and evaluate outcomes of patients treated with bypass surgery in the modern endovascular era. Methods We retrospectively reviewed the charts of all patients who underwent direct Cerebral Revascularization procedures between January 2006 and March 2013. Results In total, 121 patients underwent 131 direct microsurgical Revascularization procedures. The indications for bypass surgery were moyamoya angiopathy (40 patients, 47 bypasses), complex aneurysms (54 patients, 56 bypasses), and occlusive vascular disease (27 patients, 28 bypasses). Revascularization resulted in improvement of symptoms in 77.5% of patients with moyamoya angiopathy (mean clinical follow-up 18.8 months) and 55.5% of patients with occlusive vascular disease (mean clinical follow-up 10.4 months). Among the aneurysm patients treated with Revascularization, 81.5% had a favorable outcome (Glasgow Outcome Scale score 4–5) at long-term follow-up (mean clinical followup 18.5 months). Conclusions Although microvascular Cerebral Revascularization is no longer performed as commonly as in the past, it remains an essential part of the skill set required to treat select vascular pathologies. Complex aneurysms are the single largest indication for direct bypass procedures. Moyamoya disease is by far the largest indication if indirect bypass procedures are included in the analysis. In experienced hands, the morbidity and mortality of patients undergoing Cerebral Revascularization procedures are low and long-term outcomes generally excellent.
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urgent Cerebral Revascularization bypass surgery for iatrogenic skull base internal carotid artery injury
Neurosurgery, 2014Co-Authors: Leonardo Rangelcastilla, Robert F. Spetzler, Cameron G Mcdougall, Peter NakajiAbstract:Abstract When feasible, the management of iatrogenic internal carotid artery (ICA) injury during skull base surgery is mainly endovascular. To propose a Cerebral Revascularization procedure as a rescue option when endovascular treatment is not feasible. We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent. Iatrogenic injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a Cerebral Revascularization procedure.
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Cerebral Revascularization performed using posterior inferior cerebellar artery posterior inferior cerebellar artery bypass report of four cases and literature review
Journal of Neurosurgery, 2002Co-Authors: Michael G Lemole, Vivek R Deshmukh, Sam P Javedan, Jeffrey S Henn, Robert F. SpetzlerAbstract:✓ Cerebral Revascularization is often required for the surgical treatment of complex intracranial aneurysms. In certain anatomical locations, vascular anatomy and redundancy make in situ bypass possible. The authors present four patients who underwent Revascularization performed using the rarely reported posterior inferior cerebellar artery (PICA)—PICA in situ bypass after their aneurysms had been trapped. At Barrow Neurological Institute, between 1991 and the present, four male patients underwent PICA—PICA bypasses to treat aneurysms involving the vertebral artery, the PICA, or both. The mean age of these patients was 34 years (range 5–49 years). Follow-up studies revealed patent bypasses and no evidence of infarction. Patient outcomes were excellent or good. Multiple surgical techniques have been described for Revascularization of at-risk Cerebral territories. Often, the blood supply must be derived from extracranial sources through a mobilized pedicle or interposited graft. Certain anatomical locations...
Kristine Ravina - One of the best experts on this subject based on the ideXlab platform.
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rescue Cerebral Revascularization in patients with progressive steno occlusive ischemia of the anterior intracranial circulation
World Neurosurgery, 2020Co-Authors: Jeffrey A Steinberg, Kristine Ravina, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:BACKGROUND: Despite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from Cerebral Revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease. METHODS: A retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle Cerebral artery over a 4-year period (July 2014-July 2018). Surgical and clinical outcomes were recorded. RESULTS: Seventeen patients (average age 62 +/- 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle Cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 +/- 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 +/- 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score >/=4, and 13 (85%) achieved a modified Rankin Scale score
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rescue Cerebral Revascularization in patients with progressive steno occlusive ischemia of the anterior intracranial circulation
World Neurosurgery, 2020Co-Authors: Jeffrey A Steinberg, Kristine Ravina, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:Background Despite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from Cerebral Revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease. Methods A retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle Cerebral artery over a 4-year period (July 2014–July 2018). Surgical and clinical outcomes were recorded. Results Seventeen patients (average age 62 ± 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle Cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 ± 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 ± 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score ≥4, and 13 (85%) achieved a modified Rankin Scale score ≤2. Conclusions Bypass for steno-occlusive disease of the anterior intracranial circulation is a potentially effective treatment for patients with progressive and/or refractory ischemic symptoms, although the complication rate is significant. Optimal patient selection criteria and timing of surgery remain open questions.
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role of botulinum neurotoxin a in Cerebral Revascularization graft vasospasm prevention current state of knowledge
Neurosurgical Focus, 2019Co-Authors: Kristine Ravina, Joseph N Carey, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:: Graft stenosis and occlusion remain formidable complications in Cerebral Revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in Revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for Cerebral Revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.
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ec ic bypass for Cerebral Revascularization following skull base tumor resection current practices and innovations
Journal of Surgical Oncology, 2018Co-Authors: Erik M Wolfswinkel, Mark J Landau, Kristine Ravina, Niels Kokot, Jonathan J Russin, Joseph N CareyAbstract:: Complex skull base tumors can involve critical vessels of the head and neck. To achieve a gross total resection, vessel sacrifice may be necessary. In cases where vessel sacrifice will cause symptomatic Cerebral ischemia, surgical Revascularization is required. The purpose of this paper is to review Cerebral Revascularization for skull base tumors, the indications for these procedures, outcomes, advances, and future directions.
Laligam N Sekhar - One of the best experts on this subject based on the ideXlab platform.
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Cerebral Revascularization for skull base tumors
Chordomas and Chondrosarcomas of the Skull Base and Spine (Second Edition), 2018Co-Authors: Harley Brito Da Silva, David C Straus, Laligam N SekharAbstract:Abstract Chordomas and chondrosarcomas are malignant tumors whose gross total resection significantly increases the overall survival. They are locally invasive; as they breach normal anatomic planes, chordomas and chondrosarcomas may encroach upon or encase major Cerebral blood vessels. Cerebral Revascularization becomes necessary when critical blood vessels are irreparably injured during tumor removal or when resection of an encased internal carotid artery (ICA) or vertebral artery is indicated oncologically in an attempt to resect all tumor or to reduce the risk of ICA pseudoaneurysm and rupture by rerouting the artery away from exposure to nasopharyngeal infection resulting from surgical exposure or tumor invasion. In this chapter we discuss the technique of Cerebral bypass in treating chordomas and chondrosarcomas.
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Cerebral Revascularization for difficult skull base tumors a contemporary series of 18 patients
World Neurosurgery, 2014Co-Authors: Tong Yang, Farzana Tariq, Joe Chabot, Ricky Madhok, Laligam N SekharAbstract:Objective Cerebral Revascularization has been used in treating difficult skull base tumors when the preservation of the involved native arteries is deemed challenging, and the patients are at risk of developing vascular complications. We aimed to evaluate a recent series of patients who needed high flow Cerebral bypasses as part of the surgical treatment strategies for their difficult skull base tumors; to assess current indications and the results of such treatments. Methods A prospectively collected consecutive series of patients were studied. These patients received high flow Cerebral bypasses in conjunction with surgical resections of the skull base tumors during a 9-year period. Results A total of 20 high flow bypasses on 18 patients were performed, as part of the treatment plan for skull base tumors. The mean age was 41 years. Four patients had preoperative transient ischemic attack symptoms, three of which had progressed to acute strokes preoperatively. Thirteen patients (72.2%) had gross total resection. There were no acute perioperative stroke or graft occlusions. The mean follow-up was 47 months (2–104 months). One patient developed asymptomatic graft stenosis 8 months after surgery, which was surgically corrected. Fifteen patients had achieved good clinical outcomes (modified Rankin scale, ≤2) at the latest follow-up; one patient died postoperatively and two died of their disease. Conclusions High flow bypass for Cerebral Revascularization is a good surgical option for treating certain difficult skull base tumors. High rate of graft patency and low risk of perioperative stroke can be achieved in experienced hands with concurrent high rate of gross total resection of the tumor and good clinical outcome of the patients.
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Cerebral Revascularization for ischemia aneurysms and cranial base tumors
Neurosurgery, 2008Co-Authors: Laligam N Sekhar, Sabareesh K Natarajan, Richard G Ellenbogen, Basavaraj GhodkeAbstract:THIS ARTICLE EXTENSIVELY reviews the history, indications for bypass, choice of grafts, techniques, complications, and results after Cerebral Revascularization. The current role and future perspectives of Cerebral Revascularization are discussed. The results of 295 direct Revascularization procedure
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Cerebral Revascularization for aneurysms and tumors
Neurosurgery, 2002Co-Authors: Laligam N Sekhar, Chandrasekar KalavakondaAbstract:OBJECTIVE: To discuss the indications, techniques, pitfalls, complication avoidance, and management of Cerebral Revascularization techniques for the treatment of aneurysms and cranial base tumors. METHODS: The indications for Cerebral Revascularization procedures included microsurgical occlusion of a parent vessel during the treatment of aneurysms and occlusion of a major vessel during the treatment of basal tumors. The techniques discussed include arterial patch grafting, end-to-end anastomosis, side-to-side anastomosis, arterial interposition grafting, and extracranial-to-intracranial bypass grafting, using radial artery grafts or saphenous vein grafts. RESULTS: During the 15-year period between 1985 and 2000, the senior author performed 24 radial artery grafts, 105 saphenous vein grafts, and 8 other Revascularization procedures, among 50 patients with aneurysms and 83 patients with cranial base tumors. The overall patency rate was 95.6%. Twenty-three patients experienced a Cerebral infarction; among those patients, 17 (12.5%) exhibited symptoms but the majority demonstrated considerable recovery during the follow-up period. One hundred one patients recovered to an excellent (Glasgow Outcome Scale score of 5) or good (Glasgow Outcome Scale score of 4) condition. Fifteen patients died as a result of recurrence or progression of tumors during the follow-up period. There were five perioperative deaths. For the last 35 patients, the surgical mortality rate was 0%, with all patients returning to an excellent or good condition. CONCLUSION: Although highly specialized, these sophisticated Cerebral Revascularization techniques should be learned and practiced by all neurosurgeons who wish to microsurgically treat intracranial aneurysms or cranial base tumors.
Robert C Rennert - One of the best experts on this subject based on the ideXlab platform.
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rescue Cerebral Revascularization in patients with progressive steno occlusive ischemia of the anterior intracranial circulation
World Neurosurgery, 2020Co-Authors: Jeffrey A Steinberg, Kristine Ravina, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:Background Despite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from Cerebral Revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease. Methods A retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle Cerebral artery over a 4-year period (July 2014–July 2018). Surgical and clinical outcomes were recorded. Results Seventeen patients (average age 62 ± 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle Cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 ± 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 ± 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score ≥4, and 13 (85%) achieved a modified Rankin Scale score ≤2. Conclusions Bypass for steno-occlusive disease of the anterior intracranial circulation is a potentially effective treatment for patients with progressive and/or refractory ischemic symptoms, although the complication rate is significant. Optimal patient selection criteria and timing of surgery remain open questions.
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rescue Cerebral Revascularization in patients with progressive steno occlusive ischemia of the anterior intracranial circulation
World Neurosurgery, 2020Co-Authors: Jeffrey A Steinberg, Kristine Ravina, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:BACKGROUND: Despite the failure of 2 randomized controlled trials assessing the utility of bypass for steno-occlusive cerebrovascular disease, a specific subset of patients with progressive and/or refractory symptoms may benefit from Cerebral Revascularization. This study assessed the efficacy and outcomes of bypass surgery for progressive and/or refractory steno-occlusive cerebrovascular disease. METHODS: A retrospective database review was performed to identify patients who underwent bypass for progressive and/or refractory steno-occlusive disease of the internal carotid artery or middle Cerebral artery over a 4-year period (July 2014-July 2018). Surgical and clinical outcomes were recorded. RESULTS: Seventeen patients (average age 62 +/- 11 years) underwent extracranial-intracranial bypass for refractory and/or progressive steno-occlusive disease of the internal carotid artery or middle Cerebral artery. Thirteen patients presented with stroke, 3 presented with recurrent transient ischemic attacks, and 1 presented with progressive hemiparesis. All patients had preoperative perfusion imaging deficits. Average temporary clip time was 35 +/- 8 minutes. An interposition graft was used in 7 patients. There was 3 ischemic and 3 hemorrhagic perioperative strokes (35%); all were minor or related to anticoagulation. Over an average of 10 +/- 10 months of follow-up, there were no ischemic strokes in the bypass-dependent territories. Of 17 patients, 16 (78%) achieved a Glasgow Outcome Scale score >/=4, and 13 (85%) achieved a modified Rankin Scale score
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role of botulinum neurotoxin a in Cerebral Revascularization graft vasospasm prevention current state of knowledge
Neurosurgical Focus, 2019Co-Authors: Kristine Ravina, Joseph N Carey, Ben A Strickland, Robert C Rennert, Jonathan J RussinAbstract:: Graft stenosis and occlusion remain formidable complications in Cerebral Revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in Revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for Cerebral Revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.