BACKGROUND: Spinal arteriovenous malformations (AVMs) are rare disease entities with significant morbidity if untreated. Risk factors of complications, hospitalization and costs-of-care remain in need of characterization.METHODS: Using the National Inpatient Sample years 2002-2014, adult subjects with spinal AVMs who underwent either laminectomy with lesion excision or endovascular embolization were extracted using ICD-9-CM diagnostic code 747.82. Predictors of inpatient complications, hospital length of stay (HLOS), and discharge home were evaluated using multivariable regression. Cost was evaluated using inflation-adjusted healthcare cost [charge*(cost/charge ratio)]. Mean differences (B), odds ratios (OR) and 95% CIs are reported. Significance was assessed at P<0.001.RESULTS: In 2546 weighted admissions, age was 54.4±16.5-years (laminectomy: 70.0%, embolization: 30.0%). Fifteen percent suffered inpatient complications. Cost of hospitalization was $ 41216±38511 and was elevated for subjects with complications ($67571±2636, vs. no complications: $36562±723, P<0.001). Increased costs for categories of complications ranged from $ 16525 (renal/urinary) to $62246 (thromboembolism). In surgical subjects, complications were more costly ($ 69761±2896, vs. no complications: 36520±809, P<0.001). On multivariable analysis, major/extreme disease severity and major/extreme mortality risk were associated with increased complications and HLOS (P<0.001). Elective admissions had shorter HLOS (B=-4.3-days, [-4.8, -3.8], P<0.001) and higher odds of discharge home (OR=2.6 [2.1-3.2], P<0.001). Laminectomy (vs. embolization) was associated with complications (OR=2.6, 95% CI [1.7-3.8], P<0.001), HLOS (B=3.4-days [2.9-4.0], P<0.001), and decreased discharge home (OR=0.3 [0.2-0.4], P<0.001).CONCLUSIONS: In spinal AVMs, high disease severity, non-elective admissions, and surgery are associated with complications, HLOS, and discharge to a non-home facility. Costs are elevated in patients suffering complications. Future studies are warranted.
Object The use of flow-diverting stents has gained momentum as a curative approach in the treatment of complex proximal anterior circulation intracranial aneurysms. There have been some reported attempts of treating formidable lesions in the posterior circulation. Posterior circulation giant fusiform aneurysms have a particularly aggressive natural history. To date, no one approach has been shown to be comprehensively effective or low risk. The authors report the initial results, including the significant morbidity and mortality encountered, with flow diversion in the treatment of large or giant fusiform vertebrobasilar aneurysms at Millard Fillmore Gates Circle Hospital. Methods The authors retrospectively reviewed their prospectively collected endovascular database to identify patients with intracranial aneurysms who underwent treatment with flow-diverting devices and determined that 7 patients had presented with symptomatic large or giant fusiform vertebrobasilar aneurysms. The outcomes of these patients, based on the modified Rankin Scale (mRS), were tabulated, as were the complications experienced. Results Among the 7 patients, Pipeline devices were placed in 6 patients and Silk devices in 1 patient. At the last follow-up evaluation, 4 patients had died (mRS score of 6), all of whom were treated with the Pipeline device. The other 3 patients had mRS scores of 5 (severe disability), 1, and 0. The deaths included posttreatment aneurysm ruptures in 2 patients and lack of improvement in neurological status related to presenting brainstem infarcts and subsequent withdrawal of care in the other 2 patients. Conclusions Whether flow diversion will be an effective strategy for treatment of large or giant fusiform vertebrobasilar aneurysms remains to be seen. The authors' initial experience suggests substantial morbidity and mortality associated with the treatment and with the natural history. As outcomes data slowly become available for patients receiving these devices for fusiform posterior circulation aneurysms, practitioners should use these devices judiciously.
Background: Intracranial hemorrhage (ICH) is often the initial presenting symptom for patients with brain arteriovenous malformations (bAVM), which is further complicated in the setting of pregnancy. There are no standard guidelines for management of pregnant women with bAVM, and few studies have reported on maternal and fetal outcomes in those with bAVM ICH. The purpose of this descriptive study was to review our case series for maternal and fetal outcomes in women with bAVM ICH during pregnancy. Methods: We conducted a retrospective review of our database for women between the ages of 15-50 years who presented with a bAVM ICH during pregnancy between 2000-2017. Demographics, angiographic characteristics, gestational age/trimester at ICH, mode and timing of AVM treatment, and maternal (e.g. modified Rankin Scale, mRS) and fetal outcomes (e.g. healthy or intrauterine fetal death) were recorded from the medical records. Results: We identified 16 bAVM cases who were pregnant at the time of ICH. Mean age of cases was 27±6.7 years, 56% were non-Caucasian, and 81% presented with an ICH during the second or third trimester. Of 16 patients, 2 terminated pregnancies in the 1 st trimester, 1 miscarried immediately after ICH, and 13 patients carried to term (69% delivered cesarean and 23% vaginal). Of 13 patients with live births, 77% received emergent AVM treatment (embolization+resection or resection only) at time of ICH, while 3 deferred treatment until after birth. The majority of bAVMs were Spetzler-Martin grade 2 or 3 (87%), 56% had deep venous drainage, and mean AVM size was 2.5±1.2cm. At 2-year follow-up, 85% of women had good outcomes (mRS 0-2). Only one patient did worse after AVM treatment due to a permanent neurological deficit. All cases had healthy fetal outcomes at time of delivery and at 2-yr follow-up. Conclusion: Our case series suggest good fetal and maternal outcomes in ruptured bAVM patients presenting during pregnancy, the majority of which were treated before delivery. Treatment of ruptured AVMs during pregnancy should be tailored to the needs of each specific patient in close consultation with the obstetrics and neurosurgery teams.
<b><i>Introduction:</i></b> Tumor-associated intracranial aneurysms are rare and not well understood. <b><i>Case Presentation:</i></b> We describe a 4-year-old female with multiple intracranial aneurysms intimately associated with a suprasellar germ cell tumor (GCT). We provide the clinical history, medical, and surgical treatment course, as well as a comprehensive and concise synthesis of the literature on tumor-associated aneurysms. <b><i>Discussion:</i></b> We discuss mechanisms for aneurysm formation with relevance to the current case, including cellular and paracrine signaling pertinent to suprasellar GCTs and possible molecular pathways involved. We review the complex multidisciplinary treatment required for complex tumor and cerebrovascular interactions.
The endoscopic endonasal approach (EEA) offers a minimally invasive route to treat medial intraconal space (MIS) lesions. Understanding the configuration of the ophthalmic artery (OphA) and the central retinal artery (CRA) is crucial.
INTRODUCTION: Small, unruptured cerebral aneurysms are frequently found incidentally, but management remains controversial because of their uncertain natural history. Based on prospective studies, the rupture rate for small aneurysms is minimal. As a result, in the absence of other high-risk factors, small aneurysms are generally observed. However, subarachnoid hemorrhage (SAH) from small aneurysms is commonly observed in practice. Patient- and aneurysm-related risk factors for rupture, including a risk score (PHASES), help guide clinical decision-making. To determine the usefulness of size and the PHASES risk score as predictors of rupture, we studied a consecutive series of ruptured aneurysms over a 10-yr period. METHODS: We identified 629 patients with aneurysmal SAH at our hospital treated by the senior authors between 2008 and 2018. We collected patient data including population, hypertension, age, size of aneurysm, earlier SAH from another aneurysm, and site of aneurysm. A PHASES score was calculated in each case to estimate a predicted risk of rupture. RESULTS: The mean aneurysm size was 6.1 mm (standard deviation 3.9). Almost 3 quarters of aneurysms were less than 7 mm. The mean PHASES score was 4.9 (standard deviation 2.6). CONCLUSION: In our cohort, small aneurysms < 7 mm accounted for a majority of SAH cases. Furthermore, the mean PHASES score corresponded to a 5-yr risk of rupture of only 1.3%. Many, if not most, of our patients would have been conservatively managed. Natural history studies have selection bias and may underestimate the risk of rupture.
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