Dr. Jimenez is Professor and Chairman, Dr. Savage is Resident, and Dr. Barone is Clinical Professor, Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229; This article is the second of two parts. E-mail: [email protected]. The authors have disclosed that they have no significant relationships with or financial interests in any commercial organizations pertaining to this educational activity. All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. Lippincott CME Institute, Inc., has identified and resolved all faculty and staff conflicts of interest regarding this educational activity. Category: Pediatric From the Editor: I am very pleased to announce that retroactive to Volume 25, Issue 1, the American Association of Neurological Surgeons attests that this educational activity has been recognized for co-sponsored/endorsement for 1.5 Category 1 CME credits of the American Association of Neurological Surgeons' Continuing Education Award in Neurosurgery.
The roles of endovascular internal trapping (EIT), proximal parent artery occlusion (PAO), and flow diversion (FD) in the contemporary management of ruptured vertebral artery dissecting aneurysms (VADA) have evolved with advances in endovascular technology, but remain controversial. The aim of this retrospective cohort study is to assess the outcomes of patients with ruptured VADAs who underwent endovascular management with EIT as a first-line treatment approach.
Methods
We evaluated an institutional database of patients with ruptured VADAs who were treated at Auckland City Hospital from 1998–2017. Baseline and outcomes data were analyzed to compare patients treated by EIT with those treated by PAO or FD. All cases of PAO involved occlusion of the parent VA. All cases of EIT involved occlusion of the VADA with preservation of flow through the proximal VA.
Results
The study cohort was comprised of 45 ruptured VADA patients with a mean age of 47 years. EIT, PAO, and flow diversion were performed in 32 (71.1%), 12 (26.7%), and one (2.2%) case, respectively. The overall procedural complication rate was 13.3%, including procedural neurological morbidity in 4.4%. At last follow-up (mean duration 13 months), the aneurysm occlusion rate was 100%. Despite presenting with a significantly lower mean GCS (9.8 vs 13.3, p=0.029), patients treated with EIT demonstrated a significantly higher rate of neurological improvement (84.4% vs 58.3%, p=0.019), compared with those who underwent PAO. The rates of favorable outcome (modified Rankin Scale 0–2) and CSF shunt placement were not significantly different between the EIT and PAO-FD groups.
Conclusion
Although individual aneurysm and anatomical characteristics must be taken into account prior to treatment, EIT remains an effective and durable first-line therapy for the majority of ruptured VADAs. Assessment of the likely origin of brainstem perforators (VA vs PICA), and of the ASA, are essential in planning potential deconstructive treatment options; flow diversion may be an option for VADAs involving the dominant VA in the absence of sufficient collateral circulation.
Disclosures
D. Raper: None. D. Ding: None. J. Savage: None. J. Liu: None. J. Caldwell: None. S. Brew: None. B. McGuinness: None.
OBJECT.: There are rare indications for upper cervical spine fusion in young children. Compared with nonrigid constructs, rigid instrumentation with screw fixation increases the fusion rate and reduces the need for halo fixation. Instrumentation may be technically challenging in younger children. A number of screw placement techniques have been described. Use of C-2 translaminar screws has been shown to be anatomically feasible, even in the youngest of children. However, there are few data detailing the clinical outcome. In this study, the authors describe the clinical and radiographic follow-up of 18 children 5 years of age or younger who had at least one C-2 translaminar screw as part of an occipitocervical or C1-2 fusion construct.A retrospective review of all children treated with instrumented occipitocervical or C1-2 fusion between July 1, 2007, and June 30, 2013, at Riley Children's Hospital and Texas Children's Hospital was performed. All children 5 years of age or younger with incorporation of at least one C-2 translaminar screw were identified.Eighteen children were studied (7 boys and 11 girls). The mean age at surgery was 38.1 months (range 10-68 months). Indications for surgery included traumatic instability (6), os odontoideum (3), destructive processes (2), and congenital instability (7). A total of 24 C-2 translaminar screws were placed; 23 (95.8%) of 24 were satisfactorily placed (completely contained within the cortical walls). There was one medial cortex breach without neurological impingement. There were no complications with screw placement. Three patients required wound revisions. Two patients died as a result of their original condition (trauma, malignant tumor). The mean follow-up duration for the surviving patients was 17.5 months (range 3-60 months). Eleven (91.7%) of the 12 patients followed for 6 months or longer showed radiographic stability or completed fusion.Use of C-2 translaminar screws provides an effective anchor for internal fixation of the upper cervical spine. In this study of children 5 years of age or younger, the authors found a high rate of radiographic fusion with a low rate of complications.
A logarithmic relationship exists between TBSA (%) burn and total allograft requirement (cm2). Significant variations in the amount of allograft used exist. These most likely reflect rationale behind allograft use. In our unit allograft is: • Used for deep and full-thickness burns. Average allograft used per patient per week 1017 patients admitted with burns 2006 –2011: • 55% of patients with burn injuries over 30% TBSA used allograft. • <1% of patients with burn injuries under 30% TBSA used allograft.
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