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Erratum. Reliability assessment of the Biffl Scale for blunt traumatic cerebrovascular injury as detected on computer tomography angiography

Paul M. Foreman

InJournal of Neurosurgery Volume 127: Issue 3 (Sep 2017)

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Multidisciplinary staged surgical management of bifrontal meningoencephalocele with long-term follow-up

Case report

Jeffrey P. Blount, Amber S. Gordon, Paul M. Foreman, and John H. Grant

The authors report on an infant with a bifrontal encephalocele that was associated with multisuture craniosynostosis, spasticity, and a progressively severe epilepsy. They describe the initial presentation, genetic screening results, staged multidisciplinary operative plans, clinical course, complications, and long-term surgical and developmental follow-up. To their knowledge, the comprehensive surgical management of this type of complicated congenital cranial anomaly has not been previously described.

Surgical management was staged and multidisciplinary and required careful attention to all 3 components of the condition: 1) hydrocephalus, 2) frontal meningoencephalocele, and 3) epilepsy.

InJournal of Neurosurgery: Pediatrics Volume 11 (2013): Issue 4 (Apr 2013)

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Optical coherence tomography of traumatic aneurysms of the internal carotid artery: report of 2 cases

Christoph J. Griessenauer, Paul M. Foreman, John P. Deveikis, and Mark R. Harrigan

The pathophysiology of extracranial traumatic aneurysm formation has not been fully elucidated. Intraarterial optical coherence tomography (OCT), an imaging modality capable of micrometer cross-sectional resolution, was used to evaluate patients presenting with saccular traumatic aneurysms of the internal carotid artery (ICA). Two consecutive trauma patients diagnosed with saccular traumatic aneurysms of the cervical ICA, per the institutional screening protocol for traumatic cerebrovascular injury, underwent digital subtraction angiography (DSA) with OCT. Optical coherence tomography demonstrated disruption of the intima with preservation and stretching of the more peripheral layers. In 1 patient the traumatic aneurysm was associated with thrombus formation and a separate, more proximal dissection not visible on CT angiography (CTA) or DSA. Imaging with OCT indicates that saccular traumatic aneurysms may develop from disruption of the intima with at least partial preservation of the media and adventitia. This provides in vivo evidence that saccular traumatic aneurysms result from a partial arterial wall tear rather than complete disruption. Interestingly, OCT was also able to detect arterial injury and thrombi not visible on CTA or DSA.

InJournal of Neurosurgery Volume 124 (2016): Issue 2 (Feb 2016)

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Letter to the Editor. Biffl Scale for blunt traumatic cerebrovascular injury

Xiao Wu and Ajay Malhotra

InJournal of Neurosurgery Volume 127: Issue 3 (Sep 2017)

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Ependymomas in Children

InJournal of Neurosurgery Volume 90: Issue 3 (Mar 1999)

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Extracranial traumatic aneurysms due to blunt cerebrovascular injury

Clinical article

Paul M. Foreman, Christoph J. Griessenauer, Michael Falola, and Mark R. Harrigan

Object

Traumatic aneurysms occur in 10% of extracranial blunt traumatic cerebrovascular injuries (TCVI). The clinical consequences and optimal management of traumatic aneurysms are poorly understood.

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A prospective study of TCVI at a Level I trauma center identified 7 patients with 19 extracranial traumatic carotid artery or vertebral artery aneurysms. An additional 6 patients with 7 traumatic aneurysms were followed outside of the prospective study, giving a total of 13 patients with 26 traumatic aneurysms. All patients were treated with 325 mg aspirin daily and underwent clinical and imaging follow-up beyond the initial hospitalization. Endovascular treatment was reserved for aneurysms demonstrating significant enlargement on follow-up imaging. Clinical and radiographic features were assessed.

Results

The 7 patients with traumatic aneurysms identified in the prospective cohort comprised 10.3% of all patients with TCVI. Two (15.4%) of the 13 total patients suffered an ischemic stroke in the setting of TCVI with traumatic aneurysm formation. No patient experienced an ischemic stroke or new symptoms after the initiation of antiplatelet therapy. Clinical and radiographic follow-up averaged 15.8 months (range 0.4–41.7 months) and 22.0 months (range 6.6–55.7 months), respectively. Ten (38.5%) of 26 aneurysms were not visualized on last follow-up, 10 (38.5%) were smaller, 1 (3.8%) was unchanged, and 5 (19.2%) were larger. Saccular aneurysms were more likely to enlarge than fusiform aneurysms (33.3% vs 11.8%). Results of a Fisher exact test tend to support the assertion that the 2 different aneurysm morphologies behave differently (p = 0.07). Two saccular aneurysms were treated with stenting.

Conclusions

The majority of traumatic aneurysms can be managed with an antiplatelet regimen of 325 mg aspirin daily and serial imaging. Saccular aneurysms have a greater tendency to enlarge when compared with fusiform aneurysms.

InJournal of Neurosurgery Volume 120 (2014): Issue 6 (Jun 2014)

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The nonsurgical nature of patients with subarachnoid or intraparenchymal hemorrhage associated with mild traumatic brain injury

Benjamin J. Ditty, Nidal B. Omar, Paul M. Foreman, Daxa M. Patel, Patrick R. Pritchard, and Mamerhi O. Okor

OBJECT

Mild traumatic brain injury (mTBI), as defined by Glasgow Coma Scale (GCS) score of 13 or higher, is a common problem in the United States and worldwide, estimated to affect more than 1 million patients yearly. When associated with intracranial hemorrhage, it is a common reason for neurosurgical consultation and transfer to tertiary care centers. The authors set out to investigate the clinical implications of subarachnoid hemorrhage (SAH) and/or intraparenchymal hemorrhage (IPH) associated with mTBI in hopes of standardization of mTBI clinical care and optimization of resource allocation.

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The authors performed a retrospective review of 500 consecutively treated patients with mTBI and SAH and/or IPH admitted to a Level I trauma center in Alabama between May 2003 and May 2013. They performed a review of medical records to confirm the diagnosis, determine neurological condition at admission, and assess for episodes of neurological decline or brain injury–related complications including altered mental status, seizures, and hyponatremia.

RESULTS

Of the 500 patients for whom data were reviewed, 304 (60.8%) were male and 196 (39.2%) were female. Average age was 46.3 years. Overall, 63 patients (12.6%) had isolated IPH, 411 (82.2%) had isolated SAH, and 26 (5.2%) had radiographic evidence of both IPH and SAH. One hundred forty-five patients (29%) were transferred an average distance of 64.5 miles. The authors identified no patients who experienced neurological worsening during their hospital course. Two patients experienced hyponatremia that required treatment with sodium supplementation.

CONCLUSIONS

Patients with the constellation of SAH and/or IPH and mTBI do not require neurosurgical consultation, and these findings should not be used as the sole criteria to justify transfer to tertiary referral centers.

InJournal of Neurosurgery Volume 123 (2015): Issue 3 (Sep 2015)

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Perioperative outcomes and complications associated with allogeneic duraplasty for the management of Chiari malformations Type I in 48 pediatric patients

Clinical article

Paul Foreman, Sam Safavi-Abbasi, Melanie C. Talley, Lindsay Boeckman, and Timothy B. Mapstone

Object

The authors debate the optimal management for Chiari malformation Type I (CM-I) while sharing their experience with posterior fossa decompression and duraplasty (PFDD).

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The charts of 48 consecutive pediatric patients surgically treated for CM-I were retrospectively reviewed.

Results

Patients ranged in age from 2 to 17 years with an average age of 9.8 years. The most common presentations were headache, affecting 34 patients (71%), and pain (neck, back, or extremities), affecting 21 patients (44%). Twenty-seven patients (56%) had a syrinx. All 48 patients underwent PFDD utilizing acellular tissue matrix. The average hospital stay overall was 3.56 days, whereas the average stay for patients with (29 [60%] of 48) or without (19 [40%] of 48) scoliosis and/or syringomyelia was 3.72 and 3.32 days, respectively. The odds of a patient having a hospital stay of 4 or more days was nearly 3 times greater in patients with scoliosis and/or syringomyelia as compared with patients without either condition (OR 2.73, 95% CI 0.74–10.11, p = 0.1330). The average hospital stay for patients 0–8 years of age was 3.29 days; and for those 9–17 years of age, 3.78 days. The odds of a patient having a hospital stay of 4 or more days was nearly 4 times greater in 9- to 17-year-olds as compared with 0- to 8-year-olds (OR 3.73, 95% CI 1.03–13.52, p = 0.0455). Forty patients (89%) experienced early improvement in their signs and symptoms following PFDD. There were 2 revision PFDDs (4%).

Conclusions

Posterior fossa decompression and duraplasty is a safe and effective surgical option in the management of pediatric CM-I.

InJournal of Neurosurgery: Pediatrics Volume 10 (2012): Issue 2 (Aug 2012)

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The lateral extracavitary approach to the thoracolumbar spine: a case series and systematic review

保罗·m·福尔曼罗伯特·p·Naftel托马斯·a·摩尔II, and Mark N. Hadley

OBJECT

Since its introduction in 1976, the lateral extracavitary approach (LECA) has been used to access ventral and ventrolateral pathology affecting the thoracolumbar spine. Reporting of outcomes and complications has been inconsistent. A case series and systematic review are presented to summarize the available data.

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病历的回顾性研究穿孔ormed, which identified 65 consecutive patients who underwent LECA for the treatment of thoracolumbar spine and spinal cord pathology. Cases were divided according to the presenting pathology. Neurological outcomes and complications were detailed. In addition, a systematic review of outcomes and complications in patients treated with the LECA as reported in the literature was completed.

RESULTS

Sixty-five patients underwent the LECA to the spine for the treatment of thoracic spine and spinal cord pathology. The most common indication for surgery was thoracic disc herniation (23/65, 35.4%). Neurological outcomes were excellent: 69.2% improved, 29.2% experienced no change, and 1.5% were worse. Two patients (3.1%) experienced a complication. The systematic review revealed comparable neurological outcomes (74.9% improved) but a notably higher complication rate (32.2%).

CONCLUSIONS

The LECA provides dorsal and unilateral ventrolateral access to and exposure of the thoracolumbar spine and spinal cord while allowing for posterior instrumentation through the same incision. Although excellent neurological results can be expected, the risk of pulmonary complications should be considered.

InJournal of Neurosurgery: Spine Volume 24 (2016): Issue 4 (Apr 2016)

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Corrective spinal surgery may be protective against stroke in patients with blunt traumatic vertebral artery occlusion

Paul M. Foreman, Christoph J. Griessenauer, Michelle Chua, Mark N. Hadley, and Mark R. Harrigan

OBJECT

大约有10%的患者创伤extracranial cerebrovascular injury have a complete occlusion of the vertebral artery (VA). Ischemic stroke due to embolization of thrombus from an occluded VA following cervical spine surgery has been observed. The risk of ischemic stroke with cervical spine surgery in the presence of an occluded VA, however, has never been determined.

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A retrospective chart review of 52 patients with a VA occlusion following a blunt trauma was performed. Clinical and radiographic characteristics were collected and analyzed.

RESULTS

10例(19.2%)出现一个缺血性中风ttributable to a traumatic VA occlusion. Univariate analysis demonstrated that patients with ischemic stroke were significantly older (p = 0.042) and had a lower rate of cervical spine surgery (p < 0.005). Multivariate analysis found cervical spine surgery to be protective against ischemic stroke (OR 0.049 [95% CI 0.014–0.167], p = 0.014); increasing age and bilateral VA injury (bilateral occlusion or unilateral occlusion with contralateral dissection) were risk factors for ischemic stroke (OR 1.05 [95% CI1.02–1.07], p = 0.065 and OR 13.2 [95% CI 2.98–58.9], p = 0.084, respectively).

CONCLUSIONS

Traumatic VA occlusion is associated with a risk of ischemic stroke and mortality. Corrective cervical spine surgery potentially decreases the risk of ischemic stroke by stabilizing the spine and thereby reducing motion across the occluded segment of the VA and preventing embolization of thrombus. While a high stoke risk may be inherent to the disease, novel therapies should be investigated.

InJournal of Neurosurgery: Spine Volume 23 (2015): Issue 5 (Nov 2015)

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