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1.  Preoperative Embolization of Hypervascular Thoracic, Lumbar, and Sacral Spinal Column Tumors: Technique and Outcomes from a Single Center 
Interventional Neuroradiology  2013;19(3):377-385.
The existing literature on preoperative spine tumor embolization is limited in size of patient cohorts and diversity of tumor histologies. This report presents our experience with preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors in the largest series to date.
We conducted a retrospective review of 228 angiograms and 188 pre-operative embolizations for tumors involving thoracic, lumbar and sacral spinal column. Tumor vascularity was evaluated with conventional spinal angiography and was graded from 0 (same as normal adjacent vertebral body) to 3 (severe tumor blush with arteriovenous shunting). Embolic materials included poly vinyl alcohol (PVA) particles and detachable platinum coils and rarely, liquid embolics. The degree of embolization was graded as complete, near-complete, or partial. Anesthesia records were reviewed to document blood loss during surgery.
Renal cell carcinoma (44.2%), thyroid carcinoma (9.2%), and leiomyosarcoma (6.6%) were the most common tumors out of a total of 40 tumor histologies. Hemangiopericytoma had the highest mean vascularity (2.6) of all tumor types with at least five representative cases followed by renal cell carcinoma (2.0) and thyroid carcinoma (2.0). PVA particles were used in 100% of cases. Detachable platinum coils were used in 51.6% of cases. Complete, near-complete, and partial embolizations were achieved in 86.1%, 12.7%, and 1.2% of all cases, respectively. There were no new post-procedure neurologic deficits or other complications with long-term morbidity. The mean intra-operative blood loss for the hypervascular tumors treated with pre-operative embolization was 1745 cc.
Preoperative embolization of hypervascular thoracic, lumbar, and sacral spine tumors can be performed with high success rates and a high degree of safety at high volume centers.
PMCID: PMC3806015  PMID: 24070089
spine, tumor, preoperative embolization, surgery
2.  Endovascular Therapy for Acute Stroke in Patients With Cancer 
The Neurohospitalist  2014;4(3):133-135.
Intravenous thrombolysis is the standard treatment for acute ischemic stroke (AIS). However, patients with cancer who have stroke are often precluded from therapy because of coagulopathy or recent surgery. Endovascular therapy may be a more suitable recanalization strategy for some patients with cancer and stroke, but no prior detailed reports documenting its use in this population exist. We present a case series from a tertiary care referral center of 2 patients with active systemic cancer who were successfully treated with endovascular therapy for AIS. Both patients had active lung cancer with excellent premorbid functional status and presented with severe AIS from left middle cerebral artery occlusions. Intravenous thrombolysis was deferred because of absolute contraindications. Mechanical embolectomy was performed instead and revascularization was achieved within 5 hours in both patients, resulting in dramatic neurological recoveries—National Institutes of Health Stroke Scale improved from 14 to 0 and from 23 to 3 from admission to discharge, respectively. In conclusion, endovascular therapy may be beneficial for select patients with cancer and AIS who are ineligible for intravenous thrombolysis. However, further studies are needed to determine the safety and efficacy of endovascular therapy in the population with cancer.
PMCID: PMC4056416  PMID: 24982717
endovascular; stroke; cancer; intervention; embolectomy
3.  Transoral C2 biopsy and vertebroplasty 
Pathologic fractures involving the C2 vertebral body and odontoid process pose a unique dilemma, as the surgical approach for direct odontoid process screw fixation has several limitations. There have been a small number of transoral approach C2 vertebroplasty or kyphoplasty reported in the literature. Previous attempts were performed utilizing fluoroscopy or CT guidance. We report a case of a fluoroscopically guided transor-al approach vertebroplasty in a patient with a lytic lesion involving the C2 vertebral body, extending into the odontoid process with an underlying pathologic fracture. This case is unique as two separate punctures were required in order to adequately stabilize the pathologic fracture, CTA was performed preoperatively to better evaluate regional vasculature, and a post-procedure rotational flat panel CT was performed to assess cement placement.
PMCID: PMC3831803  PMID: 24265894
biopsy; C2; odontoid; pathologic fracture; spine; transoral; vertebroplasty
4.  Thoraco-lumbar artery aneurysms associated with a metameric paraspinal lesion presenting with retroperitoneal hemorrhage: Endovascular management 
Retroperitoneal hemorrhage is a life-threatening condition. This is the first reported case of rupture of one of multiple thoraco-lumbar artery aneurysms associated with a metameric paraspinal vascular lesion.
Case Description:
A 77-year-old female patient presented to the emergency room with a new onset of left-sided low back pain shooting down the leg associated with weakness, numbness, and inability to walk. On physical examination, there was a notable left paraspinal swelling with a harsh bruit audible in the same area, left flank ecchymosis and a positive straight leg raising test. A computed tomography (CT) scan showed a large retroperitoneal hematoma. Digital subtraction angiography showed a large left paraspinal high-flow arteriovenous lesion, with large arterial aneurysms of the left T11, T12, and L1 segmental arteries. The patient was successfully treated with endovascular aneurysm embolization using coils and Onyx-34. Six months following the procedure, the patient had fully recovered, and a follow-up angiogram showed no residual or recurrent aneurysms.
Thoraco-lumbar artery aneurysms have never previously been described in association with a metameric paraspinal vascular malformation. We report a case of retroperitoneal hemorrhage due to rupture of one of several high-flow artery aneurysms of a paraspinal arteriovenous malformation (AVM). The diagnosis was made on CTA, MRI, and angiography, and the lesion was successfully treated by transarterial embolization.
PMCID: PMC3205498  PMID: 22059132
Arteriovenous malformation; endovascular embolization; metameric lesion; Onyx-34
5.  Endovascular management of distal anterior inferior cerebellar artery aneurysms: Report of two cases and review of the literature 
Aneurysms of the anterior inferior cerebellar artery (AICA), especially those located in the distal portion of the AICA, are rare. There are few reported cases treated with surgery or endovascular embolization.
Case Description:
We report two cases of fusiform distal AICA aneurysms presenting with subarachnoid hemorrhage. Parent artery occlusion with coils and n-butyl cyanoacrilate (n-BCA) resulted in complete aneurysm occlusion and prevented rebleeding. Both patients presented postprocedure neurological deficits, but have made a good recovery at 4 and 10 months, respectively.
Occlusion of the parent artery for the treatment of ruptured fusiform distal AICA aneurysms is effective but has significant neurological risks.
PMCID: PMC3130468  PMID: 21748047
Anterior inferior cerebellar artery aneurysm; coil; endovascular therapy; meatal; parent artery occlusion; postmeatal
6.  Interventional management for secondary intracranial extension of spontaneous cervical arterial dissection 
Spontaneous cervical artery dissection (sCAD) is an important etiology of stroke and subarachnoid hemorrhage (SAH) in young patients. Anticoagulation and platelet antiaggregant medications are the treatment of choice, while the indications of endovascular treatment are still to be defined.
Case Description:
We report two cases of medically refractory sCAD with intracranial extension treated successfully with multiple intra and extracranial stents. The patients were evaluated at 4 years and 1-year follow-up.
Progressive, spontaneous cervical artery dissection with intracranial extension despite adequate medical therapy is rare and associated with worse prognosis. Given the rapid evolution of interventional technology and techniques, if we are better able to predict the cohort of patients that fail medical management, earlier endovascular therapy may be considered.
PMCID: PMC3011101  PMID: 21206534
Cervical artery dissection; stent; transient ischemic attack

Results 1-6 (6)