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Restenosis After Carotid Endarterectomy: Insight into risk factors and modification of postoperative management. - World neurosurgery
Restenosis after carotid endarterectomy (CEA) is a potential complication after surgery for carotid stenosis. Stroke after CEA is a debilitating complication secondary to restenosis and modification of postoperative care may be necessary to decrease incidence of postoperative stroke after CEA. We sought to identify clinical and patient factors that are associated with this complication.A retrospective analysis of all neurosurgical patients who underwent carotid endarterectomy for symptomatic or asymptomatic carotid stenosis was performed. Factors were compared against the outcome variable in univariate analysis. Multivariate logistic regression model was utilized to identify independent predictive variables. We used Kaplan-Meier analysis to compare the effect of variables on long-term event-free survival.A total of 273 CEA procedures and their outcomes were analyzed with a mean follow-up was 50.7 months. Twenty-one patients had restenosis (7.6%). Rates of restenosis and restenosis free survival were analyzed with Kaplan Meier curves (log-rank test). In the multivariate model, family history of stroke was the only variable that was significantly associated with restenosis after CEA.Our findings suggest that family history of stroke is an important factor that predisposes patients to restenosis after CEA. Restenosis free survival is influenced by the presence of hyperlipidemia, age, and family history of stroke. Closer surveillance with more frequent follow-up and multidisciplinary management may be beneficial in patients who have these risk factors in order to prevent restenosis and prolong restenosis-free survival.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Risk Factors Associated with Ipsilateral Ischemic Events Following Carotid Endarterectomy for Carotid Artery Stenosis. - World neurosurgery
Patients undergoing carotid endarterectomy (CEA) are at risk of developing ipsilateral stroke or transient ischemic attacks (TIAs). In this study, we explored factors associated with development of these events following CEA in patients with long-term follow-up.We performed a retrospective analysis of all neurosurgical patients who underwent CEA and presented with ipsilateral ischemic stroke, TIA, or amaurosis fugax. Factors were compared against the outcome variable in univariate analysis. Multivariate logistic regression model was used to identify independent predictive variables. We used Kaplan-Meier analysis (log-rank test) to compare the effect of variables on long-term event-free survival.Our study included 270 patients with an average age of 67.2 years. Two-hundred and forty-nine patients within our study cohort (92.2%) with 273 CEAs were followed at our institution. At presentation, 187 patients (68.5%) were symptomatic. The average follow-up was 50.2 months (113.2 lesion-years). Event-free survival was 91.6% and 89.9% at 2 years and 5 years, respectively. Family history of stroke (PÂ = 0.002), cigarette smoking (PÂ = 0.021), and atrial fibrillation (PÂ = 0.005) significantly increased the risk of adverse events, whereas symptomatic presentation demonstrated a trend toward significance (PÂ = 0.057). A higher risk for ischemic events was observed in female patients as compared with males with asymptomatic presentation (PÂ = 0.005).Our data suggest that family history of stroke, cigarette smoking, and atrial fibrillation are independent risk factors for developing ischemic events after CEA. In patients with asymptomatic presentation, female gender is also a risk factor. Identification of patients at risk is critical for tailored postoperative patient management and patient education.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Delayed Hemorrhage Following Treatment of Brain Arteriovenous Malformations (AVMs). - World neurosurgery
The risk of delayed hemorrhage, occurring greater than 2 years following treatment in brain arteriovenous malformations (AVM) is rarely reported. In this study, we compare the risk of delayed hemorrhage across different treatment modalities.We performed a retrospective chart review of treated patients with a single intracranial AVM seen at our institution from 1990-2013. Delayed hemorrhage was defined as hemorrhage occurring at least 2 years after last treatment. Survival analysis was used to assess risk of delayed hemorrhage by treatment modalities.Our study included 420 patients. Spetzler-Martin grades were: I(12.6%), II(36.2%), III(32.6%), IV(15.0%), V(3.6%). Average follow-up time is 5.1 years. Twenty-two patients (5.2%) were found to have 28 delayed hemorrhages. Average interval between last treatment and delayed hemorrhage is 7.6 years, with the longest being 24.2 years. Proportions of delayed hemorrhages by treatment modalities were: surgery Â± embolization (group I, 9.1%), radiosurgery Â± embolization (group II, 63.6%), embolization only (group III, 22.7%) and surgery + radiosurgery Â± embolization (group IV, 4.5%). Annualized hemorrhage risk after 2 years for each treatment group was: group I(0.4%), group II(1.2%), group III(3.7%), group IV(1.7%). Survival analysis demonstrated lowest risk of delayed hemorrhage for group 1 (p < 0.01).This study is the first to compare the risk of delayed hemorrhage across different treatment modalities. Surgical resection is associated with the lowest risk for delayed hemorrhage compared to other treatment modalities. Patients with partially embolized AVMs should seek timely definitive treatment to reduce the risk of delayed hemorrhage.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Long-term Outcomes of Patients With Giant Intracranial Arteriovenous Malformations. - Neurosurgery
Giant intracranial arteriovenous malformations (AVMs) are rare cerebrovascular lesions that pose management challenges.To further clarify outcomes in patients with giant cerebral AVMs managed with conservative or interventional therapies.We performed a retrospective review of all patients diagnosed with AVMs evaluated at our institution from 1990 to 2013. Patients with a single intracranial AVM >6 cm were included. Patients were divided into 2 groups: conservative management or intervention (microsurgery, radiosurgery, or embolization). Functional outcome was assessed with the modified Rankin Scale (mRS) and compared between the 2 groups.A total of 55 patients with giant AVMs were included, and 35 patients (63.6%) had clinical follow-up with a mean of 11.8 years. Spetzler-Martin grades were as follows: grade III, n = 2 (3.6%); grade IV, n = 15 (27.3%); and grade V, n = 38 (69.1%). Twenty-four patients (43.6%) were conservatively managed. The patients in the conservatively managed group had larger AVMs (P < .05) with more frequent involvement of the temporal lobe (P = .02). Five patients (26.3%) in the conservatively managed group and 5 (31.3%) in the intervention group experienced hemorrhage during follow-up, translating to an annualized risk of 2.7% and 4.1%, respectively. No significant difference in risk of first subsequent hemorrhage was observed (P = .78). Despite comparable mRS scores at presentation, we observed a trend toward better outcomes (mRS < 2) in patients undergoing conservative management (P = .06) compared with the intervention group at last follow-up.This study suggests that interventions for giant AVMs should be considered cautiously because hemorrhagic risk is similar regardless of management strategy and functional outcome is likely to be same or better in the conservatively managed population.AVM, arteriovenous malformationmRS, modified Rankin Scale.
Surgical complications following malignant brain tumor surgery: An analysis of 2002-2011 data. - Clinical neurology and neurosurgery
To estimate the incidence of surgical complications and associated in-hospital morbidity and mortality following surgery for malignant brain tumors.The Nationwide Inpatient Sample (NIS) database was queried from 2002 to 2011. All adult patients who underwent elective brain surgery for a malignant brain tumor were included. Surgical complications included wrong side surgery, retention of a foreign object, iatrogenic stroke, meningitis, hemorrhage/hematoma complicating a procedure, and neurological complications. A regression model was conducted to estimate the odds ratios (OR) with their 95% confidence intervals (95% CI) of in-hospital mortality for each surgical complication.A total of 16,530 admissions were analyzed, with 601 (36.2 events per 1000 cases) surgical complications occurring in 567 patients. Over the examined 10-year period, the overall incidence of surgical complications did not change (P=0.061) except for iatrogenic strokes, which increased in incidence from 14.1 to 19.8 events per 1000 between 2002 and 2011 (P=0.023). Patients who developed a surgical complication had significantly longer lengths of stay, total hospital costs, and higher rates of other complications. Patients who experienced an iatrogenic stroke had a significantly increased risk of mortality (OR 9.6; 95% 6.3-14.8) and so were patients with a hemorrhage/hematoma (OR 3.3; 95% CI 1.6-6.6).In this study of an administrative database, patients undergoing surgery for a malignant brain tumor who suffered from a surgical complication had significantly longer lengths of stay, total hospital charges, and complication rates. Having a surgical complication was also an independent risk factor for in-hospital mortality. Nonetheless, it is unclear whether all surgical complications were clinically relevant, and further research is encouraged.Copyright Â© 2015 Elsevier B.V. All rights reserved.
Lower Risk of Intracranial Arteriovenous Malformation Hemorrhage in Patients With Hereditary Hemorrhagic Telangiectasia. - Neurosurgery
Patients diagnosed with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing intracranial arteriovenous malformations (AVM). However, the clinical manifestations and natural history of HHT-related AVMs remain unclear due to the rarity of these lesions.To clarify the clinical characteristics and hemorrhagic risk in HHT-related AVMs.We performed a retrospective review of all patients diagnosed with both HHT and intracranial AVMs who were evaluated at our institution from 1990 to 2013. Patients with missing data or lost to follow-up were excluded. Baseline characteristics and subsequent hemorrhagic risk were evaluated.In an AVM database of 531 patients with 542 AVMs, a total of 12 HHT patients (2.3%) with 23 AVMs were found. Mean age at diagnosis was 36.5 years, with 41.7% male. Compared to patients with sporadic AVMs, patients with HHT were less likely to present with ruptured AVM (P = .04), headaches (P = .02), and seizures (P = .02), and presented with better modified Rankin scores (P < .01). HHT-related AVMs were smaller in size (P < .01), of lower Spetzler-Martin grade (P = .01), and had less temporal lobe involvement (P = .02) compared to sporadic AVMs. Six HHT patients (50.0%) were found with multiple intracranial AVMs. One hemorrhage was found during an observation period of 149.6 patient-years and 297.5 lesion-years, translating to 1.3% per patient per year or 0.7% per AVM per year.HHT-related AVMs are smaller in size with lower Spetzler-Martin grade and less temporal lobe involvement than sporadic AVMs. Patients with HHT frequently present with multiple intracranial AVMs. Conservative management is generally recommended due to lesion multiplicity and relatively low hemorrhagic risk.AVM, arteriovenous malformationsHHT, hereditary hemorrhagic telangiectasiaICH, intracranial hemorrhages.
Ventral and Dorsal Persistent Primitive Ophthalmic Arteries. - Neurosurgery
Before the development of the adult ophthalmic artery (OA), the primitive maxillary artery (MA), the primitive dorsal OA, and the primitive ventral OA contribute to the vascularization of early ocular structures, whereas the primitive olfactory artery (OlfA) forms in the vicinity of the optic vesicle. These vessels are involved in several OA origin variants.To clarify the developmental history of the OA, emphasizing in particular the criteria used to define persistent primitive OAs.Eight rare variants relevant to the discussion of aberrant OA origins are presented.Five abnormal anatomic configurations are described including (1) OAs branching from the cavernous internal carotid artery (ICA) involving a persistent primitive MA, (2) OAs originating from the distal supraclinoid ICA involving persistent primitive ventral or dorsal OAs, (3) an OA originating from the anterior cerebral artery (ACA) involving a persistent primitive OlfA, (4) a persistent primitive OlfA, and (5) infraoptic ACAs involving the persistent primitive MA, OlfA, and OA.Discrepancies regarding the identification of persistent primitive OAs appear to result from a misinterpretation of the literature. Notably, an OA arising from the cavernous segment of the ICA derives from a primitive MA, whereas an OA arising from the ACA represents the partial persistence of a primitive OlfA; neither corresponds to a persistent primitive OA. Two new observations of this latter variant, which is exceptional, are presented.ACA, anterior cerebral arteryDSA, digital subtraction angiographyICA, internal carotid arteryILT, inferolateral trunkMA, maxillary arteryMMA, middle meningeal arteryMRA, magnetic resonance angiographyOA, ophthalmic arteryOlfA, olfactory arteryPComA, posterior communicating arterySOF, superior orbital fissure.
Hemorrhage risk and clinical features of multiple intracranial arteriovenous malformations. - Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
The aim of this report is to examine clinical characteristics, treatment strategies, and annual hemorrhage incidence rate for patients with multiple arteriovenous malformations (MAVM). The PubMed and EMBASE databases and the arteriovenous malformations (AVM) database at The Johns Hopkins Hospital were searched to identify patients with MAVM. Data related to demographics, clinical features, management, and treatment outcomes were analyzed with descriptive statistics. Thirty-eight patients met the inclusion criteria. The annual hemorrhage incidence rate was 6.7%. Surgical intervention remained the most common single-modality treatment from 1949-2011. Between 1990 and 2011, multiple-modality treatment strategies (36% of cases) were employed more frequently. The most common presenting features were neurological deficit (74%) and hemorrhage (63%). In patients undergoing staged treatment of MAVM, hemorrhage of an untreated nidus (n=5), visualization of a new nidus (n=9), and disappearance of an untreated nidus (n=2) were observed. Limitations of this study include small sample size and reporting bias. The annual hemorrhage incidence rate for MAVM patients was approximately two- to three-fold greater than the reported annual hemorrhage rates for solitary AVM. Combining different treatment modalities has become the most common management strategy. The potential instability of remaining nidi with staged or incomplete treatment necessitates close follow-up in these cases.Copyright Â© 2015 Elsevier Ltd. All rights reserved.
Haptoglobin 2-2 Genotype Is Associated With Cerebral Salt Wasting Syndrome in Aneurysmal Subarachnoid Hemorrhage. - Neurosurgery
Haptoglobin (Hp) genotype has been shown to be a predictor of clinical outcomes in subarachnoid hemorrhage. Cerebral salt wasting (CSW) has been suggested to precede the development of symptomatic vasospasm.To determine if Hp genotype was associated with CSW and subsequent vasospasm after aneurysmal subarachnoid hemorrhage.Hp genotypic determination was done for patients admitted with a diagnosis of subarachnoid hemorrhage. Outcome measures included CSW, delayed cerebral infarction, and Glasgow Outcome Score of 4 to 5 at 30 days. Criteria for CSW included hyponatremia <135 mEq/L, and urine output >4 L in 12 hours with urine sodium >40 mEq/L.A total of 133 patients were included in the study. The 3 Hp subgroups did not differ in terms of baseline characteristics. CSW occurred in 1 patient (3.4%) with Hp 1-1, 8 (14.0%) patients with Hp 2-1, and 15 (31.9%) patients with Hp 2-2 (P = .004). In the multivariate regression model, Hp 2-2 was associated with CSW (odds ratio [OR]: 4.94; CI: 1.78-17.43; P = .01), but Hp 2-1 was not (OR: 2.92; CI: 0.56-4.95; P = .15) compared with Hp 1-1. There were no associations between Hp genotypes and functional outcome or delayed cerebral infarction. CSW was associated with delayed cerebral infarction (OR: 7.46; 95% CI: 2.54-21.9; P < .001).Hp 2-2 genotype was an independent predictor of CSW after subarachnoid hemorrhage. Because CSW is strongly associated with delayed cerebral infarction, the use of Hp genotype testing requires more investigation, and larger prospective confirmation is warranted. Additionally, a more objective definition of CSW needs to be delineated.CSW, cerebral salt wastingDCI, delayed cerebral ischemiaGOS, Glasgow Outcome ScaleHp, HaptoglobinmRS, modified Rankin ScaleSAH, subarachnoid hemorrhageTCD, transcranial Doppler.
Cocaine use as an independent predictor of seizures after aneurysmal subarachnoid hemorrhage. - Journal of neurosurgery
OBJECT Seizures are relatively common after aneurysmal subarachnoid hemorrhage (aSAH). Seizure prophylaxis is controversial and is often based on risk stratification; middle cerebral artery (MCA) aneurysms, associated intracerebral hemorrhage (ICH), poor neurological grade, increased clot thickness, and cerebral infarction are considered highest risk for seizures. The purpose of this study was to evaluate the impact of recent cocaine use on seizure incidence following aSAH. METHODS Prospectively collected data from aSAH patients admitted to 2 institutional neuroscience critical care units between 1991 and 2009 were reviewed. The authors analyzed factors that potentially affected the incidence of seizures, including patient demographic characteristics, poor clinical grade (Hunt and Hess Grade IV or V), medical comorbidities, associated ICH, intraventricular hemorrhage (IVH), hydrocephalus, aneurysm location, surgical clipping and cocaine use. They further studied the impact of these factors on "early" and "late" seizures (defined, respectively, as occurring before and after clipping/coiling). RESULTS Of 1134 aSAH patients studied, 182 (16%) had seizures; 81 patients (7.1%) had early and 127 (11.2%) late seizures, with 26 having both. The seizure rate was significantly higher in cocaine users (37 [26%] of 142 patients) than in non-cocaine users (151 [15.2%] of 992 patients, p = 0.001). Eighteen cocaine-positive patients (12.7%) had early seizures compared with 6.6% of cocaine-negative patients (p = 0.003); 27 cocaine users (19%) had late seizures compared with 10.5% non-cocaine users (p = 0.001). Factors that showed a significant association with increased risk for seizure (early or late) on univariate analysis included younger age (< 40 years) (p = 0.009), poor clinical grade (p = 0.029), associated ICH (p = 0.007), and MCA aneurysm location (p < 0.001); surgical clipping was associated with late seizures (p = 0.004). Following multivariate analysis, age < 40 years (OR 2.04, 95% CI 1.355-3.058, p = 0.001), poor clinical grade (OR 1.62, 95% CI 1.124-2.336, p = 0.01), ICH (OR 1.95, 95% CI 1.164-3.273, p = 0.011), MCA aneurysm location (OR 3.3, 95% CI 2.237-4.854, p < 0.001), and cocaine use (OR 2.06, 95% CI 1.330-3.175, p = 0.001) independently predicted seizures. CONCLUSIONS Cocaine use confers a higher seizure risk following aSAH and should be considered during risk stratification for seizure prophylaxis and close neuromonitoring.
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