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## Bifrontal approach for clip ligation of bilateral ethmoidal dural arteriovenous fistulas: operative video

Venous interruption through surgical clip ligation is the gold standard treatment for ethmoidal dural arteriovenous fistula (e-dAVF). Their malignant natural history is attributable to the higher predilection for retrograde cortical venous drainage. This video illustrates an e-dAVF in a 70-year-old man with progressive tinnitus and headache. Angiogram revealed bilateral e-dAVFs (Borden III–Cognard III) with one fistula draining into cavernous sinus and another to the sagittal sinus. A bifrontal craniotomy was utilized for venous interruption of both e-dAVFs. Postoperative angiography confirmed curative obliteration with no postoperative anosmia. Bilateral e-dAVFs are rare but can be safely treated simultaneously through a single craniotomy.

The video can be found here: https://youtu.be/666edwKHGKc.

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## Patient out-of-pocket spending in cranial neurosurgery: single-institution analysis of 6569 consecutive cases and literature review

### OBJECTIVE

With drastic changes to the health insurance market, patient cost sharing has significantly increased in recent years. However, the patient financial burden, or out-of-pocket (OOP) costs, for surgical procedures is poorly understood. The goal of this study was to analyze patient OOP spending in cranial neurosurgery and identify drivers of OOP spending growth.

### METHODS

For 6569 consecutive patients who underwent cranial neurosurgery from 2013 to 2016 at the authors’ institution, the authors created univariate and multivariate mixed-effects models to investigate the effect of patient demographic and clinical factors on patient OOP spending. The authors examined OOP payments stratified into 10 subsets of case categories and created a generalized linear model to study the growth of OOP spending over time.

### RESULTS

In the multivariate model, case categories (craniotomy for pain, tumor, and vascular lesions), commercial insurance, and out-of-network plans were significant predictors of higher OOP payments for patients (all p < 0.05). Patient spending varied substantially across procedure types, with patients undergoing craniotomy for pain ($1151 ±$209) having the highest mean OOP payments. On average, commercially insured patients spent nearly twice as much in OOP payments as the overall population. From 2013 to 2016, the mean patient OOP spending increased 17%, from $598 to$698 per patient encounter. Commercially insured patients experienced more significant growth in OOP spending, with a cumulative rate of growth of 42% ($991 in 2013 to$1403 in 2016).

### CONCLUSIONS

Even after controlling for inflation, case-mix differences, and partial fiscal periods, OOP spending for cranial neurosurgery patients significantly increased from 2013 to 2016. The mean OOP spending for commercially insured neurosurgical patients exceeded \$1400 in 2016, with an average annual growth rate of 13%. As patient cost sharing in health insurance plans becomes more prevalent, patients and providers must consider the potential financial burden for patients receiving specialized neurosurgical care.

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## Contralateral transcallosal resection of a ventricular body arteriovenous malformation: 3D operative video

A 46-year-old male presented with an incidentally discovered left ventricular body arteriovenous malformation (AVM). It measured 2 cm in diameter and had drainage via an atrial vein into the internal cerebral vein (Spetzler-Martin Grade III, Supplementary Grade 4). Preoperative embolization of the posterior medial choroidal artery reduced nidus size by 50%. Subsequently, he underwent a right-sided craniotomy for a contralateral transcallosal approach to resect the AVM. This case demonstrates strategic circumferential disconnection of feeding arteries (FAs) to the nidus, the use of aneurysm clips to control large FAs, and the use of dynamic retraction and importance of a generous callosotomy. Postoperatively, he was neurologically intact, and angiogram confirmed complete resection.

The video can be found here: https://youtu.be/j0778LfS3MI.

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## Introduction to the supratentorial cerebral arteriovenous malformation video supplement

It is with great pleasure that we present this Neurosurgical Focus video supplement on supratentorial cerebral arteriovenous malformations (AVMs). We were privileged to view a remarkable number of outstanding videos demonstrating current state-of-the-art management of brain AVMs using endovascular and microsurgical modalities. Careful and critical review was required to narrow down the submitted videos to a workable volume for this supplement, which reflects the excellent work being done at multiple centers with these lesions.

This issue consists of videos that represent modern microsurgical and neuroendovascular techniques for the treatment of supratentorial cerebral AVMs. The videos demonstrate cutting-edge therapies as well as standard ones, which will be valuable to both novice and expert neurointerventionists and neurosurgeons. We are honored to be involved with this project and proud of its content and expert authors. We believe you will enjoy the video content of this supplement and hope that it will raise the collective expertise of our community of AVM surgeons.

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## Microsurgical resection of ambient cistern arteriovenous malformation

The middle tentorial incisural space, located lateral to the midbrain and medial to the temporal lobe, contains the ambient cistern through which courses the third, fourth, and fifth cranial nerves, posterior cerebral artery (PCA), superior cerebellar artery, and the choroidal arteries. Arteriovenous malformations (AVMs) in this compartment are supplied by the thalamogeniculate and posterior temporal branches of the PCA, and drain into tributaries of the basal vein of Rosenthal. We present a case of an AVM in this middle tentorial incisural space that persisted after embolization and radiosurgery, and was microsurgically resected through a subtemporal approach. This case demonstrates the anatomy of the middle incisural space and technical aspects in microsurgical resection of these rare AVMs.

The video can be found here: https://youtu.be/V-dIWh8ys3E.

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## “Picket Fence” clipping technique for large and complex aneurysms

The “picket fence” clipping technique is a method for clipping large aneurysms when conventional clipping across the neck is not feasible, either due to complex anatomy, atherosclerosis, calcification, or compromise of branch origins. This has also been described as a dome fenestration tube. Parallel straight clips, simple and/or fenestrated, are stacked vertically from dome to neck with the tips reconstructing the neck. In this video, the “picket fence” clipping technique is demonstrated on a large middle cerebral artery (MCA) aneurysm. A total of 14 clips reconstructed the neck, completely occluding the aneurysm and preserving outflow in all branch vessels.

The video can be found here: http://youtu.be/0N5rYR6Op8Y.

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## Comparative effectiveness of treatments for cerebral arteriovenous malformations: trends in nationwide outcomes from 2000 to 2009

### Object

The development of multimodality approaches for the treatment of cerebral arteriovenous malformations (AVMs), including microsurgery, endovascular therapy, and radiosurgery, has shifted modern treatment paradigms in the last 10 years. This study examines these changes in detail from a nationwide perspective.

### Methods

The authors examined data from 2001 to 2009 in the Nationwide Inpatient Sample (NIS) database, and they assessed the safety, quality, and cost-effectiveness, including the total number of discharges, discharge proportion, length of stay, and hospital charges. The authors also examined patient demographics (including age, sex, income level, and insurance), hemorrhage status at presentation, and trends in open surgical and endovascular treatment.

### Results

A total of 33,997 inpatient admissions for patients with a primary diagnosis of intracranial AVM were identified, with a mean of 4191 patients admitted annually. The mean hospital charges increased 2-fold over the study period without significant differences in outcomes. There were substantial differences between surgical, endovascular, radiosurgical, and multimodality treatments. The proportion of AVMs treated microsurgically remained stable over this period, while the proportion treated endovascularly dramatically increased in size, and the data demonstrate important patient-level distinctions among groups. Outcomes and complication profiles were significantly different between treatment modalities and were impacted by age and hemorrhage status.

### Conclusions

Charges associated with treatment of cerebral AVMs to the payer and society have increased dramatically over the first decade of the 21st century without clear improvements in quality parameters. However, analysis of the 3 primary treatment modalities has demonstrated differences and warrants further investigation to understand which patient population would benefit maximally from each. Unfortunately, with only imprecise measurements of quality in health care delivery, it remains imperative to develop national databases in which parameters, such as survival, functional outcomes, quality of life, and complication rates, can be assessed to examine the value of care delivered in a more meaningful way. Demonstrating an ever-increasing value of delivered health care will be imperative in our evolving health care system.

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## Clinical presentation and surgical management of intramedullary spinal cord cavernous malformations

### Object

Intramedullary cavernous malformation (CM) is a rare entity, accounting for 5% of all intraspinal lesions. The objective in this study was to define the clinical characteristics of this disease, detail the surgical approach and technique, and present the clinical outcome.

### Methods

Retrospective chart review was performed in 22 patients with histologically confirmed CMs. The authors used a laminectomy approach for midline dorsal lesions, with unilateral radical facetectomy and dentate ligament resection for laterally or ventrally located lesions. Patient profiles, operative indications, surgical approaches, operative findings, complications, and long-term follow-up were reviewed.

### Results

The average age of patients in the cohort was 43 ± 14 years, the average duration of symptoms was 7 ± 7 months, and the average follow-up was 6 ± 4 years. The average size of the lesion was 1 ± 0.4 cm, the average surgical time was 4 ± 0.96 hours, and the average estimated blood loss was 350 ± 131 ml. The rate of complication was 5% (1 patient; due to a wound infection). According to the McCormick classification, the score for the cohort was 1.8 ± 1.2 preoperatively, 2.1 ± 1.2 postoperatively, and 1.3 ± 0.65 at late follow-up. (All preceding values are given as the mean ± SD.) There was a significant neurological improvement at follow-up compared with the preoperative state (p < 0.05). The majority of patients (50%) had a stable outcome compared with their preoperative state, with a large proportion (41%) having an improved outcome. A minority of patients (9%) had a worsened outcome due to dysesthetic pain. Patients with dysesthesia had a longer duration of clinical symptoms prior to surgery compared with patients without dysesthesia (p < 0.05).

### Conclusions

The authors demonstrated the safety, efficacy, and durability of their surgical approach for resection of spinal intramedullary CM. Proper examination, preoperative imaging, and prompt surgical intervention were necessary for a satisfactory outcome.

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## Nonsaccular aneurysms of the azygos anterior cerebral artery

### Object

The azygos or undivided anterior cerebral artery (ACA) is a rare variant, and aneurysms associated with this variant are particularly rare. Most reported azygos ACA aneurysms are saccular, but the authors encountered four patients with this variant who had nonsaccular aneurysms. A review of the management of these lesions and this morphological distinction is presented.

### Methods

A retrospective review of patients with aneurysms treated over a 6-year period identified five Type I (according to the Baptista classification) azygos ACA lesions, of which four were nonsaccular. Aneurysms associated with other ACA variants (Baptista Types II and III) were excluded.

Azygos ACA aneurysms accounted for 0.5% of all treated lesions and 1.7% of all ACA and anterior communicating artery aneurysms. One lesion in this series was located proximally at the azygos ACA origin, and three were located distally. All four aneurysms were large (>10 mm in diameter), and two were thrombotic. All aneurysms were treated with microsurgical clip occlusion.

### Conclusions

Azygos ACA aneurysms are rare, and may have unusual nonsaccular anatomy (for example, fusiform shape, broad base, complex branching, and/or thrombus in the lumen). The nonsaccular morphology of these aneurysms may render them unsuitable for endovascular coil placement, and may complicate their microsurgical management.