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Krishna C. Joshi, Daniel M. Heiferman, André Beer-Furlan and Demetrius K. Lopes

External carotid artery (ECA) to internal carotid artery (ICA) bypass is a well-established procedure for the treatment of chronic ischemic diseases of the carotid artery. Rarely de novo aneurysms can develop at the site of anastomosis. The treatment of these aneurysms can be very challenging due to various factors, including the presence of graft, previous craniotomy, atherosclerotic vessels, and lack of direct access. In this video the authors report and discuss the management of a right middle cerebral artery (MCA) wide-necked de novo aneurysm by stent-assisted coiling through a retrograde trans-posterior communicating artery access.

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Waleed Brinjikji, Harry J. Cloft, Giuseppe Lanzino, Leonardo Rangel-Castilla and Pearse P. Morris

Arteriovenous fistulae of the internal maxillary artery are exceedingly rare, with less than 30 cases reported in the literature. Most of these lesions are congenital, iatrogenic, or posttraumatic. The most common presentation of internal maxillary artery fistulae is pulsatile tinnitus and headache. Because these lesions are single-hole fistulae, they can be easily cured with endovascular techniques. The authors present a case of a patient who presented to their institution with a several-year history of pulsatile tinnitus who was found to have an internal maxillary artery arteriovenous fistula, which was treated endovascularly with transarterial coil and Onyx embolization.

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Leonardo Rangel-Castilla, Hussain Shallwani and Adnan H. Siddiqui

Transvenous embolization (TE) has been increasingly applied for arteriovenous malformation (AVM) treatment. Transient cardiac standstill (TCS) has been described in cerebrovascular surgery but is uncommon for endovascular embolization. The authors present a patient with a ruptured thalamic AVM in whom both techniques were applied simultaneously. Surgery was considered, but the patient refused. Transarterial embolization was performed with an incomplete result. The deep-seated draining vein provided sole access to the AVM. A microcatheter was advanced into the draining vein. Under TCS, achieved with rapid ventricular pacing, complete AVM embolization was obtained. One-year magnetic resonance imaging and cerebral angiography demonstrated no residual AVM.

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Oriela Rustemi, Loris Di Clemente, Fabio Raneri, Lorenzo Volpin and Giuseppe Iannucci

Distal, dissecting, middle cerebral artery (MCA) aneurysms are changing surgically and endovascularly. Endovascular treatment requires flow diverter stenting. A good vessel visualization is crucial for safe navigation. Three-dimensional rotational digital subtraction angiography (3D-DSA) is used routinely in diagnostic imaging. The utilization of the 3D-DSA road map in vessel navigation and stent deployment is novel. An illustrative video of a distal, dissecting left MCA aneurysm treated with flow diverter stenting is presented. The technical issues were distal location, dissecting nature with double lumen, proximal stenosis, and vessel curves. The 3D-DSA road map helped to enhance visualization with a safer procedure.

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David G. Brachman, Emad Youssef, Christopher J. Dardis, Nader Sanai, Joseph M. Zabramski, Kris A. Smith, Andrew S. Little, Andrew G. Shetter, Theresa Thomas, Heyoung L. McBride, Stephen Sorensen, Robert F. Spetzler and Peter Nakaji


Effective treatments for recurrent, previously irradiated intracranial meningiomas are limited, and resection alone is not usually curative. Thus, the authors studied the combination of maximum safe resection and adjuvant radiation using permanent intracranial brachytherapy (R+BT) in patients with recurrent, previously irradiated aggressive meningiomas.


Patients with recurrent, previously irradiated meningiomas were treated between June 2013 and October 2016 in a prospective single-arm trial of R+BT. Cesium-131 (Cs-131) radiation sources were embedded in modular collagen carriers positioned in the operative bed on completion of resection. The Cox proportional hazards model with this treatment as a predictive term was used to model its effect on time to local tumor progression.


Nineteen patients (median age 64.5 years, range 50–78 years) with 20 recurrent, previously irradiated tumors were treated. The WHO grade at R+BT was I in 4 (20%), II in 14 (70%), and III in 2 (10%) cases. The median number of prior same-site radiation courses and same-site surgeries were 1 (range 1–3) and 2 (range 1–4), respectively; the median preoperative tumor volume was 11.3 cm3 (range 0.9–92.0 cm3). The median radiation dose from BT was 63 Gy (range 54–80 Gy). At a median radiographic follow-up of 15.4 months (range 0.03–47.5 months), local failure (within 1.5 cm of the implant bed) occurred in 2 cases (10%). The median treatment-site time to progression after R+BT has not been reached; that after the most recent prior therapy was 18.3 months (range 3.9–321.9 months; HR 0.17, p = 0.02, log-rank test). The median overall survival after R+BT was 26 months, with 9 patient deaths (47% of patients). Treatment was well tolerated; 2 patients required surgery for complications, and 2 experienced radiation necrosis, which was managed medically.


R+BT utilizing Cs-131 sources in modular carriers represents a potentially safe and effective treatment option for recurrent, previously irradiated aggressive meningiomas.

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Time is spine: a review of translational advances in spinal cord injury

JNSPG 75th Anniversary Invited Review Article

Jetan H. Badhiwala, Christopher S. Ahuja and Michael G. Fehlings

Acute traumatic spinal cord injury (SCI) is a devastating event with far-reaching physical, emotional, and economic consequences for patients, families, and society at large. Timely delivery of specialized care has reduced mortality; however, long-term neurological recovery continues to be limited. In recent years, a number of exciting neuroprotective and regenerative strategies have emerged and have come under active investigation in clinical trials, and several more are coming down the translational pipeline. Among ongoing trials are RISCIS (riluzole), INSPIRE (Neuro-Spinal Scaffold), MASC (minocycline), and SPRING (VX-210). Microstructural MRI techniques have improved our ability to image the injured spinal cord at high resolution. This innovation, combined with serum and cerebrospinal fluid (CSF) analysis, holds the promise of providing a quantitative biomarker readout of spinal cord neural tissue injury, which may improve prognostication and facilitate stratification of patients for enrollment into clinical trials. Given evidence of the effectiveness of early surgical decompression and growing recognition of the concept that “time is spine,” infrastructural changes at a systems level are being implemented in many regions around the world to provide a streamlined process for transfer of patients with acute SCI to a specialized unit. With the continued aging of the population, central cord syndrome is soon expected to become the most common form of acute traumatic SCI; characterization of the pathophysiology, natural history, and optimal treatment of these injuries is hence a key public health priority. Collaborative international efforts have led to the development of clinical practice guidelines for traumatic SCI based on robust evaluation of current evidence. The current article provides an in-depth review of progress in SCI, covering the above areas.

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Alex B. Valadka, Jaclyn S. Valadka, Patrick R. Valadka and Patricia C. Valadka

The theme of the 2018 American Association of Neurological Surgeons Annual Meeting was “The Privilege of Service.” In the current climate of rapid change in healthcare delivery and increasing pressure on physicians, this theme was chosen to remind us of our true priorities and of the amazing opportunities that we have as neurosurgeons. In parallel to the classic triple-threat practitioner who excels in teaching, research, and clinical care, future neurosurgeons will need to acquire mastery in three areas of service, which have been summarized as the three A’s: administration, advocacy, and altruism. The blessings that we enjoy afford us a platform from which we can take advantage of the many opportunities to experience the privilege of serving others.