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Lorenzo Rinaldo, Waleed Brinjikji and Leonardo Rangel-Castilla

An 80-year-old female presented with a long history of severe pulsatile tinnitus, vertigo, and decreased hearing. She was found to have a large right-sided tentorial arteriovenous fistula (AVF) with enlarged deep draining veins, including the vein of Rosenthal. The patient underwent Onyx embolization of the fistula via a combined transarterial and transvenous approach resulting in complete obliteration of the fistula. Her symptoms improved immediately after the procedure and at 6-months’ follow-up she was clinically asymptomatic with no evidence of residual fistula on neuroimaging. Transvenous embolization of AVF is at times necessary when transarterial access is not possible.

The video can be found here: https://youtu.be/uOMHY7eaOoQ.

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Thomas J. Sorenson, Lucio De Maria, Leonardo Rangel-Castilla and Giuseppe Lanzino

Craniocervical junction dural arteriovenous fistulas (dAVFs) are rare vascular lesions with a potentially dangerous natural history due to the onset of neurological deficit secondary to intracranial hemorrhage or myelopathy due to venous congestion. Despite advances in endovascular techniques, many dAVFs located in this area continue to require surgical treatment as embolization is often not feasible or safe. In this video, the authors illustrate a patient with a symptomatic craniocervical junction dAVF who had undergone attempted Onyx embolization at another institution. Because of persistent filling of the fistula and worsening myelopathy after the previous attempt, the patient was referred to the authors’ clinic for definitive surgical treatment. The video illustrates the typical location of the early draining vein in most craniocervical junction dAVFs immediately below the emergence of the vertebral artery from the dura. The patient underwent successful definitive clip ligation of the fistula, which was exposed through a lateral suboccipital craniotomy.

The video can be found here: https://youtu.be/Bvg6VKLgwO0.

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Bradley Kolb, Hassan Fadel, Gary Rajah, Hamidreza Saber, Ali Luqman and Leonardo Rangel-Castilla

OBJECTIVE

Steno-occlusive diseases of the cerebral vasculature have been associated with cognitive decline. The authors performed a systematic review of the existing literature on intracranial steno-occlusive disease, including intracranial atherosclerosis and moyamoya disease (MMD), to determine the extent and quality of evidence for the effect of revascularization on cognitive performance.

METHODS

A systematic search of PubMed/MEDLINE, the Thomson Reuters Web of Science Core Collection, and the KCI Korean Journal Database was performed to identify randomized controlled trials (RCTs) in the English-language literature and observational studies that compared cognitive outcomes before and after revascularization in patients with steno-occlusive disease of the intracranial vasculature, from which data were extracted and analyzed.

RESULTS

Nine papers were included, consisting of 2 RCTs and 7 observational cohort studies. Results from 2 randomized trials including 142 patients with symptomatic intracranial atherosclerotic steno-occlusion found no additional benefit to revascularization when added to maximal medical therapy. The certainty in the results of these trials was limited by concerns for bias and indirectness. Results from 7 observational trials including 282 patients found some cognitive benefit for revascularization for symptomatic atherosclerotic steno-occlusion and for steno-occlusion related to MMD in children. The certainty of these conclusions was low to very low, due to both inherent limitations in observational studies for inferring causality and concerns for added risk of bias and indirectness in some studies.

CONCLUSIONS

The effects of revascularization on cognitive performance in intracranial steno-occlusive disease remain uncertain due to limitations in existing studies. More well-designed randomized trials and observational studies are needed to determine if revascularization can arrest or reverse cognitive decline in these patients.

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Avital Perry, Christopher S. Graffeo, Lucas P. Carlstrom, William J. Anding, Michael J. Link and Leonardo Rangel-Castilla

OBJECTIVE

Sylvian fissure dissection following subarachnoid hemorrhage (SAH) is a challenging but fundamental skill in microneurosurgery, and one that has become increasingly difficult to develop during residency, given the overarching management trends. The authors describe a novel rodent model for simulation of sylvian fissure dissection and cerebrovascular bypass under SAH conditions.

METHODS

A standardized microvascular anastomosis model comprising rat femoral arteries and veins was used for the experimental framework. In the experimental protocol, following exposure and skeletonization of the vessels, extensive, superficial (1- to 2-mm) soft-tissue debridement was conducted and followed by wound closure and delayed reexploration at intervals of 7, 14, and 28 days. Two residents dissected 1 rat each per time point (n = 6 rats), completing vessel skeletonization followed by end-to-end artery/vein anastomoses. Videos were reviewed postprocedure to assess scar score and relative difficulty of dissection by blinded raters using 4-point Likert scales.

RESULTS

At all time points, vessels were markedly invested in friable scar, and exposure was subjectively assessed as a reasonable surrogate for sylvian fissure dissection under SAH conditions. Scar score and relative difficulty of dissection both indicated 14 days as the most challenging time point.

CONCLUSIONS

The authors’ experimental model of femoral vessel skeletonization, circumferential superficial soft-tissue injury, and delayed reexploration provides a novel approximation of sylvian fissure dissection and cerebrovascular bypass under SAH conditions. The optimal reexploration interval appears to be 7–14 days. To the authors’ knowledge, this is the first model of SAH simulation for microsurgical training, particularly in a live animal system.

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Lorenzo Rinaldo, Harry J. Cloft, Giuseppe Lanzino and Leonardo Rangel-Castilla

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Giovanni Vercelli, Thomas J. Sorenson, Enrico Giordan, Giuseppe Lanzino and Leonardo Rangel-Castilla

Cerebral protection device utilization during carotid artery stenting (CAS) has been demonstrated to decrease the risk of perioperative stroke. The ProximAl Protection with the MO.MA Device During CaRotid Stenting (ARMOUR) Trial had the lowest event rates of any independently adjudicated study. In this video of two cases of severe carotid artery stenosis, the authors present the nuances of the CAS procedure utilizing a dual-balloon guide catheter device (MO.MA). This device has the benefit of being in place before the lesion is crossed with any device, being able to arrest flow while the atherosclerotic lesion is crossed, and aiding in protection from distal emboli and stroke.

The video can be found here: https://youtu.be/0o8DlC1n6_M.

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Leonardo Rangel-Castilla and Giuseppe Lanzino

In elderly patients with acute ischemic stroke, tortuosity of the proximal vertebral artery makes access from the transfemoral route challenging and time consuming. In such cases, a transradial approach (TA) offers a more direct vertebral artery (VA) access that overcomes proximal VA tortuosity. In this video the authors illustrate nuances of the TA for acute basilar artery occlusion in two patients with challenging proximal VA anatomy. Techniques, devices, and pitfalls are discussed. In both patients, mechanical clot retrieval was successful and resulted in significant recovery of function. The authors believe that the TA should be the initial approach for basilar artery (BA) occlusion management in elderly patients and should be considered for selected patients with other conditions requiring endovascular treatment.

The video can be found here: https://youtu.be/_Ym9tMKUy_4.

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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.

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

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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.

The video can be found here: https://youtu.be/CAzb9md_xBU.

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Gary Rajah, Hamidreza Saber, Rasanjeet Singh and Leonardo Rangel-Castilla

Neuromodulation and deep brain stimulation (DBS) have been increasingly used in many neurological ailments, including essential tremor, Parkinson’s disease, epilepsy, and more. Yet for many patients and practitioners the desire to utilize these therapies is met with caution, given the need for craniotomy, lead insertion through brain parenchyma, and, at many times, bilateral invasive procedures. Currently endovascular therapy is a standard of care for emergency thrombectomy, aneurysm treatment, and other vascular malformation/occlusive disease of the cerebrum. Endovascular techniques and delivery catheters have advanced greatly in both their ability to safely reach remote brain locations and deliver devices. In this review the authors discuss minimally invasive endovascular delivery of devices and neural stimulating and recording from cortical and DBS targets via the neurovascular network.