indications have arrived on the market. Devices in use range from carotid artery stents for treatment of cervical carotid artery stenoocclusive disease (an area in which interventional neuroradiology, endovascular neurosurgery, interventional cardiology, and peripheral endovascular surgery overlap), to low metal surface area buttressing stents for intracranial use as adjuncts to standard microcoil embolization techniques, to flow diverters such as the PED, to the new frontier of combination buttress/flow-diverting devices like the PulseRider (Codman/Pulsar Vascular), which
Brian M. Corliss, Adam J. Polifka, Neil S. Harris, Brian L. Hoh, and W. Christopher Fox
Kimon Bekelis, Dan Gottlieb, Nicos Labropoulos, Yin Su, Stavropoula Tjoumakaris, Pascal Jabbour, and Todd A. MacKenzie
, with a growing number of hybrid neurosurgeons performing both clipping and coiling. 1 Endovascular coiling is also performed by radiologists and other proceduralists who solely focus on this approach for the treatment of cerebral aneurysms. It is often questioned whether hybrid neurosurgeons can perform endovascular surgery as successfully and safely as providers focusing only on coiling. However, limited literature exists that has attempted to answer this question. De Vries and Boogaarts published a single-center series 6 on the outcomes of coiling of ruptured
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.
The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms
JNSPG 75th Anniversary Invited Review Article
Michael T. Lawton and Michael J. Lang
Despite the erosion of microsurgical case volume because of advances in endovascular and radiosurgical therapies, indications remain for open resection of pathology and highly technical vascular repairs. Treatment risk, efficacy, and durability make open microsurgery a preferred option for cerebral cavernous malformations, arteriovenous malformations (AVMs), and many aneurysms. In this paper, a 21-year experience with 7348 cases was reviewed to identify trends in microsurgical management. Brainstem cavernous malformations (227 cases), once considered inoperable and managed conservatively, are now resected in increasing numbers through elegant skull base approaches and newly defined safe entry zones, demonstrating that microsurgical techniques can be applied in ways that generate entirely new areas of practice. Despite excellent results with microsurgery for low-grade AVMs, brain AVM management (836 cases) is being challenged by endovascular embolization and radiosurgery, as well as by randomized trials that show superior results with medical management. Reviews of ARUBA-eligible AVM patients treated at high-volume centers have demonstrated that open microsurgery with AVM resection is still better than many new techniques and less invasive approaches that are occlusive or obliterative. Although the volume of open aneurysm surgery is declining (4479 cases), complex aneurysms still require open microsurgery, often with bypass techniques. Intracranial arterial reconstructions with reimplantations, reanastomoses, in situ bypasses, and intracranial interpositional bypasses (third-generation bypasses) augment conventional extracranial-intracranial techniques (first- and second-generation bypasses) and generate innovative bypasses in deep locations, such as for anterior inferior cerebellar artery aneurysms. When conventional combinations of anastomoses and suturing techniques are reshuffled, a fourth generation of bypasses results, with eight new types of bypasses. Type 4A bypasses use in situ suturing techniques within the conventional anastomosis, whereas type 4B bypasses maintain the basic construct of reimplantations or reanastomoses but use an unconventional anastomosis. Bypass surgery (605 cases) demonstrates that open microsurgery will continue to evolve. The best neurosurgeons will be needed to tackle the complex lesions that cannot be managed with other modalities. Becoming an open vascular neurosurgeon will be intensely competitive. The microvascular practice of the future will require subspecialization, collaborative team effort, an academic medical center, regional prominence, and a large catchment population, as well as a health system that funnels patients from hospital networks outside the region. Dexterity and meticulous application of microsurgical technique will remain the fundamental skills of the open vascular neurosurgeon.
Pablo Sosa, Manuel Dujovny, Ibe Onyekachi, Noressia Sockwell, Fabián Cremaschi, and Luis E. Savastano
surgical procedures involving this region. 6 Methods A search of the English- and Spanish-language literature was performed using the PubMed, BioMed, and Google Scholar scientific databases using the following key indexing terms: cerebellopontine angle, cerebellar flocculus, cerebellar paraflocculus, parafloccular space, brainstem perforating vessels, and anteroinferior cerebellar artery, in combination with anatomy, histology, physiology, neurology, neuroradiology, microsurgery, endovascular surgery, surgical complications, and stroke. Then, 7
Yiping Li, Jason Kim, Dustin Simpson, Beverly Aagaard-Kienitz, David Niemann, Ignatius N. Esene, and Azam Ahmed
( Table 5 ). The final multivariate model identified an increased number of DWI lesions as the only significant association with the development of PNEs (p < 0.001, OR 49.85, 95% CI 5.56–447.10). Discussion In this study, we used an MRI protocol to study the relationship between BBBD and neurological complications in patients undergoing endovascular treatment of unruptured IAs. To the best of our knowledge, this is the first report comparing the extent of BBBD and ischemia between TNEs and PNEs after endovascular surgery. Consistent with the literature, we
William T. Couldwell
topics of the video issues will be much more diverse, covering the breadth of operative neurosurgery. This will encompass both macro- and microsurgical video, and cover such diverse clinical arenas such as spine, functional, skull base, and open and endovascular surgery. Our wish is that these video supplements will enhance the educational materials offered by Focus and enable surgeons around the world to learn from subspecialty leaders of our field.
Louis J. Kim
of excellence? Finally, the authors describe the state of the art in endovascular robotics, providing firsthand experience that demonstrates its feasibility and relative ease of use. Whether the advantages of robotic endovascular surgery are sufficient to justify the cost and training of users has yet to be determined. The potential for remote-controlled surgery and reduced radiation exposure to operators remains attractive. This is a useful update in 3 technologies that provides much food for thought in acute stroke care. References 1 Thiel P , Masters
Yasuaki Imajo, Tsukasa Kanchiku, Yuichiro Yoshida, Norihiro Nishida, and Toshihiko Taguchi
T he occurrence of epidural or paraspinal arteriovenous fistula (AVF) is rare, 3 and that of spinal intraosseous AVF is extremely rare. Only 2 cases of spinal intraosseous AVF associated with a fracture of the vertebral body have been reported in the English literature. 1 , 2 One of the 2 cases 1 had a fracture of the L-3 vertebral body with a large flow void. In general, spinal reconstruction is required in such cases. However, the details of spinal reconstruction, functional recovery, and remodeling of the L-3 vertebra after endovascular surgery were
Charles J. Prestigiacomo and T. Forcht Dagi
history.” Difficulties arise from both an evaluative and a nosological standpoint. For example, from an evaluative standpoint, how does one stratify the relative importance of corticosteroids, osmotic diuretics, and CSF drainage techniques and technologies in the control of intracranial pressure and the facilitation of exposure for base of skull surgery? How does one think about the idea of hybrid surgery and stereotactic radiation? What will be the long-term view of anatomical approaches to giant basilar aneurysms in the light of endovascular surgery? Have we reached a