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Excimer laser–assisted nonocclusive anastomosis

An emerging technology for use in the creation of intracranial–intracranial and extracranial–intracranial cerebral bypass

David J. Langer, Albert Van Der Zwan, Peter Vajkoczy, Leena Kivipelto, Tristan P. Van Doormaal and Cornelis A. F. Tulleken

Excimer laser–assisted nonocclusive anastomosis (ELANA) has been developed over the past 14 years for assistance in the creation of intracranial bypasses. The ELANA technique allows the creation of intracranial–intracranial and extracranial–intracranial bypasses without the need for temporary occlusion of the recipient artery, avoiding the inherent risk associated with occlusion time. In this review the authors discuss the technique and its indications, while reviewing the clinical results of the procedure. The technique itself is explained using cartoon drawings and intraoperative photographs. Advantages and disadvantages of the technique are also discussed.

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Annick Kronenburg, Tristan van Doormaal, Pieter van Eijsden, Albert van der Zwan, Frans Leijten and Kuo Sen Han

Transcranial magnetic stimulation (TMS) is a noninvasive activation method that is increasingly used for motor mapping. Preoperative functional mapping in vascular surgery is not routinely performed; however, in cases of high-grade arteriovenous malformations (AVMs), it could play a role in preoperative decision making. A 16-year-old male was suffering from a giant, right-sided insular, Spetzler-Martin Grade V AVM. This patient's history included 3 hemorrhagic strokes in the past 3 years, resulting in Medical Research Council Grade 2–3 (proximal) and 2–4 (distal) paresis of the left side of the body and hydrocephalus requiring a ventriculoperitoneal shunt. Preoperative TMS showed absent contralateral innervation of the remaining left-sided motor functions. Subsequently, the AVM was completely resected without any postoperative increase of the left-sided paresis. This case shows that TMS can support decision making in AVM treatment by mapping motor functions.