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Sepideh Amin-Hanjani, William E. Butler, Christopher S. Ogilvy, Bob S. Carter, and Fred G. Barker II

—IC bypass. 28, 29, 44, 62, 70, 75, 100 This bypass procedure is also used to prevent stroke after therapeutic CA occlusion for unclippable aneurysms 56, 78, 88, 92, 93 and when sacrifice of the CA is necessary in resecting tumors at or below the skull base. 19, 39, 59, 87, 89 Reported results from specialized centers have been favorable; however, the number of EC—IC bypass procedures performed in the US outside such centers and the results achieved in these other settings remain unknown. We used a national hospital discharge database to study the use and short

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Tarek Rayan and Sepideh Amin-Hanjani

W ith large or giant aneurysms, the use of multiple tandem clips can be essential for complete obliteration of the aneurysm neck. 9 One disadvantage of this technique, however, is the considerable cumulative weight of these clips, potentially leading to kinking of the underlying parent vessels. We illustrate a simple technique that can be useful in addressing this problem, guided by intraoperative blood flow measurements. Technical Case Report Clinical Presentation A 47-year-old woman, with no medical history, presented with a Hunt and Hess

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Omar M. Qahwash, Ali Alaraj, Victor Aletich, Fady T. Charbel, and Sepideh Amin-Hanjani

T he advent and development of endovascular techniques has revolutionized the management of neurovascular disease. Particularly, it has facilitated the treatment of ruptured intracranial aneurysms by providing a complementary approach to open surgery for direct occlusion, 6 , 12 and for the treatment of consequent vasospasm. 4 , 10 , 19 Early intervention for exclusion of the ruptured aneurysm is preferred to eliminate the risk of rebleeding, and also to facilitate treatment of subsequent vasospasm; these entities are major causes of morbidity and death

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Ali Alaraj, William W. Ashley Jr., Fady T. Charbel, and Sepideh Amin-Hanjani

T he STA-MCA bypass is a technique that provides a conduit for blood flow from the external carotid artery to the MCA territory. This technique was first described by Dr. Yaşargil in 1977 18 and traditionally utilizes either the anterior or posterior branch of the distal STA as an in situ arterial graft. The standard STA-MCA bypass is the workhorse of cerebral revascularization and has been used in the management of cerebovascular occlusive diseases and complex aneurysms. 1 , 3 , 13 , 14 , 18 However, the distal STA is not always an adequate source of

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L. Fernando Gonzalez, Sepideh Amin-Hanjani, Nicholas C. Bambakidis, and Robert F. Spetzler

Posterior circulation lesions constitute approximately 10% of all intracranial aneurysms. Their distribution includes the basilar artery (BA) bifurcation, superior cerebellar artery, posterior inferior cerebellar artery, and anterior inferior cerebellar artery. The specific features of a patient's aneurysm and superb anatomical knowledge help the surgeon to choose the most appropriate approach and to tailor it to the patient's situation. The main principle that must be applied is maximization of bone resection. This allows the surgeon to work within a wider corridor, which facilitates the use of surgical instruments and minimizes retraction of the brain.

The management of aneurysms within the posterior circulation requires expertise in skull base and vascular surgery. Endovascular treatments have become increasingly important, but in this paper the authors focus on the surgical management of these difficult aneurysms. The paper is divided into three parts: the first section is a brief review of the anatomy of the BA; the second part is a review of the techniques associated with the management of posterior fossa aneurysms; and in the third section the authors describe the different approaches, their nuances and indications based on the location of the aneurysm, and its relationship to the surrounding bone (especially the clivus, dorsum sellae, and the free edge of the petrous apex).

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E. Sander Connolly Jr.

Alaraj and colleagues 1 report on 5 patients who, following the surgical repair of ruptured anterior communicating artery (ACoA) aneurysms aided by spinal drainage with or without fenestration of the lamina terminalis, demonstrated clinical “brain sag” with classic CT features: elongation of the midbrain and effacement of the basal cisterns. In all cases the angiogram obtained during the “sag episode” showed inferior displacement of the basilar artery when compared with the “pre-sag” angiogram, and in 3 cases, this displacement was so severe that the

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William W. Ashley Jr., Sepideh Amin-Hanjani, Ali Alaraj, John H. Shin, and Fady T. Charbel

misrepresented the benefit of bypass in properly selected patients. 8 , 12 , 13 Indeed, some continued to perform bypasses in patients with giant aneurysms or other skull base lesions, moyamoya disease, or in certain patients with symptomatic cerebral ischemia refractory to medical therapy. Thus, this phase was characterized by efforts to define a clinical population that could benefit from bypass. Work by Yonas et al. 55 , 58 and others sought to define this population using Xe CT to obtain quantitative measurements of cerebral blood flow. In addition, novel technical

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Christopher J. Stapleton, Gursant S. Atwal, Ahmed E. Hussein, Sepideh Amin-Hanjani, and Fady T. Charbel

surgical revascularization for flow replacement in aneurysm or tumor surgery. In addition, in order to study a homogeneous patient cohort, we included only superficial temporal artery (STA)–to–middle cerebral artery (MCA) bypasses. The technical aspects of EC-IC bypass and measurement of intraoperative blood flow parameters have been described previously. 3 , 9 All bypasses were performed by the senior authors (S.A.H. and F.T.C.). Patients with atherosclerotic disease were considered suitable candidates for revascularization if the following criteria were met: 1

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Sepideh Amin-Hanjani, John H. Shin, Meide Zhao, Xinjian Du, and Fady T. Charbel

E xtracranial–intracranial bypass surgery is a microsurgical technique used for cerebrovascular revascularization since the 1970s. 9 , 36 , 42 Bypasses are currently performed for two types of primary indications: flow augmentation in selected cases of occlusive cerebrovascular disease 2 , 3 , 24 , 26 and flow replacement in the setting of planned vessel occlusion for aneurysm obliteration 2 , 17 , 34 or resection of skull base tumors 18 , 35 involving major vessels. Assessment of EC–IC bypass patency and function has traditionally been performed using

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David H. Jho, Sergey Neckrysh, Julian Hardman, Fady T. Charbel, and Sepideh Amin-Hanjani

under the replaced flap, related to shunt malfunction. In eight patients (7.8%) replanted bone flaps became infected, and pus was observed at the time of flap removal; most samples sent from the operating room grew staphylococcus ( Table 2 ). These skull defects were eventually reconstructed using PMMA with satisfactory results. F ig . 2. Axial CT scans obtained in a 42-year-old man with SAH due to a ruptured anterior communicating artery aneurysm, who underwent left pterional craniectomy with reconstructive cranioplasty at 5 months after initial decompressive