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Dale Ding and Kenneth C. Liu

AS , Albuquerque FC , Niemann DB , Aagaard-Kienitz B , : US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results . Stroke 38 : 881 – 887 , 2007 9 Freitas JM , Zenteno M , Aburto-Murrieta Y , Koppe G , Abath C , Nunes JA , : Intracranial arterial stenting for symptomatic stenoses: a Latin American experience . Surg Neurol 68 : 378 – 386 , 2007 10 Geremia G , Haklin M , Brennecke L : Embolization of experimentally created aneurysms with

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Robert M. Starke, Dale Ding, Christopher R. Durst, R. Webster Crowley, and Kenneth C. Liu

Dissecting vertebral artery (VA) aneurysms are difficult to obliterate when the parent artery cannot be safely occluded. In this video, we demonstrate a combined microsurgical and endovascular treatment technique for a ruptured, dissecting VA aneurysm incorporating the origin of the posterior inferior cerebellar artery (PICA). We first performed a PICA-PICA side-to-side bypass to preserve flow through the right PICA. An endovascular approach was then utilized to embolize the proximal portion of the aneurysm from the right VA and the distal portion of the aneurysm from the left VA.

The video can be found here: http://youtu.be/dkkKsX2BiJI.

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Douglas Kondziolka

factors. Early reduction in flow following radiosurgery may increase obliteration rates and decrease the length of the period in which the patient is at risk of hemorrhage. Of course, postradiosurgical endovascular repair of an associated aneurysm seems important. In this series, only 6% of patients had associated aneurysms, 1 a number less than that reported by some other authors who have noted associated aneurysms in up to 50% of patients. I think that our understanding of why an AVM ruptures is far from complete. We need to better understand how flow dynamics, blood

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Robert M. Starke, Chun-Po Yen, Dale Ding, and Jason P. Sheehan

ganglia, thalamus, or brainstem 264 (26.1) 0.79 0.58–1.06 0.119 eloquent location of AVM 677 (66.9) 0.62 0.47–0.82 0.001 mean AVM vol ± SD (cm 3 ) 3.5 ± 3.3 0.80 0.76–0.84 <0.001 AVM diameter  0–3 cm 799 (79.0) 1.00  3–6 cm 213 (21.0) 0.30 0.22–0.41 <0.001 mean maximal diameter ± SD (cm) 2.28 ± 0.91 0.45 0.39–0.53 <0.001 deep venous drainage 526 (52.0) 0.95 0.74–1.23 0.708 associated aneurysm 97 (9.6) 0.75 0.49–1.14 0.181 history of embolization 244 (24.1) 0

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Dale Ding, Chun-Po Yen, Robert M. Starke, Zhiyuan Xu, and Jason P. Sheehan

draining veins in 198 patients (35.0%). Associated aneurysms, defined as those on feeding arteries in, or proximal to, the nidus, were present in 32 cases (5.7%) including 13 intranidal aneurysms (2.3%) and 19 perinidal aneurysms (3.4%). The Spetzler-Martin grade, which factors in AVM diameter, superficial or deep venous drainage, and eloquence of involved cortex, was I in 71 patients (12.6%), II in 179 patients (31.7%), III in 252 patients (44.6%), IV in 63 patients (11.1%), and V in 0 patients. 44 The radiosurgery-based AVM score (RBAS), which factors in patient age

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Mayur Sharma, Beatrice Ugiliweneza, Enzo M. Fortuny, Nicolas K. Khattar, Noberto Andaluz, Robert F. James, Brian J. Williams, Maxwell Boakye, and Dale Ding

U nruptured intracranial aneurysms (UIAs) have traditionally been reported to have a prevalence of 1%–2%, and they account for up to 85% of spontaneous subarachnoid hemorrhages. 8 More recently, the increased use of neuroimaging modalities has led to an escalated frequency of UIA diagnoses, with prevalences of 7% in patients between 35 and 75 years of age 20 and 8.8% overall. 19 The International Study of Unruptured Intracranial Aneurysms (ISUIA) 46 reported 5-year cumulative hemorrhage risks, stratified by aneurysm size and location, that ranged from 0% for

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Dale Ding, Chun-Po Yen, Zhiyuan Xu, Robert M. Starke, and Jason P. Sheehan

intranidal aneurysms and those with intranidal arteriovenous shunts. For the majority of low-grade AVMs, the neoadjuvant role of embolization prior to microsurgery or radiosurgery seems similarly minor. However, as advances in endovascular technology continue to be made and our understanding of multimodality AVM treatment continues to evolve, the impact of embolization on AVMs, such as after rather than before radiosurgery, has yet to reach its maximum potential. Role of Radiosurgery for Treatment of SM Grade I and II AVMs In a large cohort of low-grade AVM patients

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Jason Sheehan, Dale Ding, and Robert M. Starke

T he successful obliteration of selected cerebral arteriovenous malformations (AVMs) using the Gamma Knife prompted the treatment of cavernous malformations (CMs) and aneurysms. For CMs, their small volume, lack of intervening normal brain tissue, and relatively low rate of clinically significant hemorrhage made them an appealing target for stereotactic radiosurgery (SRS). Radiosurgery for aneurysms was quickly abandoned as a failure, but radiosurgery for CMs persists despite controversy regarding its therapeutic value. 13 Unlike for AVMs, radiosurgery

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Ching-Jen Chen, Pedro Norat, Dale Ding, George A. C. Mendes, Petr Tvrdik, Min S. Park, and M. Yashar Kalani

AVM-associated morbidity and mortality can be attributed to hemorrhage secondary to rupture of the nidus or flow-related aneurysms. 3 , 16 , 47 The inherent lack of normal smooth muscle properties, as a result of aberrant angiogenesis and vascular remodeling in the vascular beds of AVMs, predisposes these lesions to rupture. 4 , 30 , 55 Risk factors for AVM rupture include prior hemorrhage, associated arterial aneurysms, exclusively deep venous drainage, and deep AVM location. 19 , 28 Despite this, elimination of hemorrhage risk by extirpation or endoluminal

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I. Jonathan Pomeraniec, Dale Ding, Robert M. Starke, Kenneth C. Liu, E. Kelly Mrachek, M. Beatriz Lopes, and Jason P. Sheehan

RM , Yen CP , Shih HH , Buell TJ , : Radiosurgery for cerebral arteriovenous malformations with associated arterial aneurysms . World Neurosurg 87 : 77 – 90 , 2016 19 Ding D , Xu Z , Yen CP , Starke RM , Sheehan JP : Radiosurgery for cerebral arteriovenous malformations in elderly patients: effect of advanced age on outcomes after intervention . World Neurosurg 84 : 795 – 804 , 2015 20 Ding D , Xu Z , Yen CP , Starke RM , Sheehan JP : Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric