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Bradley A. Gross, Alexander E. Ropper, and Rose Du

T he association of cerebral AVMs and aneurysms is well established in the literature. 2 , 4 , 8 Recent natural history data have clearly suggested the significance of this association, as AVMs with associated aneurysms are more likely to have hemorrhagic presentation 9 , 11 as well as hemorrhage on follow-up. 2 , 4 In contrast, the frequency and significance of aneurysms associated with cerebral DAVFs is infrequently addressed, and is limited to case reports and small patient series. 3 , 5–7 , 10 In this report, we review our own patient cohort of

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Bradley A. Gross, Daryoush Tavanaiepour, Rose Du, Ossama Al-Mefty, and Ian F. Dunn

W ith a notoriously malevolent natural history, 2 , 39 , 45 , 61 complex posterior circulation aneurysms often merit treatment, unless contraindicated by patient age or medical comorbidities. Although endovascular approaches have facilitated safe treatment of narrow-necked aneurysms of the posterior circulation, more complex, larger lesions remain a significant challenge for either endovascular or microsurgical approaches. 14 , 15 , 18 , 44 , 45 , 52 Recent enthusiasm for endovascular flow-diverting stents has been curbed by poorly explained delayed

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Bradley A. Gross and Rose Du

patients with AVMs, and those providing overall annual hemorrhage rates for patients with any type of vascular malformation were excluded. Data Extraction We both independently performed data extraction, which was consistent. We extracted epidemiological data including patient age, patient sex, AVM location, AVM size, AVM drainage pattern, prior rupture, and associated aneurysms. We then calculated the number of hemorrhages and patient-years of follow-up across these studies, also making note of subgroup analyses for annual hemorrhage rates and risk factors. Hazard

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Ning Lin, Allen Ho, Bradley A. Gross, Steven Pieper, Kai U. Frerichs, Arthur L. Day, and Rose Du

T he prevalence of cerebral aneurysms is estimated to be 1%–2% 16 , 17 , 23 in the general population and could be higher in the elderly. 7 The management of an incidentally discovered intracranial aneurysm remains one of the most controversial topics in neurosurgery. Therapeutic options such as microsurgical clipping or endovascular coiling are offered to eradicate the risk of aneurysm rupture, which results in SAH and can lead to devastating morbidity and mortality. As a result of the ISUIA (International Study of Unruptured Intracranial Aneurysms), 4

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Hormuzdiyar H. Dasenbrock, Robert F. Rudy, Timothy R. Smith, William B. Gormley, Nirav J. Patel, Kai U. Frerichs, M. Ali Aziz-Sultan, and Rose Du

T he decision analysis of clipping an unruptured cerebral aneurysm depends on weighing the benefit of treatment with the risk of perioperative morbidity and mortality. 14 , 16 , 19 , 24 , 26 , 38 However, predicting both rupture and postprocedural complications from aneurysm treatment is difficult. 16 Several prospective studies have evaluated the rupture risk of aneurysms, including the International Study of Unruptured Intracranial Aneurysms (ISUIA) and at the Unruptured Cerebral Aneurysm Study. 16 , 26 , 41 Risk stratification algorithms have been

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Bradley A. Gross, Pui Man Rosalind Lai, and Rose Du

information was extracted: patient age, sex, initial GCS score, hemorrhage pattern (intraparenchymal, subarachnoid, and/or intraventricular), AVM Spetzler-Martin grade (size, location, drainage), 11 associated aneurysms, and whether the patient underwent early surgery to treat the AVM and/or evacuate the hemorrhage (within 2 weeks). Trace SAH in a single convexity sulcus was not included as a formal subarachnoid bleed for our analysis. Our criteria for EVD placement mirror those for patients with aneurysmal SAH—nonpharmacological drowsiness and/or obtundation as a

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Giuseppe Lanzino

Treatment of small, unruptured intracranial aneurysms is controversial, and the decision of whether to intervene is a difficult one. While a very small subset of unruptured aneurysms go on to rupture, the vast majority remain quiescent for years. Different factors (related to patient, aneurysm, and surgeon/technique) are taken into consideration to guide the decision-making process. The development of 3D imaging techniques has triggered an expanding number of reports on the predictive role of various geometric and hemodynamic measurements on the formation

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Bradley A. Gross and Rose Du

proclivity toward causing symptomatic mass effect or venous hypertension. 27 , 44 , 49 Although their ability to cause hemorrhage is known, 4 , 8 , 28 it is yet to be quantified. Considering their large size, the impact of partial treatment of these lesions on natural history is particularly important to address. Does targeted therapy, such as targeted obliteration of associated aneurysms, improve their natural history? In this report, we attempt to address these questions by compiling demographic information, hemorrhage risk data, and treatment results for these lesions

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I-Duo Wang and Dueng-Yuan Hueng

T o T he E ditor : We are very interested in the clinical article by Lin et al. 2 (Lin N, Ho A, Gross BA, et al: Differences in simple morphological variables in ruptured and unruptured middle cerebral artery aneurysms. Clinical article. J Neurosurg 117: 913–919, November 2012). Ruptured aneurysms often contribute to a high mortality rate and severe morbidity. In particular, aneurysms on middle cerebral arteries (MCAs) are more prone to rupture than those in other anatomical locations. 1 It is a crucial issue for clinicians to determine the treatment

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Brian W. Hanak, Gabriel Zada, Vikram V. Nayar, Ruth Thiex, Rose Du, Arthur L. Day, and Edward R. Laws

9 Bramwell B : Clinical and pathological memoranda: two enormous intracranial aneurisms . Edinburgh Med J 32 : 911 – 922 , 1887 10 Cabezudo JM , Carrillo R , Vaquero J , Areitio E , Martinez R : Intracavernous aneurysm of the carotid artery following transsphenoidal surgery. Case report . J Neurosurg 54 : 118 – 121 , 1981 11 Chang EF , Zada G , Kim S , Lamborn KR , Quinones-Hinojosa A , Tyrrell JB , : Long-term recurrence and mortality after surgery and adjuvant radiotherapy for nonfunctional pituitary adenomas . J