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interest as it may provide a theoretical rationale for the innovative attempt to remove subarachnoid blood nonmechanically after aneurysm rupture. Like Nosko, et al. , 1 during the last several years we have performed experimental and clinical studies investigating the role of arachidonic acid metabolites in the pathogenesis of cerebral vasospasm. 2 In these studies, we have been able to demonstrate that arachidonic acid metabolism undergoes marked pathological changes following SAH, with subsequent accumulation of spasmogenic eicosanoids, especially thromboxane A 2

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Erdem Güresir, Patrick Schuss, Volker Seifert, and Hartmut Vatter

O culomotor nerve palsy in patients harboring PCoA aneurysms is a well-known clinical entity. 8 , 12 , 32 , 33 Direct compression of the oculomotor nerve by the aneurysm itself, with or without pulsatility, is considered to be the mechanism causing ONP in patients without SAH. Treatment of unruptured intracranial aneurysms together with ONP is performed to address the disabling effect of ONP and prevent aneurysm rupture. In patients with SAH, aneurysm treatment is performed to prevent rebleeding. Resolution of ONP has been reported after clipping 1 , 2

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Volker Seifert and Dietmar Stolke

A neurysms of the basilar trunk and vertebrobasilar junction represent a surgical challenge because of the direct proximity of highly vulnerable neural structures such as the brainstem and cranial nerves. A direct approach to these aneurysms is often blocked by the petrous bone. A number of approaches have been attempted over the years to gain access to these lesions; among these are: the pterional, 35 subtemporal, 4, 21, 24, 33 suboccipital—retromastoidal, 30, 33 far-lateral, 10, 22, 29 and transoral—transclival. 2, 3, 11, 35 Only recently have lateral

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Volker Seifert and Dietmar Stolke

Aneurysms of the basilar trunk and vertebrobasilar junction represent an exceptional challenge to the neurosurgeon. Surgical access to these deep and confined lesions is hampered by the direct proximity of highly vulnerable neural structures such as the brainstem and cranial nerves, as well as by the structure of the petrous bone, which blocks direct surgical approach to these aneurysms. A number of surgical tactics consisting of different supra- and infratentorial approaches have been applied over the years to gain access to these treacherous lesions. Only recently have lateral approaches, such as the anterior transpetrosal, the retrolabyrinthine-transsigmoidal, and the combined supra/infratentorial-posterior transpetrosal approaches, directed through parts of the petrous bone, been reported for surgery of basilar trunk and vertebrobasilar junction aneurysms. Because detailed reports of direct operative intervention using the transpetrosal route for these rare and difficult lesions are scarce, the authors present their surgical experiences in nine patients with basilar trunk and vertebrobasilar junction aneurysms, in whom they operated via the supra/infratentorial-posterior transpetrosal approach. In eight patients, including one with a giant partially thrombosed basilar trunk aneurysm, direct clipping of the aneurysm via the transpetrosal route was possible. In one patient with a giant vertebrobasilar junction aneurysm, the completely calcified aneurysm sac was resected after occlusion of the vertebral artery. In total, one patient died and another experienced postoperative accentuation of preexisting cranial nerve deficits. Two patients had transient cerebrospinal fluid leakage, and the postoperative course was uneventful in the remaining seven. Postoperative angiography demonstrated complete aneurysm clipping in eight patients and relief of preoperative brainstem compression in the patient with the giant vertebrobasilar junction aneurysm. It is concluded that the supra/infratentorial-posterior transpetrosal approach allows excellent access to the basilar artery trunk and vertebrobasilar junction and can be considered the approach of choice to selected aneurysms located in this area.

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Gerhard Marquardt, Soledad M. Barduzal Angles, Fouad D. Leheta, and Volker Seifert

I mpingement on peripheral nerves by aneurysmal or thrombosed vessels has been identified as a cause of symptomatic peripheral nerve compression. Arterial vessels have been reported to compress peripheral nerves both spontaneously and as a result of the formation of true or posttraumatic false aneurysms. 3, 6–8 Incidences of venous pseudoaneurysms causing symptomatic peripheral nerve compression have also been reported as a complication of brachial artery—basilic vein anastomoses in patients with uremia, who are receiving long-term hemodialysis. 1, 5

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Neurosurgical Forum: Letters to the Editor To The Editor Leonard I. Malis , M.D. Mount Sinai School of Medicine New York, New York 1072 1073 I enjoyed the article by Seifert and Stolke (Seifert V, Stolke D: Posterior transpetrosal approach to aneurysms of the basilar trunk and vertebrobasilar junction. J Neurosurg 85: 373–379, September, 1996), which demonstrated their ability to perform a combined transpetrosal approach, sparing the lateral sinus and ligating only the superior petrosal sinus by making the

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Andreas Raabe, Jürgen Beck, Stefan Rohde, Joachim Berkefeld, and Volker Seifert

The use of surgical navigation systems is becoming an increasingly important part of both planning and performing intracranial surgery. There are numerous clinical reports in which the authors have described image guidance as a useful adjunct to surgery that allows neurosurgical procedures to be less invasive and more effective. 2–6 , 8 , 9 , 14 Heretofore, advances in image-guided surgery have had little influence on the microsurgical clip application of aneurysms. Few publications in the literature have focused on image guidance via MR or CT angiography 1

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Patrick Schuss, Erdem Güresir, Joachim Berkefeld, Volker Seifert, and Hartmut Vatter

B esides rupture, intracranial aneurysms can become symptomatic because of their mass effect, 11 that is, by compression of the visual pathway. 4 , 7 Aneurysms causing compression of the visual pathway commonly arise from the ophthalmic segment of the internal carotid artery (ICA), anterior communicating artery (ACoA), and ICA bifurcation. 7 Aneurysm-related visual dysfunction has been described as extremely variable in type and degree, ranging from blurred vision or blindness to visual field defects, without a typical clinical presentation. 4 , 7 , 21

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Patrick Schuss, Jürgen Konczalla, Johannes Platz, Hartmut Vatter, Volker Seifert, and Erdem Güresir

R upture of an intracranial aneurysm usually results in an SAH. In 2%–10.3% of patients with aneurysmal SAH, a simultaneous acute SDH can be found. 16 , 19 Patients presenting with both SAH and acute SDH have commonly been reported to be in a poor admission grade and have a poor prognosis. 8 , 14 Nevertheless, recent reports have suggested early and aggressive treatment to facilitate neurological outcome in these severely ill patients. 11 , 13 , 20 Aggressive therapy in poor-grade patients suffering from SAH is still controversially discussed. We

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Juergen Konczalla, Johannes Platz, Stephan Fichtlscherer, Haitham Mutlak, Ulrich Strouhal, and Volker Seifert

C urrently , most aneurysms can be treated by primary clip reconstruction or by endovascular coil embolization (with or without stents), or with newer devices such as flow diverters or a woven endobridge (WEB) device (Sequent Medical). However, morbidity, mortality, and mid- to long-term occlusion rates of the newer endovascular devices have not been as good as expected. 7 , 8 , 15 , 32 With increasing size and complexity of the aneurysm (wide neck, calcifications, incorporation of branching vessels), the rate of fully occluded aneurysms on postoperative digital