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Mark E. Linskey, Laligam N. Sekhar, Joseph A. Horton, William L. Hirsch Jr., and Howard Yonas

N ot long ago, intracavernous carotid artery aneurysms could be treated only by cervical carotid artery ligation with or without extracranial-intracranial bypass, 19, 29, 46 or by direct surgical repair with cardiac standstill. 35 The rapid and simultaneous development of interventional radiological balloon catheter techniques 5, 8, 18, 23, 39, 51 as well as improved direct surgical approaches to the cavernous sinus 11–13, 36, 40–43 have significantly expanded our therapeutic armamentarium for these lesions. Several recent papers have reported acceptable

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Sang Youl Lee and Laligam N. Sekhar

C ertain types of intracranial aneurysms cannot be treated by clipping because of extensive involvement with arterial walls. When a large intracranial artery, such as the internal carotid artery (ICA) or the basilar artery, is involved by such aneurysms, an extracranial—intracranial bypass procedure followed by proximal occlusion or aneurysm trapping is a good treatment alternative. 8, 11, 13, 18, 19, 20, 36–38, 40, 49 However, when a small artery is involved by an aneurysm, reimplantation of the artery or a direct reconstruction using an interpositional

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Griffith R. Harsh IV and Laligam N. Sekhar

, developed by one of us (L.N.S.), enhance the exposure of lesions anterior to the upper brain stem: intradural rather than extradural removal of petrous apex and clival bone; complete division rather than fenestration of the tentorium; and mobilization of the trigeminal nerve root, ganglion, and third division after dissection of Meckel's cave and the inferior, posterior, and lateral aspects of the cavernous sinus. This subtemporal, transcavernous, anterior transpetrosal approach has proven useful in two patients with aneurysms of the retrosellar basilar artery bifurcation

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Laligam N. Sekhar and Jack F. Wasserman

B ased upon the studies of Wasserman 17 and Olinger and Wasserman, 13 the authors have used a modified electronic stethoscope for noninvasive detection of intracranial vascular lesions in 45 patients during the past 3 years. This report details the sensitivity and specificity of the technique and the present problems involved in its use. Description of Technique Principles of Instrumentation This technique is based on principles described previously. 13 Briefly, intracranial aneurysms and arteriovenous malformations (AVM's) emit specific sound

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Louis J. Kim, Farzana Tariq, and Laligam N. Sekhar

C erebral bypass is a useful microsurgical technique in the treatment of complex intracranial aneurysms 2 , 4 , 5 , 13 , 19–21 , 23 , 27 , 29 , 31 , 33 , 38 , 40 , 41 , 43–46 and skull base tumors. 1 , 24 , 26 , 27 , 34 , 39 , 42 In well-selected patients, this technique has been successfully used to provide alternative blood flow after carotid artery sacrifice, 39 to preserve flow after small vessel sacrifice, and to provide collateral flow prior to arterial trapping. 23 Various microsurgical series have shown good long-term outcomes and patency rates

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Ramesh P. Babu, Laligam N. Sekhar, and Donald C. Wright

 headache  fusion, ELTC, ELTF  anomalies  VA decompression 13 F, 37 mid clivus to foramen magnum; lt 12th CN palsy, 9th–10th STIT, ELTC chordoma total CSF leak, delayed neck tilt & persistent CN palsies no tumor yes 80/90 15  prior surgery & irradiation  CN paresis  pain 14 M, 70 VA gait ataxia ELTC, presigmoid giant VA aneurysm occlusion of 9th–10th CN paresis intact patent graft no 80/100 15  aneurysm, vein graft 15 M, 56

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Chandra Nath Sen and Laligam N. Sekhar

L esions ventral to the brain stem in the region of the petrous apex and clivus consist of meningiomas, neurilemomas, cholesteatomas, and aneurysms of the vertebrobasilar system. Approaches to these lesions include the retromastoid paracerebellar, frontotemporal transsylvian, posterior subtemporal, 22 combined supra- and infratentorial, 1, 10, 11, 15, 21 translabyrinthine, 4 and transcochlear 6 techniques. Difficulties experienced by the surgeon when using these approaches for deep-seated lesions ventral to the brain stem arise from the great depth of the

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Laligam N. Sekhar and Aage R. Møller

venous space with multiple trabeculations. 37 Tumors that originate primarily within the cavernous sinus are rare and usually are meningiomas or neurinomas. However, many tumors may invade the sinus secondarily from adjacent areas; these lesions include meningiomas, neurinomas, chordomas, chondromas, chondrosarcomas, pituitary neoplasms, nasopharyngeal carcinomas, esthesioneuroblastomas, nasopharyngeal angiofibromas, and metastatic lesions. In addition, giant aneurysms of the cavernous carotid artery often present with signs and symptoms resembling a tumor of this

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Roberto C. Heros and Laligam N. Sekhar

–671, 1977 3. Anderson RM , Schechter MM : A case of spontaneous dissecting aneurysm of the internal carotid artery. J Neurol Neurosurg Psychiatry 22 : 195 – 201 , 1959 Anderson RM, Schechter MM: A case of spontaneous dissecting aneurysm of the internal carotid artery. J Neurol Neurosurg Psychiatry 22: 195–201, 1959 4. Barnett HJM : Delayed cerebral ischemic episodes distal to occlusion of major cerebral arteries. Neurology 28 : 769 – 774 , 1978 Barnett HJM: Delayed cerebral ischemic episodes

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Michael D. Cusimano and Laligam N. Sekhar

: preretrosigmoid cisternograms 3 44, F lt CS PC FTC, OZO divided divided PE rhinorrhea iohexol none ipsilat clear unknown meningioma cisternogram 4 39, F lt CS ICA FTC, OZO divided divided PE, E, & T none none bilat † mucus rt eye dries up aneurysm, rhinorrhea; when warm, pituitary facial no lacrimation adenoma flushing of lt eye 5 56, F lt CS PC FTC, OZO repair divided PE