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Giuseppe Lanzino and Robert F. Spetzler

A n intraoperative aneurysm rupture related to partial avulsion of the aneurysm neck can be a difficult problem to solve. We illustrate a simple technique that we have found to be useful in treating the partial avulsion of an aneurysm neck. Case History This 60-year-old woman presented with a Hunt and Hess Grade 2 subarachnoid hemorrhage from a ruptured ACoA aneurysm ( Fig. 1 ). She was taken to surgery to undergo clipping of the aneurysm. During clip placement, a partial avulsion occurred at the junction of the aneurysm neck and the ACoA ( Fig. 2 ). The

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Joshua B. Bederson and Robert F. Spetzler

T he extracranial-intracranial bypass (EC-IC) bypass procedure has evolved considerably since its inception. 2, 18 Prior to the reports of The EC/IC Bypass Study Group 3, 4 in 1985, enthusiasm for the technique led to its widespread use for the treatment of intracranial occlusive disease. Cerebral revascularization is still used for a smaller set of indications that includes the treatment of giant intracranial aneurysms. 9, 14, 15 To a great extent, the success of cerebral revascularization depends on the availability of a suitable donor vessel. In

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Julian E. Bailes, Robert F. Spetzler, Mark N. Hadley, and Hillel Z. Baldwin

T raditionally , the outlook for patients presenting with aneurysmal subarachnoid hemorrhage (SAH) in Hunt and Hess 24 Grade IV or V has been dismal. 3, 22, 25, 37, 50 These poor-grade patients were usually excluded from active treatment regimens, including surgery. Believing that early operative intervention affords the best chance for a good outcome in patients with ruptured intracranial aneurysms, we employed a prospective protocol for treatment of poor-grade patients involving immediate ventriculostomy placement, early surgery, and aggressive

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W. Michel Bojanowski, Robert F. Spetzler, and L. Philip Carter

T he introduction of microsurgical techniques in the last two decades has markedly improved the surgical management of intracranial aneurysms. These technical advances have modified the treatment of difficult giant aneurysms when a direct approach toward restoration of a normal physiological anatomy is favored. This report describes the reconstruction of portions of two middle cerebral artery (MCA) branches to form one major MCA after excision of a giant aneurysm. Case Report and Operative Technique This 59-year-old right handed man presented with

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Joshua B. Bederson, Joseph M. Zabramski, and Robert F. Spetzler

S everal strategies exist for treating unclippable aneurysms, including intravascular techniques, 10 proximal occlusion of the parent artery or trapping of the aneurysm, 4, 11, 13 microsurgical bypass of the involved arterial segment, 1, 22, 25 and reinforcement of the aneurysm dome. 3, 5, 8, 15–17, 20 Reinforcement or wrapping is frequently used when the other techniques are thought to be unsafe. Whatever treatment is chosen, complete obliteration of the aneurysm wall is required to avoid recurrence, 6, 18, 23 and perforating arteries must be spared to

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John A. Anson, Michael T. Lawton, and Robert F. Spetzler

F usiform and dolichoectatic aneurysms are uncommon cerebral aneurysms, which often have clinical presentations and therapeutic considerations that differ from those associated with saccular aneurysms. There appears to be a spectrum of dolichoectatic aneurysms ranging from small fusiform aneurysmal dilations of a single vessel to giant dolichoectatic aneurysms filled largely with thrombus. The latter have also been described as giant serpentine aneurysms. These aneurysms, particularly the large partially thrombosed lesions, often produce clinical symptoms by

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Patrick P. Han, Felipe C. Albuquerque, Francisco A. Ponce, Christopher I. Mackay, Joseph M. Zabramski, Robert F. Spetzler, and Cameron G. McDougall

I ntracranial stent placement is an emerging procedure for the treatment of cerebrovascular disease. 2, 13, 14, 20, 28–30, 37, 38, 41 To date few reports on the technique and results of stent placement for nonatherosclerotic intracranial cerebrovascular disease have been published. 18, 36, 46 Gruber, et al., 15 described outcomes in the embolization of 31 very large (> 2 cm) or giant aneurysms with GDCs, without the addition of a stent. Only five of 25 aneurysms originally deemed more than 90% occluded displayed a stable degree of occlusion on angiograms

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A. Giancarlo Vishteh and Robert F. Spetzler

Dolichoectasia most often affects the vertebrobasilar system and leads to fusiform dilation of vessels. 1–4 Patients with aneurysmal dolichoectasia may become symptomatic from compression of neural tissue, ischemia (as the result of local perforating vessel thrombosis or distal thromboembolism), and subarachnoid hemorrhage. 1, 3 Some of these lesions may remain quiescent, but most have a dismal prognosis once the patient becomes symptomatic. It is hypothesized that continual growth of a dolichoectatic aneurysm may lead to the formation of a so-called giant

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Carlos A. David, A. Giancarlo Vishteh, Robert F. Spetzler, Michael Lemole, Michael T. Lawton, and Shahram Partovi

P ostoperative angiography is routinely used to evaluate patients who have undergone surgical obliteration of an aneurysm. It provides information on the results of clipping, the presence of residual unclipped aneurysm, other unclipped aneurysms, and the occlusion of major vessels. Apart from this initial evaluation, however, few surgeons pursue late angiographic follow-up review in patients surgically treated for aneurysms. Increasingly, the need for late outcome data related to various treatments has become apparent. In particular, the long-term efficacy of

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Leonardo Rangel-Castilla and Robert F. Spetzler

A 70-year-old man with progressive visual disturbances, left superior quadrantanopsia, and right-sided papilledema underwent imaging that demonstrated a right internal carotid artery (ICA) terminus aneurysm with third-ventricle mass effect and ipsilateral optic nerve and chiasm compression. We performed a right modified orbitozygomatic craniotomy, with proximal control and dissection of the aneurysm and small perforator arteries. Temporary ICA and anterior cerebral artery (ACA) clips allowed placement of a large curved permanent clip, reconstructing the ICA bifurcation and maintaining adequate patency of the ACA and middle cerebral artery. Complete aneurysm obliteration was confirmed by intraoperative indocyanine green angiography and postoperative CT angiography.

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