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John W. Thompson, Omar Elwardany, David J. McCarthy, Dallas L. Sheinberg, Carlos M. Alvarez, Ahmed Nada, Brian M. Snelling, Stephanie H. Chen, Samir Sur, and Robert M. Starke

U nruptured cerebral aneurysms (CAs) are common in the general population, with an estimated prevalence ranging from 2% to 6%. 68 If left untreated, aneurysms can progress and spontaneously rupture, producing a subarachnoid hemorrhage and resulting in significant morbidity and death. The pathophysiology of CA formation and rupture is not fully defined, but risk factors have been identified including increasing age, female sex, hypertension, excessive alcohol intake, and smoking. 16 , 34 , 68 Studies have suggested that hemodynamic stress is a critical factor

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Badih Daou, Nohra Chalouhi, Robert M. Starke, Guilherme Barros, Lina Ya'qoub, John Do, Stavropoula Tjoumakaris, Robert H. Rosenwasser, and Pascal Jabbour

W ith the tremendous advancements in endovascular therapy, cerebral aneurysms are being managed more commonly using endovascular techniques. The successful short-term outcomes of coiling are well established, with significantly reduced morbidity and mortality compared with the more invasive surgical clipping. 13 , 14 However, with the increasing number of cases treated with coiling and longer duration of followup, the long-term outcomes and drawbacks have evolved, including but not limited to high number of recurrences, incomplete obliteration, rebleeding

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Badih Daou, Elias Atallah, Nohra Chalouhi, Robert M. Starke, Jeffrey Oliver, Maria Montano, Pascal Jabbour, Robert H. Rosenwasser, and Stavropoula I. Tjoumakaris

F low diverters (FDs) are being used with increasing frequency, especially to target large and complex aneurysms that are not amenable to treatment with conventional endovascular methods. 6 , 8 , 9 , 28 The Pipeline embolization device (PED) is the first FD approved by the FDA following the results of the PUFS (Pipeline for Uncoilable or Failed Aneurysms) trial for the management of large or giant wide-necked intracranial aneurysms in the internal carotid artery (ICA) from the petrous to the superior hypophyseal segments. Although initially indicated for a

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Badih Daou, Elias Atallah, Nohra Chalouhi, Robert M. Starke, Jeffrey Oliver, Maria Montano, Pascal Jabbour, Robert H. Rosenwasser, and Stavropoula I. Tjoumakaris

F low diverters (FDs) are being used with increasing frequency, especially to target large and complex aneurysms that are not amenable to treatment with conventional endovascular methods. 6 , 8 , 9 , 28 The Pipeline embolization device (PED) is the first FD approved by the FDA following the results of the PUFS (Pipeline for Uncoilable or Failed Aneurysms) trial for the management of large or giant wide-necked intracranial aneurysms in the internal carotid artery (ICA) from the petrous to the superior hypophyseal segments. Although initially indicated for a

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Christopher R. Durst, Robert M. Starke, John R. Gaughen Jr., Scott Geraghty, K. Derek Kreitel, Ricky Medel, Nicholas Demartini, Kenneth C. Liu, Mary E. Jensen, and Avery J. Evans

T he endovascular treatment of wide-necked aneurysms can be technically challenging due to distal coil migration or impingement of the parent vessel. In a study of 1815 aneurysms treated conventionally, a wide neck was the most significant individual predictor of complications. 41 Balloons 37 , 38 and neurovascular stents 18 allow for greater packing densities while protecting the parent artery. However, these techniques impart their own set of limitations and complications. While balloon and stent devices have drastically improved over the last decade

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Jorge A. Roa, Mario Zanaty, Daizo Ishii, Yongjun Lu, David K. Kung, Robert M. Starke, James C. Torner, Pascal M. Jabbour, Edgar A. Samaniego, and David M. Hasan

U nruptured intracranial aneurysms (UIAs) continue to pose a therapeutic dilemma in which the risk-benefit analysis of therapeutic interventions has to be balanced against the natural history of the disease. UIAs are found in 3%–5% of the adult population worldwide. 36 Although the large majority will never rupture, 27%–44% of patients who develop aneurysmal subarachnoid hemorrhage (aSAH) may die within 12 months, 10 , 24 and those who survive experience a 17% excess mortality after 20 years compared with the general population. 23 Results from large

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Jorge A. Roa, Mario Zanaty, Daizo Ishii, Yongjun Lu, David K. Kung, Robert M. Starke, James C. Torner, Pascal M. Jabbour, Edgar A. Samaniego, and David M. Hasan

U nruptured intracranial aneurysms (UIAs) continue to pose a therapeutic dilemma in which the risk-benefit analysis of therapeutic interventions has to be balanced against the natural history of the disease. UIAs are found in 3%–5% of the adult population worldwide. 36 Although the large majority will never rupture, 27%–44% of patients who develop aneurysmal subarachnoid hemorrhage (aSAH) may die within 12 months, 10 , 24 and those who survive experience a 17% excess mortality after 20 years compared with the general population. 23 Results from large

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Robert M. Starke

I n this issue of the Journal of Neurosurgery , Kimura et al. assess “How definitive treatment affects the rupture rate of unruptured cerebral aneurysms.” 5 They reviewed the outcomes of 722 patients with unruptured cerebral aneurysms (UCAs) diagnosed from 2000 to 2009. By 2014, 19 patients had experienced aneurysm rupture, with an overall rupture rate per year of 0.57% in 3320.8 person-years. However, cumulative incidence analysis indicated that 1.3% of the patients had a rupture within 2 years, while 38.4% of the patients underwent definitive treatment in

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Dallas L. Sheinberg, David J. McCarthy, Omar Elwardany, Jean-Paul Bryant, Evan Luther, Stephanie H. Chen, John W. Thompson, and Robert M. Starke

C erebral aneurysms (CAs) have an estimated prevalence of 1%–3% and are responsible for 80%–85% of all spontaneous subarachnoid hemorrhages. 28 CA formation and progression constitute a multifactorial disease process with dynamic contributions from genetic drivers, inflammatory reactions, and hemodynamic stress. 69 There is substantial evidence showing that endothelial cell (EC) dysfunction plays a large role in CA pathogenesis, with damage or injury to the EC layer cited as the first event in CA formation. 24 , 30 , 31 , 44 , 50 , 62 , 66 , 67 Through

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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.