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William T. Couldwell

in whom initial surgery has failed to resolve symptoms. A fascinating review paper on the phenomenon of brain atrophy seen in Cushing disease and its possible pathogenesis is included. Finally, two papers—one a historical overview and the other a contemporary review of the management of Nelson syndrome, a dreaded complication of an aggressive ACTH-secreting tumor of the pituitary developing after bilateral adrenalectomy—are presented. I would like to acknowledge the efforts of Margie Shreve and Dr. Martin Weiss. Without their expert and timely help, compiling

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William T. Couldwell

A s this new year begins, we are excited to announce new features and functionality that are being implemented and planned for Neurosurgical Focus —the first electronic web-based, peer-reviewed neurosurgical journal, and the brainchild of Dr. Martin Weiss—as we mark its 21st anniversary. Since its inception, Neurosurgical Focus has become a foundational educational element worldwide, providing the latest updates and reviews on a monthly topic that is carefully chosen to be clinically relevant and timely. Over the past several monthly issues, we have

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William T. Couldwell

complications • New technology and instrumentation In addition, in future issues we wish to initiate an operative forum for open feedback and discussion of material published. We intend this new journal to function as a world platform and encourage submissions accordingly. The quarterly format will continue, with topic-specific editors with additional experience in video editing to offer the most contemporary peer review. We invite video submissions that demonstrate both macro- and microscopic and endoscopic techniques. We hope you enjoy the inaugural issue of Neurosurgical

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Khaled M. Krisht, Kevin J. Whitehead, Toba Niazi and William T. Couldwell

, with incomplete penetrance and variable expression. The proportion of familial cases is estimated at 50% among Hispanic-American patients of Mexican descent, and seems to be less in other populations. 12 , 13 With familial forms, multiple cerebral lesions are often noted ( Fig. 1 ), whereas the majority of sporadic cases comprise a single CCM. By linkage and LOH analysis, 3 genetic loci have been implicated on chromosomal arms 7q ( CCM1 ), 7p ( CCM2 ), and 3q ( CCM3 ). 8 , 13 In this review, we describe the 3 aforementioned genes that have been implicated in CCM

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Brian T. Ragel and William T. Couldwell

Pituitary carcinomas, defined as distant metastases of a pituitary neoplasm, are rare; fewer than 140 reports exist in the English literature. The initial presenting pituitary tumor is usually a secreting, invasive macroadenoma, with adrenocorticotropic hormone (ACTH)– and prolactin (PRL)–secreting tumors being the most common. The latency period between the diagnosis of a pituitary tumor and the diagnosis of a pituitary carcinoma is 9.5 years for ACTH-producing lesions and 4.7 years for PRL-secreting tumors. Survival after documentation of metastatic disease is poor; 66% of patients die within 1 year. Treatment options include additional surgery, radiotherapy, and chemotherapy, all of which are associated with poor results. Future studies will focus on identifying those invasive pituitary tumors most likely to metastasize and treating them aggressively before they progress to pituitary carcinomas.

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Oren N. Gottfried and William T. Couldwell

Background

Carotid endarterectomy is more effective than medical management in the prevention of stroke in patients with severe symptomatic or asymptomatic atherosclerotic carotid-artery stenosis. Stenting with the use of an emboli-protection device is a less invasive revascularization strategy than endarterectomy in carotid-artery disease.

Methods

We conducted a randomized trial comparing carotid-artery stenting with the use of an emboli-protection device to endarterectomy in 334 patients with coexisting conditions that potentially increased the risk posed by endarterectomy and who had either a symptomatic carotid-artery stenosis of at least 50 percent of the luminal diameter or an asymptomatic stenosis of at least 80 percent. The primary end point of the study was the cumulative incidence of a major cardiovascular event at 1 year—a composite of death, stroke, or myocardial infarction within 30 days after the intervention or death or ipsilateral stroke between 31 days and 1 year. The study was designed to test the hypothesis that the less invasive strategy, stenting, was not inferior to endarterectomy.

Results

The primary end point occurred in 20 patients randomly assigned to undergo carotid-artery stenting with an emboli-protection device (cumulative incidence, 12.2 percent) and in 32 patients randomly assigned to undergo endarterectomy (cumulative incidence, 20.1 percent; absolute difference, −7.9 percentage points; 95 percent confidence interval, −16.4 to 0.7 percentage points; P=0.004 for noninferiority, and P=0.053 for superiority). At one year, carotid revascularization was repeated in fewer patients who had received stents than in those who had undergone endarterectomy (cumulative incidence, 0.6 percent vs. 4.3 percent; P=0.04).

Conclusions

Among patients with severe carotid-artery stenosis and coexisting conditions, carotid stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy.

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Charles B. Stillerman, Thomas C. Chen, William T. Couldwell, Wei Zhang and Martin H. Weiss

. 14, 16, 21, 24, 25, 31, 34, 38, 39, 42, 48–50, 52, 53, 68–70 However, despite facilitating ventral exposure of the disc, some of these procedures are associated with significant patient morbidity and are technically formidable to perform. 66, 67 The following report on our thoracic microdiscectomy series emphasizes presentation patterns, surgical treatment, and patient outcomes. Based on review of this experience and 13 other contemporary thoracic discectomy series, we have developed management schemes that consist of a comprehensive treatment algorithm and an

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James K. Liu and William T. Couldwell

did not correlate it with the severity or clinical outcome of this disorder. In this study, we review our experience with 28 patients who presented with pituitary apoplexy in the MR imaging era. A clinical grading scale that we have developed to facilitate classification of pituitary apoplexy is described. We also investigated and report on the clinical significance of thickened sphenoid sinus mucosa found on MR imaging. Clinical Material and Methods A retrospective review was performed in patients in whom pituitary apoplexy was diagnosed at the University of

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James K. Liu and William T. Couldwell

Cerebral revascularization is an important component in the surgical management of complex skull base tumors and aneurysms. Patients who harbor complex aneurysms that cannot be clipped directly and in whom parent vessel occlusion cannot be tolerated may require cerebrovascular bypass surgery. In cases in which skull base tumors encase the carotid artery (CA) and a resection is desired, a cerebrovascular bypass may be necessary in planned CA occlusion or sacrifice. In this review the authors discuss options for performing high-flow anterograde interposition CA bypass for lesions of the skull base. The authors review three important bypass techniques involving saphenous vein grafts: the cervical-to-petrous internal carotid artery (ICA), petrous-to-supraclinoid ICA, and cervical-to-supraclinoid ICA bypass. These revascularization techniques are important tools in the surgical treatment of complex aneurysms and tumors of the skull base and cavernous sinus.

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James K. Liu and William T. Couldwell

Neurenteric cysts are rare benign lesions of the central nervous system that are lined by endodermal cell–derived epithelium. Although they occur mostly in the spine, they can occur intracranially, most often in the posterior fossa. Neurenteric cysts that are located in the anterior cervicomedullary junction are even rarer and often require a skull base approach for adequate resection. The authors describe two cases of neurenteric cysts arising from the cervicomedullary junction that were resected via a far-lateral transcondylar approach. They discuss the surgical approach and operative nuances involved in removing these lesions, and review the clinical presentation of neurenteric cysts in this region as well as the neuroimaging characteristics, histopathological findings, and surgical management. Intraoperative videos are presented.