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Philippe Gailloud

The Polish neurologist Łucja Frey (1889–1942) is principally remembered for her description of the auriculotemporal nerve (or Frey's) syndrome. She also reported a complex case of spinal cord vascular malformation in 1928, which included one of the earliest accurate anatomopathological depictions of a spinal arteriovenous malformation as well as the first known observation of double synchronous spinal cord vascular malformation.

An abbreviated translation of Frey's report is followed by a discussion of the place occupied by her contribution in the development of our current understanding of spinovascular disorders.

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Edison P. Valle, Rafael J. Tamargo and Philippe Gailloud

The cases of 2 children with true aneurysmal subarachnoid hemorrhages (SAHs) and initial false-negative angiograms are reported. In both cases, the initial angiogram was of adequate technical quality and included the projections on which aneurysms were later documented. There was no significant vasospasm at the time of initial angiography; therefore, transient aneurysm sac thrombosis was the most likely explanation for the initial false-negative studies. It is particularly interesting to note that 1 of the 2 patients had a pattern of hemorrhage compatible with the most limited definition of a perimesencephalic SAH, that is, a small prepontine cistern hemorrhage. If a second angiogram had been deemed unnecessary based on that criterion alone, a ruptured basilar tip aneurysm would have escaped detection and treatment.

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Geoffrey P. Colby, Alexander L. Coon, Daniel M. Sciubba, Ali Bydon, Philippe Gailloud and Rafael J. Tamargo

Spinal dural arteriovenous fistulas (DAVFs) are the most common type of spinal arteriovenous malformation and are an important, underdiagnosed cause of progressive myelopathy and morbidity in patients with spine disorders. Successful microsurgical management of these lesions is dependent on the surgeon's ability to identify vessels of the fistula and to confirm its successful obliteration postintervention. Indocyanine green (ICG) fluorescent angiography is an emerging tool for delineating intraoperative vascular anatomy, and it has significant potential utility in the treatment of vascular disease in the spine.

The authors present the case of a 76-year-old man with progressive and debilitating bilateral lower-extremity weakness and numbness on exertion, in whom a left T-8 spinal DAVF was diagnosed based on results of conventional spinal angiography. Unfavorable anatomy based on angiographic findings precluded endovascular embolization of the fistula, and the patient subsequently underwent T7–9 bilateral laminectomies for microsurgical clip occlusion. Intraoperative ICG fluorescent angiography was used before clip placement to identify the arterialized veins of the fistula, and after clip placement to confirm obliteration of the fistulous connection and restoration of normal blood flow.

Intraoperative ICG angiography serves an important role in the microsurgical treatment of DAVF. It can be used to map the anatomy of the fistula in real time during surgery and to verify fistula obliteration rapidly after clip placement. This report adds to the growing body of literature demonstrating the importance of ICG angiography in vascular neurosurgery of the spine.

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Anshuman Bansal, Philippe Gailloud, Lori Jordan and Diego San Millán Ruíz

The authors present the case of an infant harboring a vein of Galen arteriovenous malformation with conspicuous cerebral calcifications that progressively regressed after staged endovascular obliteration of the lesion. The role of venous hypertension and hydrocephalus secondary to the arteriovenous shunt are discussed to explain the formation and regression of the cerebral calcifications.

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Monica Smith Pearl, Rafael Tamargo and Philippe Gailloud

The angiographic appearance of an intracranial arterial occlusion is typically distinct from that of a saccular aneurysm, with only a few reported cases of occlusion simulating aneurysm. At the same time, a small percentage of symptomatic intracranial aneurysms present with a stroke. Accurate diagnosis of these conditions is crucial, as their treatment differs. The authors report on a case of middle cerebral artery occlusion that mimicked the appearance of an aneurysm on angiography in the setting of acute stroke. The true diagnosis was not elucidated until repeated angiography 6 months later revealed recanalization of the previously occluded middle cerebral artery branch. This angiographic pitfall is important to consider when acute stroke is suspected as the mode of presentation of a saccular aneurysm.

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Rush H. Chewning, A. Daniel Sasson, Lori C. Jordan, Rafael J. Tamargo and Philippe Gailloud

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Lori C. Jordan, George I. Jallo and Philippe Gailloud

✓ The authors report the case of a 4-year-old boy with a spontaneous intracerebral hemorrhage (ICH) related to an arteriovenous malformation (AVM) that was not found with good-quality magnetic resonance (MR) imaging and MR angiography. Both modalities were used serially in the acute phase and at 2 and 7 months of follow-up. Digital subtraction angiography identified the peripheral AVM when the patient experienced rehemorrhaging 1 year after his initial presentation. This case illustrates the need for a complete diagnostic evaluation including conventional angiography in cases of idiopathic ICH in children.

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Daniel M. Sciubba, Gaurav G. Mavinkurve, Philippe Gailloud, Ira M. Garonzik, Pablo F. Recinos, Matthew J. McGirt, Graeme F. Woodworth, Timothy Witham, Yevgeniv Khavkin, Ziya L. Gokaslan and Jean-Paul Wolinsky

✓ Angiography is often performed to identify the vascular supply of hemangioblastomas prior to resection. Conventional two-dimensional (2D) digital subtraction (DS) angiography and three-dimensional (3D) DS angiography provides high-resolution images of the vascular structures associated with these lesions. However, such 3D DS angiography often does not provide reliable anatomical information about nearby osseous structures, or when it does, resolution of vascular anatomy in the immediate vicinity of bone is sacrificed. A novel angiographic reconstruction algorithm was recently developed at The Johns Hopkins University to overcome these inadequacies. By combining two separate sequences of images of bone and blood vessels in a single 3D representation, 3D fusion DS (FDS) angiography provides precise topographic information about vascular lesions in relation to the osseous environment, without a loss of resolution.

In this paper, the authors present the cases of two patients with cervical spine hemangioblastomas who underwent preoperative evaluation with FDS angiography and then successful gross-total resection of their tumors. In both cases, FDS angiography provided high-resolution 3D images of the hemangioblastoma anatomy, including each tumor’s topographic relationship with adjacent osseous structures and the location and size of feeding arteries and draining veins. These cases provide evidence that FDS angiography represents a useful adjunct to magnetic resonance imaging and 2D DS angiography in the preoperative evaluation and surgical planning of patients with vascular lesions in an osseous environment, such as hemangioblastomas in the spinal cord.