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Roberto C. Heros

This article is a very good review of a large series of intracranial aneurysms in children. Sanai and colleagues analyze data pertaining to pediatric aneurysms managed at the University of California at San Francisco (UCSF) during a 25-year period. It is important to note that theirs was one of the earliest institutions to establish endovascular therapy for aneurysms in this country and, therefore, such therapy has essentially been available for the entire period of this review. As the title of the article indicates, the authors attempt to compare the

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Roberto C. Heros

of the trigeminal nerve, which they used as an opportunity to review the literature and summarize very nicely a total of 36 cases of malignant peripheral nerve sheath tumors of the trigeminal nerve. As expected, these tumors usually present with altered facial sensation and/or facial pain, and it appears that aggressive resection followed by radiation therapy offers the best chance for survival. Sarnthein and colleagues present another interesting paper concerning neurophysiological monitoring of facial nerve function during skull base surgery. In this careful

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Roberto C. Heros

—after preoperative embolization in large tumors. I remember the days before embolization when these tumors could be devascularized satisfactorily with preoperative low-dose radiation therapy, which allowed a safe subsequent excision, and I would not hesitate to recommend this method when embolization is not possible. Fourth Ventricular Tumors Benign choroid plexus papillomas and subependymomas of the fourth ventricle can usually be removed completely without a great deal of difficulty. Hemangioblastomas, of course, are much more difficult surgical tumors, but their treatment

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Roberto C. Heros

of exposure. Such is the case with vertebral and posterior inferior cerebellar artery aneurysms, in which the surgical results are similar to those for anterior circulating aneurysms. Such may also be the case with most superior cerebellar artery aneurysms that are, of course, not associated with perforating vessels, which is the main problem with open surgery for basilar tip aneurysms. At least for most basilar tip and basilar trunk aneurysms, it is my opinion that endovascular therapy is currently preferable and is likely to remain so in the future. Middle

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Roberto C. Heros

very benign fashion, rarely if ever bleed, frequently thrombose spontaneously, and, importantly, rarely convert into the more aggressive type of fistula. 4 Therefore, the clear answer is that we should not be aggressive with treatment in these patients and should not subject them to invasive therapies that carry significant morbidity. This generally means avoiding open microsurgery and transvenous embolization in such patients. Frequently, partial palliative transarterial embolization significantly reduces flow, resulting in symptom relief and, occasionally

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Arteriovenous malformations of the medial temporal lobe

Surgical approach and neuroradiological characterization

Roberto C. Heros

in Diagnosis and Therapy. Berlin : Springer-Verlag , 1975 , pp 123 – 128 Bushe KA, Bockhorn J, Schäfer ER: Macro- and microsurgery of central angiomas, in Pia HW, Gleave JR, Grote E, et al (eds): Cerebral Angiomas: Advances in Diagnosis and Therapy. Berlin: Springer-Verlag, 1975, pp 123–128 4. Butler AB , Partain RA , Netsky MG : Primary intraventricular hemorrhage. A mild and remediable form. Neurology 22 : 675 – 687 , 1972 Butler AB, Partain RA, Netsky MG: Primary intraventricular hemorrhage. A

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Roberto C. Heros

endovascular surgery are available and where ideally the recommendation of one or the other form of therapy is tailored to each patient with relative freedom from disciplinary or financial biases. I could not agree more with this message. The authors tell us that they make a definitive recommendation to each patient without regard to the preferences of the referring physician, the patient, or the patient’s family members. I think that most would agree that the referring physician’s preferences should not influence the therapeutic recommendation, although some may take issue

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Roberto C. Heros and Laligam N. Sekhar

incidence of recurrent symptoms related to that hemisphere. 13, 23 When recurrent ischemia does occur distal to an occluded ICA, the available arteriograms should be studied carefully to try to identify cases of incomplete carotid occlusion which, in our opinion, should be treated by endarterectomy. In other cases, the arteriograms may suggest that the apparent occlusion is due to spontaneous dissection, in which case anticoagulant therapy may be considered. When a lesion, such as contralateral carotid stenosis, external carotid stenosis, or a redundant stump of the

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Roberto C. Heros

in the unsurprising conclusion that both the Simpson resection grade and WHO grade were significantly and independently associated with recurrence. Importantly, they define recurrence as actual retreatment (not need for retreatment or growth of the tumor, but actual retreatment) with repeat surgery, stereotactic radiosurgery, or conventional radiation therapy. Overall retreatment rates were 4.3% for WHO Grade I meningiomas, 9.1% for Grade II, and 50% for Grade III. Considering the Simpson resection grade, the overall retreatment rate was 3.2% for Grade I resection

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Roberto C. Heros

there appears to be no other reasonable option. My cautionary comments in this editorial are not meant as criticism but rather they are meant to emphasize what the authors state clearly: this form of therapy should only be considered where there are no other more conventional therapeutic approaches available. Please include this information when citing this paper: published online March 20, 2009; DOI: 10.3171/2009.2.JNS09112. References 1 Drake CG : Cerebral arteriovenous malformations: considerations for and experience with surgical treatment of 166