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Editorial

Role of radiosurgery for arteriovenous malformations

Giuseppe Lanzino

in different situations. 1–6 How can we incorporate the information provided into our management of these challenging lesions? Simplistically, AVMs can be divided into 3 main groups. 9 There are many options for “simple” AVMs (Spetzler-Martin Grade I and II AVMs). Surgery has been traditionally considered the main and most effective therapy for these “simple” AVMs because it removes the risk of bleeding with a very low surgical risk. However, stereotactic radiosurgery is being considered more and more as a valid therapeutic alternative to microsurgical excision

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Giuseppe Lanzino

The increased use of stent-assisted coiling, and more recently, flow diverters and the need for dual antiplatelet therapy have introduced an additional layer of complexity to the management of intracranial aneurysms. Because of the pitfalls of dual antiplatelet therapy in patients with freshly ruptured aneurysms, acute subarachnoid hemorrhage (SAH) was long considered a relative contraindication to the use of these devices. In the setting of acute SAH, dual antiplatelet therapy exposes the patient to higher risks of hemorrhagic complications, especially if

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Saul F. Morales-Valero and Giuseppe Lanzino

benefit for CEA in reducing the risk of stroke after 5 and 10 years when compared with “best” medical therapy alone. However, these studies were conducted in the late 1980s and in the 1990s, and since their completion, progress in the medical management of cardiovascular diseases has led to a progressive decrease in the yearly risk of stroke in patients with asymptomatic carotid artery stenosis managed with medical treatment alone. Thus, some have questioned the effectiveness of large-scale invasive treatment (CEA or CAS) in view of the significant improvement of

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Giuseppe Lanzino, Neal F. Kassell and the Participants

mg/hour for the first 2 hours followed by 2 mg/hour for 14 days post-SAH) or orally (60 mg every 4 hours for 14 days post-SAH), whichever was approved in a particular country. At the discretion of the investigator, nimodipine therapy could be continued to Day 21 post-SAH. If hypotension occurred, nimodipine and any other antihypertensive treatment were stopped until this condition was resolved. Administration of nimodipine could be restarted once; however, if hypotension recurred, it was discontinued and this was documented on the patient's case report form. It was

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Brian Hoh and Giuseppe Lanzino

It is with great pride that we present this Neurosurgical Focus video supplement on endovascular neurosurgery. We were privileged to view a multitude of outstanding quality videos demonstrating the current state-of-the-art in endovascular neurosurgery. Careful and critical review was required to narrow down the videos to a workable volume for this supplement, though there were many more that we would have liked to have included.

This issue consists of several videos that represent modern neuroendovascular techniques for the treatment of cerebrovascular disease. The videos demonstrate the cutting-edge as well as standard endovascular therapies, which will be valuable to both the novice and the expert endovascular neurosurgeons. We are greatly honored to be involved with this project, and are very proud of its content and expert authors. We confidently believe you will enjoy the video content of this supplement.

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Editorial

Vertebrobasilar dissections

Giuseppe Lanzino

approach to be effective in adults with ruptured dissections of the VA 1 , 3 and I have successfully treated 2 adults with isolated ruptured BA dissections with this method. One wonders about the long-term hemodynamic effects of bilateral VA occlusion in young children. For ischemic dissections I strongly agree with a conservative approach as the vast majority of dissections heal and the long-term outcome with medical therapy alone is excellent. In this age of “stent mania” it cannot be stressed enough that medical therapy is very effective for ischemic dissections

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Giuseppe Lanzino and Robert D. Brown Jr.

therapeutic decisions in patients with carotid artery stenosis. In the first article, DeMarco and Huston provide an update on this topic and summarize potential future directions. Despite the landmark trials completed in the past 20 years, the management of asymptomatic carotid artery stenosis continues to be a controversial topic. Progress in medical therapy with the widespread use of lipid-lowering agents and better antihypertensive drugs combined with lifestyle modifications has improved the outlook of patients with asymptomatic carotid artery stenosis. In view of

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of rebleeding. In the earlier studies, overall outcomes did not improve because of a higher incidence of delayed neurological deficits from vasospasm. 1, 3 Those studies were conducted before both the widespread use of nimodipine and hyperdynamic therapy, and our understanding of the importance of perioperative care and the avoidance of hypotension and hypovolemia. Indeed, recent studies have suggested a new role for antifibrinolytic agents in the early phase after hemorrhage, while patients are being stabilized for definitive neurosurgical or endovascular

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Giuseppe Lanzino

treatment of intracranial aneurysms during the period from 1993 through 2003 using data from the Nationwide Inpatient Sample (NIS). This database includes discharges from a stratified sample of hospitals from different states. The data presented show an unequivocal increase in the utilization of endovascular therapy and a 2-fold increase in the number of unruptured aneurysms treated. The absolute number of surgical procedures remained relatively constant in the period under scrutiny. There was a 20% decrease in the mortality rate associated with subarachnoid hemorrhage

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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