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Editorial

Role of radiosurgery for arteriovenous malformations

Giuseppe Lanzino

by Kano and coworkers in this multipart series, radiosurgery is a good (and probably the best) option for most thalamic and brainstem AVMs with obliteration rates approaching 70% at 5 years. 4 , 5 However, the incidence of adverse radiation effects with Gamma Knife surgery in these locations is higher than that for AVMs of equal volume in other areas of the brain. Despite all of the recent advances, treatment of most Grade IV and V AVMs remains challenging. This is especially true considering that often these large and complex AVMs are discovered incidentally or

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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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William T. Couldwell

panoramic exposure with a wide-angle lens within this region. A study performed some years ago by our group, but published in the otolaryngological literature, objectively quantified the increased volume of exposure offered by the endoscope and the microscope in the suprasellar region. 1 The exposure afforded by the endoscope was compared with that offered by the microscope in the sublabial–transsphenoidal, endonasal–transsphenoidal, and transethmoidal approaches to the sella turcica. The distances to relevant surgical landmarks and the amount of exposure superior

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Chris A. Sloffer and Giuseppe Lanzino

medicine and surgery in many areas. He produced important works on teeth, sexually transmitted diseases, inflammation, and digestion. His landmark volume, Treatise on the Blood, Inflammation, and Gun-shot Wounds, based on his observations during the Seven Years’ War, was published posthumously. Throughout his career Hunter accumulated more than 14,000 routine and abnormal anatomical specimens from his human patients as well as from many other species. After his death, this great collection was purchased by the Royal College of Surgeons, where it now constitutes the

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Lorenzo Rinaldo, Brandon A. McCutcheon, Meghan E. Murphy, Daniel L. Shepherd, Patrick R. Maloney, Panagiotis Kerezoudis, Mohamad Bydon and Giuseppe Lanzino

T he surgical clipping of an unruptured intracranial aneurysm (UIA) is a technically challenging and potentially morbidity-producing procedure. 21 Greater institutional experience in the surgical treatment of UIAs has been correlated to improved functional outcome after intervention, 4 , 8 , 15 arguing for the centralization of care at specialized centers. The effect of institutional case volume on the incidence of reportable complications during and after the clipping of UIAs, however, has not been as well defined, and thus the mechanism by which greater

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Alejandro A. Rabinstein, Seung Young Chung, Leslie A. Rudzinski and Giuseppe Lanzino

sum score before surgery; type of intervention (craniotomy, bur holes, or both); GCS sum score 24 hours after surgery; presence of pre- or postoperative seizures or epileptiform abnormalities on EEG studies; other medical complications after surgery; and functional status on discharge and at 1- to 6-month follow-up evaluations. All EEGs were interpreted by an epilepsy consultant. Epileptiform changes were defined as epileptiform discharges or electrographic seizures. Radiological measurements were made on the worst preoperative CT scan, 19 and included volume of

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Editorial

Onyx embolization of arteriovenous malformations

Giuseppe Lanzino and Harry Cloft

demonstrate the superiority of a novel agent or device over current ones—simply noninferiority. These investigators have reached the stated goal by showing that Onyx is not inferior to NBCA in achieving the primary end point (that is, ≥ 50 percent volume obliteration of the AVM). Secondary end points were operative time and blood loss, which were not significantly different between the 2 agents despite a trend toward better volume obliteration with Onyx (which in theory should have decreased operative times and blood loss). In their Discussion , the authors provide a

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Giuseppe Lanzino

artery occlusion. These authors aimed to study the effects of vasogenic edema on infarct volume and functional outcome. To eliminate the space-occupying effects of postinfarction edema, a bilateral decompressive craniectomy was prophylactically performed before reversible cerebral ischemia; the control group consisted of sham-operated animals. Infarct size was measured on MR images obtained 5 and 24 hours after ischemia onset. Ischemic lesions were consistently smaller in the craniectomy group at both the 5- and 24-hour time points. Clinical scores were also

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Waleed Brinjikji, David F. Kallmes, Harry J. Cloft and Giuseppe Lanzino

-test or a nonparametric test, depending on variable distribution. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained using multivariate logistic regression adjusted for sex, aneurysm size, aneurysm location, number of aneurysms treated, use of multiple PEDs, use of multiple exchange guidewires, practitioner’s prior experience, and center volume. For the multivariate analysis, age was modeled as a continuous variable. Role of the Funding Source An academic principal investigator and an academic steering committee supervised trial design and

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Giuseppe Lanzino and Robert D. Brown Jr.

of rupture, and women had 20% more ruptures than men. How can we interpret these data? Administrative databases are being used with increasing frequency to detect trends, outcomes, and potential effectiveness of various therapeutic interventions. The main advantage of these databases is the ability to analyze a large volume of data based on prospective, objective data submission, often based on discharge codes and less likely to be influenced by the bias of a treating physician. Numerous limitations exist, and the conclusions of these analyses must be interpreted