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  • Author or Editor: E Sander Connolly Jr x
  • Neurosurgical Focus x
  • By Author: Meyers, Philip M. x
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Jason A. Ellis, Hannah Goldstein, E. Sander Connolly Jr. and Philip M. Meyers

Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.

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Andrew F. Ducruet, Christopher P. Kellner, E. Sander Connolly Jr. and Philip M. Meyers

Developmental venous anomalies (DVAs) represent a rare cause of intraparenchymal hemorrhage. This case demonstrates an unusual DVA associated with venous hypertension, arteriovenous shunting, and a ruptured transitional aneurysm. The authors describe the first use of embolization as a treatment method for an unstable ruptured transitional aneurysm associated with a DVA. This 33-year-old man suffered acute onset of headache, gait ataxia, and left hemiparesis. Computed tomography brain scans demonstrated a deep paramedian right frontal intraparenchymal hemorrhage. No cavernous malformation was apparent on MR imaging. Diagnostic angiography revealed arteriovenous shunting from the right anterior and middle cerebral arteries to a large DVA with an associated arteriovenous fistula, with a 3-mm aneurysm in the transition from pericallosal artery to the collecting vein. Both surgical and endovascular treatment options were considered. The patient underwent repeat angiography on hospital Day 7, at which time the aneurysm had increased to 5 mm, and endovascular treatment was selected. Acrylic occlusion of the aneurysm was performed and confirmed angiographically. The patient's neurological symptoms resolved throughout the hospital stay, and he remains symptom free in the 10 months since treatment. Developmental venous anomalies are not usually associated with arteriovenous shunting and aneurysms as a source of intraparenchymal hemorrhage. Endovascular occlusion of the aneurysm without blockage of physiologically necessary venous structures is a possible method of treatment for this complex mixed vascular lesion, and has proven safe and effective in this patient. To the authors' knowledge, this is the first presentation of this situation in the literature.

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Ricardo J. Komotar, J Mocco, David A. Wilson, E. Sander Connolly Jr., Sean D. Lavine and Philip M. Meyers

Intracranial atherosclerosis is the cause of a significant number of strokes. Despite maximal medical therapy, this disease continues to carry a poor prognosis. The authors reviewed studies in which the outcomes after conservative management in patients with intracranial carotid artery atherosclerosis were reported. Analysis of the literature demonstrates that maximal medical therapy frequently fails with this disease, leaving patients at high risk for cerebral infarction and death. A better understanding of the pathophysiological aspects and natural history of this condition may serve to guide clinical decision making and the choice of therapeutic options in this patient population.

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Ricardo J. Komotar, J Mocco, David A. Wilson, E. Sander Connolly Jr., Sean D. Lavine and Philip M. Meyers

A substantial number of strokes are caused by intracranial atherosclerosis, a disease that traditionally has been treated medically. Recent technological advancements, however, have revolutionized the treatment of this condition by enabling the use of endovascular methods. In this paper the authors focus on the internal carotid artery, and review relevant studies concerning angioplasty with stent placement for the management of intracranial atherosclerosis in this vessel. With continued experience and a multidisciplinary approach in the evaluation of these patients, favorable outcomes may be achieved.