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Brian A. O'Shaughnessy, Christopher C. Getch, Bernard R. Bendok and H. Hunt Batjer

Intracranial aneurysms arising from the posterior wall of the supraclinoid carotid artery are extremely common lesions. The aneurysm dilation typically occurs in immediate proximity to the origin of the posterior communicating artery and, less commonly, the anterior choroidal artery (AChA). Because of the increasingly widespread use of non-invasive neuroimaging methods to evaluate patients believed to harbor cerebral lesions, many of these carotid artery aneurysms are now documented in their unruptured state, prior to occurrence of subarachnoid hemorrhage. Based on these factors, the management of unruptured posterior carotid artery (PCA) wall aneurysms is an important element of any neurosurgical practice.

Despite impressive recent advances in endovascular therapy, the placement of microsurgical clips to exclude aneurysms with preservation of all afferent and efferent vasculature remains the most efficacious and durable therapy. To date, an optimal outcome is only achieved when the neurosurgeon is able to combine systematic preoperative neurovascular assessment with meticulous operative technique. In this report, the authors review their surgical approach to PCA wall aneurysms, which is greatly based on the extensive neurovascular experience of the senior author. Focus is placed on their methods of preoperative evaluation and operative technique, with emphasis on neurovascular anatomy and the significance of oculomotor nerve compression. They conclude by discussing surgery-related complications, with a particular focus on intraoperative rupture of aneurysms and their management, and the postoperative ischemic AChA syndrome.

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Sunit Das, Bernard R. Bendok, Christopher C. Getch, Issam A. Awad and H. Hunt Batjer

Stroke remains the leading cause of disability in adults and the third leading cause of death in the US. Carotid artery (CA) occlusive disease is the primary pathophysiological source of 10 to 20% of all strokes. Carotid endarterectomy (CEA) has been shown to reduce the risk of stroke in patients with both symptomatic and asymptomatic extracranial CA stenosis. Carotid artery angioplasty and stent placement has recently emerged as an alternative to CEA for primary and secondary prevention of stroke related to CA stenosis. With the advent of the embolic protection device, the safety of CA angioplasty and stent placement has approached, if not surpassed, that of CEA. In particular, the former has come to be considered as a first-line therapy in the management of CA stenotic disease in individuals at high risk for complications related to surgical intervention. Preliminary data from multiple registries have demonstrated that CA angioplasty and stent placement is an effective means of treating CA stenosis. The results of the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy trial have demonstrated that this modality has a significant role in the management of CA disease in symptomatic and asymptomatic patients with risk factors for high rates of surgery-related morbidity or mortality. With the completion of the Carotid Revascularization Endarterectomy versus Stent Trial, the role of CA angioplasty and stent placement in the prevention of stroke in all individuals with significant CA stenosis should be better demarcated. This treatment modality promises to assume a central role in stroke prophylaxis in patients with CA disease who are at high risk for complications related to surgery.

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Brian A. O'Shaughnessy, Christopher C. Getch, Robin M. Bowman and H. Hunt Batjer

✓The authors present the case report of a pediatric patient with a ruptured traumatic pseudoaneurysm of the intracranial vertebral artery (VA) from which the posterior inferior cerebellar artery (PICA) emerged. After considering multiple therapeutic options, the patient was treated surgically by trapping of the aneurysm segment and direct reimplantation of the PICA distal to the rupture site. In addition to presenting this unique case, the authors discuss the treatment of VA pseudoaneurysms and the various techniques for PICA revascularization. A review of the literature on PICA reimplantation is provided as an adjunct in the treatment of complex VA aneurysms.

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Brian A. O'Shaughnessy, Christopher C. Getch, Robin M. Bowman and H. Hunt Batjer

✓The authors present the case report of a pediatric patient with a ruptured traumatic pseudoaneurysm of the intracranial vertebral artery (VA) from which the posterior inferior cerebellar artery (PICA) emerged. After considering multiple therapeutic options, the patient was treated surgically by trapping of the aneurysm segment and direct reimplantation of the PICA distal to the rupture site. In addition to presenting this unique case, the authors discuss the treatment of VA pseudoaneurysms and the various techniques for PICA revascularization. A review of the literature on PICA reimplantation is provided as an adjunct in the treatment of complex VA aneurysms.

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Brian A. O'shaughnessy, Christopher C. Getch, Bernard R. Bendok and H. Hunt Batjer

Successful microsurgical resection of an infratentorial arteriovenous malformation (AVM) requires both surgical skill and intraoperative judgment. Extensive practical experience in treating these complex lesions, which is acquired over many years, is of substantial value during each new operation. The authors present the surgical approaches and techniques used for the treatment of posterior fossa AVMs based largely on the strategies acquired and developed by the senior author (H.H.B.). Emphasis is placed on conceptual principles of AVM excision, as well as principles incorporated for the treatment of each specific type of infratentorial malformation.

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Richard J. Parkinson, Bernard R. Bendok, Christopher C. Getch, Parham Yashar, Ali Shaibani, William Ankenbrandt, Issam A. Awad and H. Hunt Batjer

✓ The treatment of large and giant paraclinoid carotid artery (CA) aneurysms often requires the use of suction decompression for safe and effective occlusion. Both open and endovascular suction decompression techniques have been described previously. In this article the authors describe a revised endovascular suction decompression technique that provides several advantages in the treatment of large and giant paraclinoid and CA aneurysms.

A 51-year-old woman presented with a relatively brief history of progressive visual loss in the right eye, nonspecific headache, and an afferent pupillary defect. After angiography studies had been obtained, it was determined that she had a giant right paraclinoid internal CA aneurysm with a dome size of approximately 26 mm on the right and a neck diameter of 10 mm.

A modified technique was performed in which suction decompression was used. With the aid of a No. 7 French Concentric balloon guide catheter (Concentric Medical, Inc., Mountain View, CA) and application of a temporary clip distal to the aneurysm, the aneurysm was trapped and decompressed using retrograde suction through the guide catheter when the balloon was inflated. After satisfactory placement of three permanent clips, an intraoperative angiogram obtained through the same guide catheter confirmed CA patency. The aneurysm was then punctured and aspirated, ensuring complete occlusion of the aneurysm sac and reconstruction of the parent vessel. The patient made an excellent recovery and did not suffer any complications. She did not experience worsening in her vision.

This technical modification to endovascular suction decompression allows several potential advantages, including higher volume decompression and the ability to deliver endovascular devices to distal arterial locations.

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John K. Hopkins, Ali Shaibani, Saad Ali, Saquib Khawar, Richard Parkinson, Stephen Futterer, Eric J. Russell and Christopher Getch

✓The authors report a unique case of subarachnoid hemorrhage caused by a traumatic pseudoaneurysm of the ophthalmic artery, which was successfully treated with coil embolization. Clinical and imaging features, as well as the relevant literature, are described.

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Jesse Jones, Sunyoung Jang, Christopher C. Getch, Alan G. Kepka and Maryanne H. Marymont

✓ Radiosurgery has proven useful in the treatment of small arteriovenous malformations (AVMs) of the brain. However, the volume of healthy tissue irradiated around large lesions is rather significant, necessitating reduced radiation doses to avoid complications. As a consequence, this can produce poorer obliteration rates. Several strategies have been developed in the past decade to circumvent dose–volume problems with large AVMs, including repeated treatments as well as dose, and volume fractionation schemes. Although success on par with that achieved in lesions smaller than 3 ml remains elusive, improvements over the obliteration rate, the complication rate or both have been reported after conventional single-dose stereotactic radiosurgery (SRS). Radiosurgery with a marginal dose or peripheral dose < 15 Gy rarely obliterates AVMs, yet most lesions diminish in size posttreatment. Higher doses may then be reapplied to any residual nidi after an appropriate follow-up period. Volume fractionation divides AVMs into smaller segments to be treated on separate occasions. Doses > 15 Gy irradiate target volumes of only 5–15 ml, thereby minimizing the radiation delivered to the surrounding brain tissue. Fewer adverse radiological effects with the use of fractionated radiosurgery over standard radiosurgery have been reported. Advances in AVM localization, dose delivery, and dosimetry have revived interest in hypofractionated SRS. Investigators dispensing ≥ 7 Gy per fraction minimum doses have achieved occlusion with an acceptable number of complications in 53–70% of patients. The extended latency period between treatment and occlusion, about 5 years for emerging techniques (such as salvage, staged volume, and hypofractionated radiotherapy), exposes the patient to the risk of hemorrhage during that period. Nevertheless, improvements in dose planning and target delineation will continue to improve the prognosis in patients harboring inoperable AVMs.

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Patrick A. Sugrue, Patrick C. Hsieh, Christopher C. Getch and H. Hunt Batjer

Complications of tonsillar herniation associated with lumbar drainage have been reported in the literature. However, acutely symptomatic tonsillar herniation after intraoperative lumbar drainage is rare. The following case illustrates the risk associated with cerebrospinal fluid (CSF) drainage in the setting of tonsillar herniation. The use of lumbar drainage during cranial surgery is a common practice for reducing intracranial pressure and enhancing exposure, but is not without complications. In addition to the complications of the insertion procedure itself, the change in pressure gradient between the intracranial and the suboccipital compartments is of key importance.

The authors present the case of a patient who underwent a subtemporal craniotomy for resection of mesial temporal cavernous malformation with intraoperative lumbar drainage. The patient had a preexisting, asymptomatic 4-mm Chiari malformation and progressive neurological deficits resulting from further cerebellar tonsillar herniation in the early postoperative period developed, which required a lumbar blood patch, decompressive suboccipital craniectomy, and C-1 laminectomy with duroplasty. After placement of the lumbar drain and subsequent CSF drainage, the change in CSF pressure gradient above and below the foramen magnum probably led to the herniation. Unfortunately, the patient has lasting neuropathic pain and cervical cord signal changes on MR images.

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Omar M. Arnaout, Bradley A. Gross, Christopher S. Eddleman, Bernard R. Bendok, Christopher C. Getch and H. Hunt Batjer

Arteriovenous malformations (AVMs) of the posterior fossa are complex neurovascular lesions that are less common than their supratentorial counterparts, accounting for < 15% of all AVMs. The majority of patients with these lesions present with intracranial hemorrhage, a factor that has been consistently shown to increase one's risk for subsequent bleeding. Studies have additionally shown a posterior fossa or deep AVM location to portend a more aggressive natural history. The authors reviewed the literature on posterior fossa AVMs, finding their annual rupture rates to be as high as 11.6%, an important factor that underscores the importance of aggressive treatment of lesions amenable to intervention as therapeutic options and results continue to improve.