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Prithvi Narayan and Daniel L. Barrow

✓ There is a growing body of evidence in the literature suggesting that cavernous malformations of the central nervous system may develop after neuraxis irradiation. The authors discuss the case of a 17-year-old man who presented with progressive back pain and myelopathy 13 years after undergoing craniospinal irradiation for a posterior fossa medulloblastoma. Spinal magnetic resonance (MR) imaging, performed at the time of his initial presentation with a medulloblastoma, demonstrated no evidence of a malformation. Imaging studies and evaluation of cerebrospinal fluid revealed no evidence of recurrence or dissemination. Spinal MR imaging demonstrated an extensive lesion in the thoracic spine with an associated syrinx suggestive of a cavernous malformation. A thoracic laminectomy was performed and the malformation was successfully resected. Pathological examination confirmed the diagnosis. The patient did well after surgery and was ambulating without assistance 6 weeks later. To the best of the authors' knowledge, this is the second reported case in the literature and the first in the young adult age group suggesting the de novo development of cavernous malformations in the spinal cord after radiotherapy. An increased awareness of these lesions and close follow-up examination are recommended in this setting.

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Brian M. Howard, Ranliang Hu, Jack W. Barrow, and Daniel L. Barrow

Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.

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Steven L. Giannotta and DanieL L. Barrow

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Daniel L. Barrow, Austin R. T. Colohan, and Robert Dawson

✓ Intradural perimedullary arteriovenous fistulas (Type IV spinal cord arteriovenous malformations (AVM's)) are rarely reported in the literature and occasionally are classified together with Type II AVM's as intradural spinal cord AVM's. The authors report eight cases of Type IV spinal cord AVM's managed over a 2-year period. Seven of these AVM's were surgically obliterated, with intraoperative angiography being used as an adjunct; one other patient was managed using endovascular therapy. One of these lesions was definitely and another possibly the result of trauma; a malformation in a newborn infant was clearly congenital. The authors believe that the pathophysiological mechanisms and anatomical features of these lesions represent a unique spinal vascular anomaly that must be recognized angiographically to plan appropriate therapy.

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Luis M. Tumialán, C. Michael Cawley, and Daniel L. Barrow

✓ The authors report the case of a 53-year-old woman in whom a T1–T2 spinal arachnoid cyst with associated arachnoiditis developed, compressing the thoracic spinal cord 1 year after the patient had suffered a Hunt and Hess Grade IV subarachnoid hemorrhage (SAH). Development of spinal arachnoiditis with or without an arachnoid cyst is a rare complication of aneurysmal SAH. Risk factors may include posterior circulation aneurysms, the extent and severity of the hemorrhage, and the need for cerebrospinal fluid diversion. Surgical drainage, shunt placement, or cyst excision, when possible, is the mainstay of treatment.

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Daniel L. Barrow, Gustavo Pradilla, and D. Jay McCracken

Intracranial blister aneurysms are difficult to treat cerebrovascular lesions that typically affect the anterior circulation. These rare aneurysms can lead to acute rupture which usually cannot be treated via endovascular methods, but still require urgent surgical intervention. Surgical options are limited given their unique pathology and often require a combination of wrapping and clip reconstruction. In this video we present two patients with acute subarachnoid hemorrhage secondary to ruptured blister aneurysms. We demonstrate several surgical techniques for repairing the vascular defect with and without intraoperative rupture.

The video can be found here: http://youtu.be/nz-JM45uKQU.

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Daniel L. Barrow and Ralph Dacey

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Brian M. Howard and Daniel L. Barrow

Many brain arteriovenous malformations (AVMs) derive dural blood supply, while 10%–15% of dural arteriovenous fistulas (dAVFs) have pial arterial input. To differentiate between the two is critical, as treatment of these entities is diametrically opposed. To treat dAVFs, the draining vein(s) is disconnected from feeding arteries, which portends hemorrhagic complications for AVMs. The authors present an operative video of a subtle cerebellar AVM initially treated as a dAVF by attempted embolization through dural vessels. The lesion was subsequently microsurgically extirpated. The authors show a comparison case of an AVM mistaken for a dAVF and transvenous embolization that resulted in a fatal hemorrhage.

The video can be found here: https://youtu.be/eDeiMrGoE0Q

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Daniel L. Barrow, Foad Nahai, and George T. Tindall

✓ The heterotopic transfer of composite tissue, with microvascular anastomosis of an arterial supply and venous drainage to locally existing vessels, has received considerable attention in the plastic surgical literature. The use of latissimus dorsi musculocutaneous free flaps has been reported in the repair of large defects of the scalp, cranium, and dura following resection of invasive neoplasms or trauma. When the defect involves primarily subcutaneous tissue loss resulting in abnormal contour, omental free flaps provide effective coverage and restoration of contour. In addition, the inherent capability of the omentum to combat infection and form an ideal bed for the establishment of skin or bone grafts provides further indications for its use.

The authors have used omental free flaps in nine cases to reconstruct gunshot wounds of the head, orbit, and face, heal chronic cavitating frontal sinus infections, form a base over exposed dura for reconstruction of the skull with rib grafts, and cover large defects after resection of invasive tumors or infected scalp. These wounds of neurosurgical interest were reconstructed with acceptable structural and aesthetic results. The indications, surgical techniques, results, alternative procedures, and potential complications of this procedure are discussed. The authors believe that omental free flaps should be considered an option in the armamentarium of reconstructive approaches for skull, dural, scalp, orbital, and facial wounds.