Neuroendovascular surgery and interventional neuroradiology both describe the catheter-based (most often) endovascular diagnosis and treatment of vascular lesions affecting the brain and spinal cord. This article traces the evolution of these techniques and their current role as the dominant and frequently standard approach for many of these conditions. The article also discusses the important changes that have been brought to bear on open cerebrovascular neurosurgery by neuroendovascular surgery and their effects on resident and fellow training and describes new concepts for clinical care.
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JNSPG 75th Anniversary Invited Review Article
Howard A. Riina
Howard A. Riina and Robert F. Spetzler
Howard A. Riina and Y. Pierre Gobin
The treatment of arteriovenous malformations (AVMs) has evolved over the last 40 years. These complex vascular lesions remain among the most difficult lesions to treat. Successful treatment of AVMs of the brain includes extensive preoperative planning, multimodality treatment options, and modern postoperative surgical care. The advent of new technologies, including interventional neuroradiology and radiosurgery, has expanded the range of malformations that can be treated effectively and has had a significant impact on those individuals who manifest this disease process. The purpose of this paper is to describe the current grading technique used by the authors and to explore the preoperative treatment and planning that leads to successful surgical obliteration of these lesions. Some description of preoperative interventions, including radiosurgery and interventional procedures will be mentioned; however, only in the context of how they impact on the surgical treatment of these lesions. In other articles in this edition of Neurosurgical Focus interventional procedures and radiosurgery as treatment adjuncts and as primary therapies will be discussed in greater detail.
Howard A. Riina and Fred G. Barker II
Rajeev D. Sen, Carolina Gesteira Benjamin, Howard A. Riina, and Donato Pacione
The authors report on an 81-year-old woman with a pathologic hangman's fracture secondary to a complex arteriovenous fistula (AVF). The patient presented with severe, unremitting neck pain and was found to have fractures bilaterally through the pars interarticularis of C-2 with significant anterior subluxation of C-2 over C-3 along with widening of the left transverse foramen. Due to an abnormally appearing left vertebral artery (VA) on CT angiography, the patient underwent conventional angiography, which revealed a complex AVF stemming from the left VA at the level of C-2 with dilated posterior cervical veins and a large venous varix. Given the radiographic evidence of bone remodeling and the chronicity of the AVF, it is believed that the C-2 vertebra was weakened over time by the pulsatile and compressive force of the vascular malformation eventually leading to fracture with minimal stress. Coil embolization of the AVF was performed followed by surgical fixation of C-1 to C-4. This case highlights the importance of investigating an underlying disease process in patients who present with significant spinal fractures in the absence of trauma.
Mark G. Hamilton, Ian Parney, Odette A. Harris, Eric A. Schmidt, and Howard A. Riina
Marc L. Otten, Howard A. Riina, Y. Pierre Gobin, and Mark M. Souweidane
✓ The authors report a case of preoperative embolization and resection of a choroid plexus papilloma of the lateral ventricle in a 4-month-old boy. These vascular tumors of the central nervous system present a significant intraoperative bleeding risk. Attempts at preoperative embolization to reduce the bleeding risk have rarely succeeded because of the small and tortuous vessels feeding these tumors in infants. The case presented here supports the feasibility of preoperative embolization as a therapeutic adjunct in infants.
Jan-Karl Burkhardt, Howard A. Riina, Omar Tanweer, Peyman Shirani, Eytan Raz, Maksim Shapiro, and Peter Kim Nelson
The authors present the unusual case of a complex unruptured basilar artery terminus (BAT) aneurysm in a 42-year-old symptomatic female patient presenting with symptoms of mass effect. Due to the fusiform incorporation of both the BAT and left superior cerebellar artery (SCA) origin, simple surgical or endovascular treatment options were not feasible in this case. A 2-staged (combined deconstructive/reconstructive) procedure was successfully performed: first occluding the left SCA with a Pipeline embolization device (PED) coupled to a microvascular plug (MVP) in the absence of antiplatelet coverage, followed by reconstruction of the BAT by deploying a second PED from the right SCA into the basilar trunk. Six-month follow-up angiography confirmed uneventful aneurysm occlusion. The patient recovered well from her neurological symptoms. This case report illustrates the successful use of a combined staged deconstructive/reconstructive endovascular approach utilizing 2 endoluminal tools, PED and MVP, to reconstruct the BAT and occlude a complex aneurysm.