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Hubert Lee, Jeffrey J. Perry, Shane W. English, Fahad Alkherayf, Joanne Joseph, Steven Nobile, Linghong Linda Zhou, Howard Lesiuk, Richard Moulton, Charles Agbi, John Sinclair and Dar Dowlatshahi


The aim of this study was to derive a clinically applicable decision rule using clinical, radiological, and laboratory data to predict the development of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients.


Patients presenting over a consecutive 9-year period with subarachnoid hemorrhage (SAH) and at least 1 angiographically evident aneurysm were included. Variables significantly associated with DCI in univariate analysis underwent multivariable logistic regression. Using the beta coefficients, points were assigned to each predictor to establish a scoring system with estimated risks. DCI was defined as neurological deterioration attributable to arterial narrowing detected by transcranial Doppler ultrasonography, CT angiography, MR angiography, or catheter angiography, after exclusion of competing diagnoses.


Of 463 patients, 58% experienced angiographic vasospasm with an overall DCI incidence of 21%. Age, modified Fisher grade, and ruptured aneurysm location were significantly associated with DCI. This combination of predictors had a greater area under the receiver operating characteristic curve than the modified Fisher grade alone (0.73 [95% CI 0.67–0.78] vs 0.66 [95% CI 0.60–0.71]). Patients 70 years or older with modified Fisher grade 0 or 1 SAH and a posterior circulation aneurysm had the lowest risk of DCI at 1.2% (0 points). The highest estimated risk was 38% (17 points) in patients 40–59 years old with modified Fisher grade 4 SAH following rupture of an anterior circulation aneurysm.


Among patients presenting with aSAH, this score-based clinical prediction tool exhibits increased accuracy over the modified Fisher grade alone and may serve as a useful tool to individualize DCI risk.

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Siok Ping Lim, Howard Lesiuk, John Sinclair and Cheemun Lum

Three-dimensional rotational digital subtraction (DS) angiography and DynaCT allow precise localization of intracranial arteriovenous fistulas (AVFs) with fiducial markers that have helped in surgical planning. These techniques are particularly useful when the AVF is not evident on cross-sectional imaging. The authors demonstrate the utility of 3D DS angiography and DynaCT in the localization of intracranial AVFs in 3 cases. Their first case was a dural AVF with multiple arterial feeders from the left occipital artery that drained into the left transverse sinus. Blood flow to the left transverse sinus was first decreased by embolizing the branch arterial feeders with polyvinyl alcohol particles. Thereafter, 3D DS angiography enabled precise localization of the site for the bur hole creation with a fiducial to allow access for the transverse sinus in the second part of the procedure where definitive transvenous sinus embolization of the dural AVF with coils was performed. They also used 3D DS angiography and DynaCT with fiducials for precise localization of a superficial pial AVF (Case 2) and a tentorial AVF (Case 3) not visible on cross-sectional angiography. With the precise localization of the target lesion, the neurosurgeons were able to perform relatively small craniotomies, minimizing the cranial opening yet allowing the opening for full access to the lesion. By correlating 3D DS angiography/DynaCT with CT images, the neurosurgeon could use neuronavigation in cases of AVF not appreciated on cross-sectional imaging.

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Michael E. Kelly, Raphael Guzman, John Sinclair, Teresa E. Bell-Stephens, Regina Bower, Scott Hamilton, Michael P. Marks, Huy M. Do, Steven D. Chang, John R. Adler, Richard P. Levy and Gary K. Steinberg


Posterior fossa arteriovenous malformations (AVMs) are relatively uncommon and often difficult to treat. The authors present their experience with multimodality treatment of 76 posterior fossa AVMs, with an emphasis on Spetzler–Martin Grades III–V AVMs.


Seventy-six patients with posterior fossa AVMs treated with radiosurgery, surgery, and endovascular techniques were analyzed.


Between 1982 and 2006, 36 patients with cerebellar AVMs, 33 with brainstem AVMs, and 7 with combined cerebellar–brainstem AVMs were treated. Natural history data were calculated for all 76 patients. The risk of hemorrhage from presentation until initial treatment was 8.4% per year, and it was 9.6% per year after treatment and before obliteration. Forty-eight patients had Grades III–V AVMs with a mean follow-up of 4.8 years (range 0.1–18.4 years, median 3.1 years). Fifty-two percent of patients with Grades III–V AVMs had complete obliteration at the last follow-up visit. Three (21.4%) of 14 patients were cured with a single radiosurgery treatment, and 4 (28.6%) of 14 with 1 or 2 radiosurgery treatments. Twenty-one (61.8%) of 34 patients were cured with multimodality treatment. The mean Glasgow Outcome Scale (GOS) score after treatment was 3.8. Multivariate analysis performed in the 48 patients with Grades III–V AVMs showed radiosurgery alone to be a negative predictor of cure (p = 0.0047). Radiosurgery treatment alone was not a positive predictor of excellent clinical outcome (GOS Score 5; p > 0.05). Nine (18.8%) of 48 patients had major neurological complications related to treatment.


Single-treatment radiosurgery has a low cure rate for posterior fossa Spetzler–Martin Grades III–V AVMs. Multimodality therapy nearly tripled this cure rate, with an acceptable risk of complications and excellent or good clinical outcomes in 81% of patients. Radiosurgery alone should be used for intrinsic brainstem AVMs, and multimodality treatment should be considered for all other posterior fossa AVMs.