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Philipp Taussky, Ricardo A. Hanel, and Fredric B. Meyer

Incidental findings pose considerable management dilemmas for the treating physician and psychological burden for the respective patient. With an aging population, more patients will be diagnosed with asymptomatic internal carotid artery stenosis. Patients will have to be counseled with regard to treatment options according to their individual risk profile and according to professionals' knowledge of evidence-based data derived from large randomized control trials. Treatment consensus has long been lacking for patients with asymptomatic carotid artery stenosis prior to any randomized controlled trials. Additionally, an individual's risk profile may be hard to assess according to knowledge gained from randomized controlled trials. Moreover, while earlier studies compared carotid endarterectomy and medical therapy, in the past years, a new therapeutic modality, carotid artery angioplasty and stenting, has emerged as a possible alternative. This has been evaluated in a recent randomized controlled trial, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which compared carotid endarterectomy with angioplasty and stenting in both symptomatic and asymptomatic patients. The following review summarizes current knowledge of the natural history, diagnosis, and treatment strategies to counsel patients with asymptomatic carotid artery stenosis.

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Philipp Taussky and Daniel W. Fults

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Silvia Gesheva, William T. Couldwell, Vance Mortimer, Philipp Taussky, and Ramesh Grandhi

Dural arteriovenous fistulae (dAVFs) are vascular anomalies formed by abnormal connections between branches of dural arteries and dural veins or dural venous sinus(es). These pathologic shunts constitute 10%–15% of all intracranial arteriovenous malformations. The hallmark of malignant dAVFs is the presence of cortical venous drainage, a finding that increases the likelihood of nonhemorrhagic neurologic deficit, intracranial hemorrhage, and mortality if left unaddressed. Endovascular approaches have become the primary modality for the treatment of dAVFs. The authors present a case of staged endovascular transarterial embolization of a malignant dAVF running parallel to the left transverse sinus in a patient with headaches and pulsatile tinnitus. The fistula was completely treated using Onyx and n-butyl cyanoacrylate.

The video can be found here: https://youtu.be/GSAto_wlC3I.

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Nam K. Yoon, Jonathan P. Scoville, and Philipp Taussky

Vein of Galen malformations are congenital high-flow vascular malformations that often present with heart failure, hydrocephalus, developmental delay, and intracranial hemorrhage. Because open surgical treatment is associated with high morbidity and mortality, endovascular embolization is increasingly becoming the preferred method of intervention. However, embolization of these lesions can be difficult because of their high-flow nature. The use of adenosine-induced cardiac standstill for treatment of vein of Galen malformations has not been previously described in neonates. The authors describe 3 treatments in 2 patients that demonstrate that the use of adenosine is well tolerated and allows safe transarterial embolization of high-flow vein of Galen malformations in the pediatric population.

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Craig Kilburg, Philipp Taussky, M. Yashar S. Kalani, and Min S. Park

The use of flow-diverting stents for intracranial aneurysms has become more prevalent, and flow diverters are now routinely used beyond their initial scope of approval at the proximal internal carotid artery. Although flow diversion for the treatment of cerebral aneurysms is becoming more commonplace, there have been no reports of its use to treat flow-related cerebral aneurysms associated with arteriovenous malformations (AVMs). The authors report the cases of 2 patients whose AVM-associated aneurysms were managed with flow diversion. A 40-year-old woman presented with a history of headaches that led to the identification of an unruptured Spetzler-Martin Grade V, right parietooccipital AVM associated with 3 aneurysms of the ipsilateral internal carotid artery. Initial attempts at balloon-assisted coil embolization of the aneurysms were unsuccessful. The patient underwent placement of a flow-diverting stent across the diseased vessel; a 6-month follow-up angiogram demonstrated complete occlusion of the aneurysms. In the second case, a 57-year-old man presented with new-onset seizures, and an unruptured Spetzler-Martin Grade V, right frontal AVM associated with an irregular, wide-necked anterior communicating artery aneurysm was identified. The patient underwent placement of a flow-diverting stent, and complete occlusion of the aneurysm was observed on a 7-month follow-up angiogram. These 2 cases illustrate the potential for use of flow diversion as a treatment strategy for feeding artery aneurysms associated with AVMs. Because of the need for dual antiplatelet medications after flow diversion in this patient population, however, this strategy should be used judiciously.

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Giuseppe Lanzino and Philipp Taussky

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Spencer Twitchell, Michael Karsy, Jian Guan, William T. Couldwell, and Philipp Taussky

The term “radiation vasculopathy” defines a heterogeneous and poorly defined complex of vessel injury due to radiation. Radiation vasculopathy remains underrecognized and poorly treated with respect to head and neck radiotherapy. Distinct injury patterns to small (≤ 100-μm), medium (> 100-μm), and large (> 500-μm) vessels can occur, resulting in carotid stenosis, intracranial stenosis, and vascular anomalies (e.g., cavernous malformations, aneurysms). Because of the lack of clinical evidence and guidelines, treatment plans involve medical management, carotid endarterectomy, and carotid artery stenting and are developed on a patient-by-patient basis. In this review, the authors discuss the current pathophysiology, imaging, clinical impact, and potential treatment strategies of radiation vasculopathy with clinical pertinence to practicing neurosurgeons and neurologists. A review of 4 patients with prior head and neck tumors in whom delayed radiation vasculopathy developed after radiotherapy demonstrates the application of various treatment options in a case-by-case manner. Earlier recognition of radiation vasculopathy disease patterns may enable earlier initiation of treatment and monitoring for complications. Standardized terminology and treatments may assist with improving clinical outcomes.

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Editorial

Cardiac standstill

Giuseppe Lanzino and Philipp Taussky

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Marcus D. Mazur, Aaron Cutler, William T. Couldwell, and Philipp Taussky

Meningiomas that invade the transverse or sigmoid sinuses are uncommon tumors that are challenging to treat surgically. Although the risk of recurrence is associated with the extent of resection, complete removal of meningiomas in these locations must be balanced with avoidance of venous outflow obstruction, which could cause venous infarction and significant neurological consequences. When a meningioma occludes a venous sinus completely, gross-total resection of the intravascular portion is commonly performed. When the tumor invades but does not completely obliterate a major venous sinus, however, opinions differ on whether to accept a subtotal resection or to open the sinus, perform a complete resection, and reconstruct the venous outflow tract. In this paper, the authors review the different strategies used to treat these lesions and provide illustrative case examples.