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R. Webster Crowley, Ricky Medel and Aaron S. Dumont

Occipital artery to posterior inferior cerebellar artery bypasses remain an important tool for cerebrovascular neurosurgeons, particularly in the management of complex aneurysms of the posterior inferior cerebellar artery requiring proximal occlusion or trapping. The procedure requires meticulous technique and attention to detail. The authors outline their technique for accomplishing this bypass emphasizing nuances for complication avoidance.

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Ricky Medel, R. Webster Crowley and Aaron S. Dumont

Endovascular cerebral revascularization is becoming a frequently used alternative to surgery for the treatment of atherosclerotic disease, especially in the intracranial circulation where options are limited. Recent literature regarding the equivalent efficacy of carotid artery stenting and carotid endarterectomy in certain patient populations, as well as the recognition of the significant risk for recurrent stroke posed by intracranial lesions, will only serve to amplify this trend. Hyperperfusion syndrome has been well documented in the setting of carotid endarterectomy; however, a paucity of literature exists regarding the incidence, pathophysiology, and management as it relates to percutaneous interventions. The purpose of this review is to outline the current state of knowledge, with particular attention to the distinct attributes of endovascular treatment that would be expected to modify the course of hyperperfusion syndrome.

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R. Webster Crowley, Ricky Medel and Aaron S. Dumont

Penetrating injuries to the neck can result in a number of abnormalities that are of interest to neurosurgeons and interventional neuroradiologists. Gunshot or stab wounds may cause damage to the cervical spinal cord, the adjacent osseous and ligamentous structures, and the peripheral or cranial nerves. In addition, a significant percentage of penetrating wounds to this location result in vascular injury. These may present insidiously or acutely and with a variety of symptoms. The authors present the case of a patient in whom an occipital lobe infarction developed roughly 2 months after the patient was struck in the neck by a bullet. He was found to have a complete transection of the left vertebral artery, with an associated vertebral-venous fistula. The fistula was eventually treated endovascularly with a combination of platinum coils and Amplatzer Vascular Plugs. The management is discussed, with specific emphasis on the technical aspects of the case.

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Ricky Medel, R. Webster Crowley and Aaron S. Dumont

Spinal vascular malformations represent a complex group of entities whose treatment paradigm continually evolves. Given the ever-increasing role of endovascular therapy, it is the goal of the authors to review the current literature regarding this therapeutic tool and to provide recommendations guiding management. A thorough literature search was conducted using Medline, with subsequent articles being identified through cross-referencing. The analysis revealed that, since its introduction in the 1960s, endovascular therapy has been used to manage the entire spectrum of spinal vascular malformations, during which period it has undergone considerable technological and technical evolution. As such, embolization has proved of growing therapeutic utility, largely resulting from the mounting evidence supporting its safety and efficacy, in addition to the inherent minimally invasive nature. This alternative to surgical intervention will be increasingly used as first-line therapy in spinal vascular malformations.

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R. Webster Crowley, Ricky Medel and Aaron S. Dumont

✓As a leading cause of death and disability in patients across the world, stroke is a problem that plagues both neurosurgeons and neurologists alike. Whether a result of atherosclerosis, moyamoya disease, or a complication in the treatment of a complex intracranial aneurysm, cerebrovascular occlusion can have devastating effects on patients. For nearly half a century neurosurgeons have searched for safer, more effective ways to increase the amount of blood flow to ischemic brain tissue. From the first extracranial–intracranial bypasses to the recent technological advancements seen with endovascular therapy, cerebral revascularization techniques have been constantly evolving. Over the years cerebral ischemia has gone from a condition that was previously considered surgically untreatable, to a condition with several viable options for prevention and treatment. In this paper the authors discuss the historical evolution of treatment for cerebrovascular occlusive disease.

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Karam Moon, Felipe C. Albuquerque, Andrew F. Ducruet, R. Webster Crowley and Cameron G. McDougall

Object

Intracranial aneurysms, especially those of the cavernous segment of the internal carotid artery (ICA), can present with cranial nerve (CN) palsies. The Pipeline Embolization Device (PED) has demonstrated safety and efficacy in the treatment of cerebral aneurysms by flow diversion, but little data exist reporting the outcomes of cranial neuropathies following treatment with the device.

Methods

The prospectively maintained Barrow Neurological Institute's endovascular database was reviewed for all patients treated with the PED after presenting with one or more CN palsies secondary to a cerebral aneurysm since May 2011. Patient charts and digital subtraction angiograms were reviewed to report clinical and angiographic outcomes. Only patients with clinical follow-up were included in the analysis.

Results

A total of 127 patients were treated with the PED at the authors' institution after FDA approval. Twentytwo patients presented with cranial neuropathies, for initial inclusion in this study. Of these, 20 had sufficient followup for analysis. Cranial neuropathies included those of CN II, III, V, and VI, with presenting symptoms of diplopia, decreased visual acuity, and facial numbness and/or pain. Thirteen lesions were cavernous segment ICA aneurysms, whereas the remainder included supraclinoid and petrous segment ICA, posterior communicating artery, and basilar trunk aneurysms. At an average clinical follow-up of 9.55 months, 15 patients (75%) had resolution or significant improvement of their cranial neuropathies, and the remaining 5 had stable symptoms. Of the 18 patients with angiographic follow-up, 12 (66.7%) demonstrated complete obliteration or small neck residual, whereas 6 (33.3%) had residual lesion. Patients with complete or near-complete obliteration of their lesion were significantly more likely to demonstrate symptomatic improvement at follow-up (p = 0.009). Two patients with persistent symptoms were eventually treated with microsurgical bypass. Transient complications in this series included 6 (30%) extracranial hemorrhagic complications related to dual-antiplatelet therapy, all of which were managed medically. There was 1 delayed right ICA occlusion following retreatment that led to microsurgical bypass.

Conclusions

Intracranial aneurysms presenting with one or more CN palsies show a high rate of clinical improvement after treatment with the PED. Clinical outcomes must be weighed against the risks and challenges faced with flow diverters. Further research is warranted for patients whose symptoms do not respond optimally to device placement.

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Karam Moon, Andrew F. Ducruet, R. Webster Crowley, Kathleen Klas, Ruth Bristol and Felipe C. Albuquerque

In this paper the authors report the case of a complex dural arteriovenous fistula (dAVF) with high-risk features in a 14-year-old girl with Bannayan-Riley-Ruvalcaba syndrome (BRRS), a phosphatase and tensin homolog–associated syndrome, presenting with signs and symptoms of increased intracranial pressure (ICP) that had previously been attributed to pseudotumor cerebri. This fistula was obliterated following 2 stages of embolization, and the patient experienced immediate symptomatic improvement. At the 2-month follow-up evaluation, the fistula remained angiographically occluded, and her symptoms continue to improve. This is the third reported case of an intracranial dAVF in a patient with BRRS. Because high-risk dAVFs can result in devastating morbidity, early detection with vascular imaging is crucial for patients with BRRS presenting with signs of increased ICP. Goals of treatment should include complete fistula obliteration whenever possible.

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Aaron S. Dumont, R. Webster Crowley and Hian K. Yeoh

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Hideo Okada, Yoshikazu Matsuda, Joonho Chung, R. Webster Crowley and Demetrius K. Lopes

Mechanical thrombectomy with stentriever and/or aspiration is the new gold standard for the treatment of acute strokes with large-vessel occlusion. As many as 20% of cases remain refractory to current stentriever and/or aspiration devices. “Saddle clots” obstructing a bifurcation may be a particular challenge for recanalization with conventional techniques and devices. The authors describe an alternative technique to bifurcation occlusions resistant to the conventional mechanical thrombectomy approach in which they simultaneously deployed 2 stentrievers into both branches of an occluded bifurcation. This stentriever Y-configuration was very effective in managing a challenging intracranial bifurcation occlusion.