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Matthew I. Tomey, Ricardo J. Komotar and J Mocco

✓Since the early 19th century, significant controversy has persisted over the competing claims of two men, Charles Bell and François Magendie, to a pivotal discovery: that the dorsal spinal roots subserve sensation, whereas the ventral spinal roots subserve motion. However, the foundations of neuroanatomy on which Bell and Magendie built their research was formed two millennia in advance. Exploration of the work of four ancient scholars—Herophilus, Erasistratus, Aretaeus, and Galen–reveals a remarkable early appreciation of the separate neural pathways (if not the correct physiology) responsible for sensory and motor control.

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Ashish H. Shah, Michael E. Ivan and Ricardo J. Komotar

Meningiomas that partially or completely occlude the superior sagittal sinus may create a pseudotumor-like syndrome in certain patients. These patients may have impaired CSF absorption as a result of higher proximal venous pressure. Higher pressures after resection may encumber adequate wound healing and worsen symptoms. Here, the authors present a small series of patients with meningiomas involving the posterior third of the superior sagittal sinus, with documented high intracranial pressure prior to surgery. This paper aims to address the proposed etiology of high intracranial pressure in these patients and its associated complications, including CSF leak, wound dehiscence, pressure-related headaches, and visual complaints. In this paper, the authors propose a management plan to avoid wound complications and pseudotumor-related complications. When considering surgical intervention for patients with compromise of the posterior third of the superior sagittal sinus, careful attention must be paid to addressing potentially elevated intracranial pressure perioperatively.

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Kim J. Burchiel

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Robert M. Starke, Ricardo J. Komotar and E. Sander Connolly

Moyamoya disease is a chronic cerebrovascular occlusive disorder that results in severe morbidity and death. There is much controversy surrounding the optimal treatment for adult patients with the disorder. There have been no randomized trials to assess the efficacy of any single surgical treatment, and existing case series suffer from inadequate power, selection bias, and inherent differences in patient characteristics. In this article the authors review the literature concerning the optimal surgical treatment of adult patients with moyamoya disease.

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Giuseppe Lanzino

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Ashish H. Shah, Angela M. Richardson, Joshua D. Burks and Ricardo J. Komotar

Recurrent treatment-refractory brain metastases can be treated with modern adjuvant therapies such as laser interstitial thermal therapy (LITT). Since previously radiated lesions may be indolent (treatment effect) or recurrent tumor, histological confirmation may be helpful. The authors present the utility of contemporaneous biopsy and LITT using intraoperative O-arm navigation in a patient who presented with multiple refractory metastases. The authors demonstrate the utility of O-arm navigation to confirm intraoperative biopsy and LITT placement. Concurrent stereotactic biopsy and LITT may be a safe and efficacious method for both the diagnosis and treatment of deep lesions that are unamenable to standard adjuvant treatment modalities.

The video can be found here: https://youtu.be/SUY-qiahMyo.

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Ricardo J. Komotar, J Mocco, Sean D. Lavine and Robert A. Solomon

✓Hunterian ligation is a well-known treatment for complex aneurysms not amenable to direct microsurgical clip application. After proximal parent vessel occlusion, cerebral angiography is typically used to confirm aneurysm thrombosis. The authors report on a vertebral artery (VA) aneurysm that had progressively expanded and caused brainstem compression after hunterian ligation, despite nondiagnostic findings on both conventional and computed tomography (CT) angiography at multiple time points.

This 64-year-old woman underwent hunterian ligation of a 1.8-cm VA aneurysm at the origin of the right posterior inferior cerebellar artery. An immediately postoperative conventional angiogram and follow-up CT angiograms obtained 5 and 6 years postligation confirmed complete obliteration of the lesion. Nine years after the initial surgery, however, the patient experienced neurological deterioration. Although CTs showed substantial aneurysm enlargement together with pontine compression, angiograms once again demonstrated complete right VA occlusion with no retrograde filling of the aneurysm. On reexploration, the aneurysm was effectively debulked, clipped, and obliterated. Arterial bleeding was found in the lesion neck, as was evidence of microrecanalization.

Hunterian ligation for complex aneurysms carries the risk of microrecanalization and lesion expansion despite non-diagnostic angiography. Although this ligation procedure remains a viable treatment option in carefully selected patients, an extended follow-up evaluation period may be required even when imaging suggests aneurysm obliteration.

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J Mocco, Brad E. Zacharia, Ricardo J. Komotar and E. Sander Connolly Jr.

✓In an effort to help clarify the current state of medical therapy for cerebral vasospasm, the authors reviewed the relevant literature on the established medical therapies used for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH), and they discuss burgeoning areas of investigation. Despite advances in the treatment of aneurysmal SAH, cerebral vasospasm remains a common complication and has been correlated with a 1.5- to threefold increase in death during the first 2 weeks after hemorrhage. A number of medical, pharmacological, and surgical therapies are currently in use or being investigated in an attempt to reverse cerebral vasospasm, but only a few have proven to be useful. Although much has been elucidated regarding its pathophysiology, the treatment of cerebral vasospasm remains a dilemma. Although a poor understanding of SAH-induced cerebral vasospasm pathophysiology has, to date, hampered the development of therapeutic interventions, current research efforts promise the eventual production of new medical therapies.

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J Mocco, Carlton S. Prickett, Ricardo J. Komotar, E. Sander Connolly and Stephan A. Mayer

✓In an attempt to elucidate the pathophysiology and clinical significance of global cerebral edema (GCE) following aneurysmal subarachnoid hemorrhage (SAH), the authors explored potential mechanisms and reviewed findings associated with this phenomenon. Admission computed tomography (CT) scans show GCE in up to 20% of patients experiencing aneurysmal SAH. This edema is likely to have been initiated by transient global ischemia, as indicated by an association between ictal loss of consciousness and the development of edema. A further cascade of events, including a rise in intracranial pressure and compromise of the blood–brain barrier, are also likely contributors. Clinically, GCE on CT after aneurysmal SAH is predictive of a poor outcome. Further investigation is needed to gain a full understanding of edema development following SAH, with the hope that the knowledge can be used to influence treatment positively and improve outcome.