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Samuel Moscovici, Felix Umansky, and Sergey Spektor

The far-lateral approach (FLA) has become a mainstay for skull base surgeries involving the anterior foramen magnum and lower clivus. The authors present a surgical technique using the FLA for the management of lesions of the anterior/ anterolateral foramen magnum and lower clivus. The authors consider this modification a “lazy” FLA. The vertebral artery (VA) is both a critical anatomical structure and a barrier that limits access to this region. The most important nuance of this FLA technique is the management of this critical vessel. When the lazy FLA is used, the VA is reflected laterally, encased in its periosteal sheath and wrapped in the dura, greatly minimizing the risk for vertebral injury while preserving a wide working space. To accomplish this step, drilling is performed lateral to the point where the VA pierces the dura. The dura is incised medial to the VA entry point by using a slightly curved longitudinal cut. Drilling of the condyle and the C-1 lateral mass is performed in a manner that preserves craniocervical stability. The lazy FLA is a true FLA that is based on manipulation of the VA and lateral bone removal to obtain excellent exposure ventral to the spinal cord and medulla, yet it is among the most conservative FLA techniques for management of the VA and provides a safer window for bone work and lesion management. Among 44 patients for whom this technique was used to resect 42 neoplasms and clip 2 posterior inferior cerebral artery aneurysms, there was no surgical mortality and no injury to the VA.

Open access

Carlos Candanedo, Samuel Moscovici, and Sergey Spektor

Removal of brainstem cavernous malformation remains a surgical challenge. We present a case of a 63-year-old female who was diagnosed with a large cavernoma located in the medulla oblongata. The patient suffered three episodes of brainstem bleeding resulting in significant neurological deficits (hemiparesis, dysphagia, and dysarthria). It was decided to remove the cavernoma through a left-sided modified far lateral approach.3

The operative video demonstrates the surgical steps and nuances of a complete removal of this complex medulla oblongata cavernous malformation. Total resection was achieved without complications. Postoperative MRI revealed no signs of residual cavernoma with clinical improvement.

The video can be found here:

Restricted access

José E. Cohen, J. Moshe Gomori, Samuel Moscovici, Andrew H. Kaye, Yigal Shoshan, Sergey Spektor, and Ronen R. Leker


Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome.


The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed.


Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0–2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage.


Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors’ experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.