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Robert F. Spetzler, Neil A. Martin, L. Philip Carter, Richard A. Flom, Peter A. Raudzens and Elizabeth Wilkinson

radiologist (R.A.F.), and two neuroanesthesiologists (E.W. and P.A.R.). Intraoperative digital subtraction angiography, extensive electroencephalographic (EEG) studies, and evoked potential monitoring were used in all cases. A summary of the patients' profiles, locations of the AVM's, feeding vessels, surgical procedures, complications, and results is presented ( Table 1 ). The angiographic findings are noteworthy because they disclosed a high incidence of AVM's fed by the external carotid artery (ECA). Angiography showed steal in all cases, with the virtual absence of

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Robert B. King and Gerald R. Schell

to identify the optimum surgical approach to subcortical lesions. 4 In selected patients intraoperative digital subtraction angiography was used to supplement the standard preoperative baseline angiograms, and was particularly useful following intraoperative embolization. In patients undergoing embolization procedures, a femoral artery catheter was placed preoperatively into the external carotid artery and withdrawn into the common carotid artery for injection of meglumine iothalamate (Conray 60). At embolization, surface vessels were selectively cannulated and

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Wesley A. King, Grant B. Hieshima and Neil A. Martin

approach. A No. 18 spinal needle was placed over the sinus as a marker, and contrast material was injected into the left carotid artery to establish the position of the cavernous sinus ( Fig. 2 left ). Intraoperative digital subtraction angiography † was performed using the system described by Foley, et al. 8 An attempt was made to place a detachable balloon into the cavernous sinus through its lateral dural wall. An angiography sheath was inserted into the anterior portion of the sinus. The balloon catheter, however, could not be advanced into the main chamber of

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Carl B. Heilman, Eddie S. Kwan, Richard P. Klucznik and Alan R. Cohen

aneurysm becomes progressively occupied with thrombus and coils placed earlier. Intraoperative digital subtraction angiography allows continued evaluation of the progress of the embolization. We believe that thrombus fills the aneurysm and propagates back into the fistula, thus obliterating the nidus of the abnormality. Embolization in this case continued until no further coils could be placed into the aneurysm. In spite of our strategy, a few coils passed out of the aneurysm and lodged in draining veins a few centimeters away ( Fig. 4 ). No coils passed into the

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Neil A. Martin, John Bentson, Fernando Viñuela, Grant Hieshima, Murray Reicher, Keith Black, Jacques Dion and Donald Becker

complications are encountered using these techniques? This report draws from experience with 105 intraoperative angiographic studies in patients treated surgically for intracranial aneurysms or AVM's. Clinical Material and Methods From March, 1985, to July, 1989, intraoperative digital subtraction angiography was performed after 105 procedures in 101 patients at the UCLA Medical Center. Angiography was performed to evaluate the result of standard neurovascular surgical procedures ( Table 1 ). Not all patients undergoing neurovascular procedures underwent intraoperative

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.73.4.0518 Intraoperative digital subtraction angiography and the surgical treatment of intracranial aneurysms and vascular malformations Neil A. Martin John Bentson Fernando Viñuela Grant Hieshima Murray Reicher Keith Black Jacques Dion Donald Becker October 1990 73 4 526 533 10.3171/jns.1990.73.4.0526 Craniopharyngiomas in children Edwin G. Fischer Keasley Welch John Shillito Jr. Ken R. Winston Nancy J. Tarbell October 1990 73 4 534 540 10.3171/jns.1990.73.4.0534 Early postoperative seizures

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Norihiko Tamaki, Shigekuni Kim, Kazumasa Ehara, Masahiro Asada, Katsuzo Fujita, Katsushi Taomoto and Satoshi Matsumoto

✓ The authors have devised a “trapping-evacuation” technique to facilitate direct clipping of giant aneurysms in the paraophthalmic region of the internal carotid artery (ICA). The giant aneurysm is collapsed by first trapping the aneurysm by temporary occlusion of the cervical common carotid and external carotid arteries, along with temporary clipping of the intracranial ICA distal to the aneurysm. Thereafter, intra-aneurysmal blood is simultaneously aspirated through a catheter placed in the cervical ICA. Exposure of the proximal end of the aneurysm neck is mandatory for successful clipping. This is accomplished by extensive unroofing of the optic canal, removal of the anterior clinoid process, opening of the anterior part of the cavernous sinus, and exposure of the most proximal intradural (C2) and genu (C3) portions of the ICA.

Four cases of giant aneuryms of the paraophthalmic ICA were successfully treated by this technique and the postoperative outcome was good in all cases. Preoperative magnetic resonance imaging for evaluation of the anatomical details, balloon occlusion test of the ICA, and intraoperative measurement of cortical blood flow were important to the success of the operation. Intraoperative digital subtraction angiography via the catheter placed in the cervical ICA was useful in confirming successful clipping.

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John A. Scott, Terry G. Horner and Thomas J. Leipzig

-lumen occlusion balloon placement. By means of the same technique, the ICA was again occluded and the aneurysm collapsed. The aneurysm was ligated with a 45° side-angled clip. The temporary clip on the ICA was removed and the balloon deflated. Intraoperative digital subtraction angiography was then performed through the distal lumen of the catheter, confirming successful obliteration of the aneurysm. The patient made an uneventful recovery. Comment Proximal balloon occlusion 2 and retrograde suction decompression 1 have been shown to be effective aids in the

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Neurosurgical Forum: Letters to the editor To The Editor Dwight Parkinson , M.D. University of Manitoba Winnipeg, Manitoba, Canada 342 342 I read with interest the article by Martin, et al. , on intraoperative digital subtraction angiography (Martin NA, Bentson J, Viñuela F, et al: Intraoperative digital subtraction angiography and the surgical treatment of intracranial aneurysms and vascular malformations. J Neurosurg 73: 526–533, October, 1990). It is encouraging to read their advocacy of intraoperative

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Fernando Viñuela, Jacques E. Dion, Gary Duckwiler, Neil A. Martin, Pedro Lylyk, Allan Fox, David Pelz, Charles G. Drake, John J. Girvin and Gerard Debrun

electroencephalographic (EEG) burst suppression was used for large AVM's, for deep AVM's requiring prolonged brain retraction, and when hypotension was induced to control troublesome bleeding. Since 1986, intraoperative digital subtraction angiography has been performed to confirm the completeness of the AVM excision. In approximately 10% of embolized cases, residual AVM was identified and located by the intraoperative angiogram. In each instance, the residual AVM nidus was found and removed. Results Morphological Obliteration by Embolization In 50 cases (49.5%), 50% to