BACKGROUND AND PURPOSE: Use of protective stents may not be effective in coil embolization of wide-neck aneurysms involving the posterior communicating artery. Successful implementation depends on the caliber of the vessel, its angle of origin, and the manner in which its orifice is incorporated into the aneurysm. Presented here are the results (clinical and radiographic) of coil embolization in aneurysms of the ICA-posterior communicating artery junction, variably aided by stents. The primary focus is angiographic configurations that impact stent placement.
BACKGROUND AND PURPOSE: Conventional platinum coils cause imaging artifacts that reduce imaging quality and therefore impair imaging interpretation on intraprocedural or noninvasive follow-up imaging. The purpose of this study was to evaluate imaging characteristics and artifact production of polymeric coils compared with standard platinum coils in vitro and in vivo.
BACKGROUND AND PURPOSE: Posterior communicating artery aneurysms with oculomotor nerve palsy may imply sudden enlargement of the aneurysm sac and have a high risk of rupture. Our aim was to identify the morphologic and hemodynamic parameters in this special period of aneurysm progression and to assess related rupture risk indices.
Abstract: Revascularization of the extracranial vertebral artery has evolved significantly since the adoption of endovascular techniques. The current neurosurgical armamentarium includes microsurgical and endovascular approaches. The indications for each treatment modality, however, still need to be further delineated. In contrast to carotid artery endarterectomy and carotid artery angioplasty/stenting, there is limited comparative evidence on the efficacy of medical, open, and endovascular treatment of atherosclerotic disease of the extracranial vertebral artery. More recently, drug-eluting stents have gained momentum after high rates of in-stent restenosis have been reported with bare metal stents placed in the vertebral artery. In this article, we discuss the indications, clinical assessment, and surgical nuances of microsurgical and endovascular revascularization for atherosclerotic disease of the extracranial vertebral artery. Despite a general tendency to consider endovascular treatment in the majority of patients, ultimately, open and endovascular revascularization of extracranial vertebral artery should be regarded as complementary therapies and both treatment options need to be discussed in selected patients.
Abstract: Stroke is the fourth leading cause of death in the United States. Intracranial atherosclerotic disease accounts for 8%-10% of ischemic stroke in the United States. So far, surgical bypass has not proved to be superior to medical therapy. As both medical and endovascular therapies for intracranial atherosclerosis evolve, so too do the guidelines for treatment. Initial reports on the results of stent placement for symptomatic high-grade intracranial atherosclerotic disease were encouraging; however, recent trials suggest that initial medical management may be preferable. Currently, intracranial angioplasty and stenting for symptomatic intracranial atherosclerosis is now more controversial. Further trials are necessary to help determine which patients are ideal for endovascular therapies.
Abstract: Of the approximately 795 000 strokes in the United States annually, 87% are ischemic and result in significant morbidity and mortality. Improvements in acute ischemic stroke (AIS) outcomes have been achieved with intravenous thrombolytics (IVT) and intra-arterial thrombolytics vs supportive medical therapy. Given its ease of administration, noninvasiveness, and most validated efficacy, IVT is the standard of care in AIS patients without contraindications to systemic fibrinolysis. However, patients with large-vessel occlusions respond poorly to IVT. Recent trials designed to select this population for randomization to IVT vs IVT with adjunctive endovascular therapy have not shown improvement in clinical outcomes with endovascular therapy. This could be due to the lack of utilization of modern thrombectomy devices such as Penumbra aspiration devices, Solitaire stent-trievers, or Trevo stent-trievers, which have shown the best recanalization results. Continued improvement in the techniques with using these devices as well as randomized controlled trials using them is warranted. This article defines the goals of AIS revascularization, presents the evolution of treatment from the initial use of IVT to modern thrombectomy devices, and discusses current treatment and ongoing AIS trials.
Abstract: The use of balloons in the field of neurosurgery is currently an essential part of our clinical practice. The field has evolved over the last 40 years since Serbinenko used balloons to test the feasibility of occluding cervical vessels for intracranial pathologies. Since that time, indications have expanded to include sacrificing cervical and intracranial vessels with detachable balloons, supporting the coil mass in wide-necked aneurysms (balloon remodeling technique), and performing intracranial and cervical angioplasty for atherosclerotic disease, as well as an adjunct to treat arteriovenous malformations. With the rapid expansion of endovascular technologies, it appears that the indications and uses for balloons will continue to expand. In this article, we review the history of balloons, the initial applications, the types of balloons available, and the current applications available for endovascular neurosurgeons.
Abstract: Endovascular technique represents an important, minimally invasive approach to treating cerebrovascular disease. In this article, we discuss the origins of endovascular neurosurgery as a discipline in the context of important technical milestones, evidence-based medicine, and future cerebrovascular neurosurgical training. Cerebrovascular neurosurgery has seen a steady, convergent evolution toward the surgeon capable of seamless incorporation of open and endovascular approaches to any complex vascular disease affecting the central nervous system. Neurosurgery must assume the leadership role in the multidisciplinary neurovascular team.
BACKGROUND: Simulation is an increasingly useful means of teaching in the era of duty hour restrictions. Since the completion of our diagnostic cerebral angiography simulator curriculum pilot program, we have performed this resident course at 2 Congress of Neurological Surgeons (CNS) annual meetings with larger participant numbers.
Flow diversion as a treatment concept for giant and wide-necked intracranial aneurysms has become a reality with Food and Drug Administration approval of the Pipeline embolization device (PED; Covidien Neurovascular, Irvine, California).1 When deployed over the neck of an intracranial aneurysm, this stentlike device discourages flow within the aneurysm and results in a gradual involution of the aneurysm. After a well-designed trial2 showed acceptable perioperative morbidity (5.6% perioperative incidence of major ipsilateral stroke or neurological death) and good occlusion rates (82% occlusion at 180 days and 86% occlusion at 1 year) for previously difficult-to-treat intracranial aneurysms, the Food and Drug Administration approved use of the PED for treatment of intracranial aneurysms of the internal carotid artery (ICA) at or proximal to the superior hypophyseal segment measuring > 10 mm in the greatest dimension.1 This treatment strategy now represents our treatment option of choice for large, wide-necked, and fusiform ICA aneurysms, which were conventionally the most difficult to treat with surgical or endovascular techniques.
BACKGROUND: Although initially considered safe when covering bifurcation sites, flow-diverting stents may provoke thrombosis of side branches that are covered during aneurysm treatment.
BACKGROUND: Prior studies have suggested that hospital case volume may be associated with improved outcomes after subarachnoid hemorrhage (SAH), but contemporary national data are limited.
BACKGROUND: Stereotactic radiosurgery (RS) is an effective tool in treating brain arteriovenous malformations (AVMs). Careful study of AVM angiographic characteristics may improve results.
BACKGROUND: Resection of cerebellopontine angle (CPA) meningiomas may result in significant neurological morbidity. Radiosurgery offers a minimally invasive alternative to surgery.
Stroke is a leading cause of morbidity and mortality and the most significant source of disability in the United States. Patients with recent transient ischemic attacks or stroke and significant intracranial stenosis are at particularly high risk of recurrent stroke. Recent trials have demonstrated that although outcomes for stroke patients are improving with aggressive medical therapy,1-3 the overall long-term prognosis is poor.
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