Neurosurgery
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The treatment of giant aneurysms remains a formidable challenge for endovascular and surgical strategies. The use of endovascular techniques in a deconstructive (e.g., parent vessel occlusion) and reconstructive (e.g., stent coiling) methodology is reviewed. ⋯ A literature review of giant aneurysm endovascular treatment strategies was undertaken after 1994, when Guglielmi detachable coils were approved by the Food and Drug Administration. Where possible, follow-up, durability, and occlusion rates are also reviewed.
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Giant (>or=25 mm in diameter) cerebral aneurysms have a poor natural history, with high risks of subarachnoid hemorrhage or progressive disability or death caused by mass effect or stroke. Surgical treatment may be effective but carries a high burden of morbidity and mortality. Thus, attempts at endovascular solutions to these complex lesions have been developed to offer therapy at reduced risk. ⋯ Treatment of giant cerebral aneurysms via endovascular therapeutics requires the interventionist to possess an extensive armamentarium. Meticulous preprocedure evaluation, patient selection, and execution of the treatment plan enable safe and effective management. Current therapies do not provide an ideal solution for every patient, so one must consider creative and evolving solutions to these difficult clinical challenges. The procedural morbidity of open surgery versus the decreased durability of current endovascular techniques must be assessed carefully.
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Review Clinical Trial
The management of vein of Galen aneurysmal malformations.
The vein of Galen aneurysmal malformation (VGAM) is a choroidal type of arteriovenous malformation involving the vein of Galen forerunner. This is distinct from an arteriovenous malformation with venous drainage into a dilated, but already formed, vein of Galen. Reports of endovascular treatment of VGAM in the literature approach the disease from a purely technical viewpoint and often fail to provide satisfactory midterm results. To focus the therapeutic challenge to a strictly morphological goal overlooks the fundamental aspects of neonatal and infant anatomy and fluid physiology. During the past 20 years, our approach to VGAM has remained the same. Our experience, based on 317 patients with VGAM who were studied in Hospital Bicêtre between October 1981 and October 2002, allows us to describe the angioarchitecture, natural history, and management of VGAM in neonates, infants, and children. ⋯ Our data demonstrate that most treated children survive and undergo normal neurological development; an understanding of the clinical, anatomical, and pathophysiological features of VGAM has, therefore, reversed the former poor prognosis. Our level of understanding about the lesion allows us to predict most situations and remedy them by applying a strict evaluation protocol and working within an optimal therapeutic window. Patient selection and timing remain the keys in the management of this condition. It is more important to restore normal growth conditions than a normal morphological appearance, with the primary therapeutic objective being normal development in a child without neurological deficit.
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Controlled Clinical Trial
Early experience from the application of a noninvasive magnetic resonance imaging-based measurement of intracranial pressure in hydrocephalus.
The decision for surgical intervention in hydrocephalic patients presenting with symptoms suggesting raised intracranial pressure (ICP) is challenging because radiographic ventricular size often lacks the specificity to predict abnormal ICP. An early assessment of the potential clinical usefulness of a noninvasive magnetic resonance imaging-based measurement of ICP (MR-ICP) in symptomatic hydrocephalic patients is reported. ⋯ A finding of a normal MR-ICP value in hydrocephalic patients presenting with symptoms suggestive of abnormal ICP is a strong predictor for resolution of symptoms or stable outcome without surgical intervention.
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Neurosurgeons have a long history of treating cerebrovascular disease. Understanding the vascular anatomy and physiology of the nervous system and management of patients with abnormalities of theses vascular structures are vitally important aspects of neurosurgery resident training. ⋯ Interventional neuroradiologists were the pioneers in developing this area of therapy, but the number of neurosurgical trainees in neuroendovascular treatment is increasing, and other specialties, including neurology, vascular surgery, and cardiology, are now entering the field of neuroendovascular treatment. The purpose of this article is to review the current credentialing guidelines for neurosurgeons to use endovascular techniques in the treatment of cerebrovascular disease and to consider options for resident training in the rapidly evolving field of endovascular neurosurgery.