Neurosurgery
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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
Therapy of brain arteriovenous malformations: multimodality treatment from a balanced standpoint.
The three therapeutic modalities for arteriovenous malformation (AVM) treatment (surgery, embolization, and radiotherapy) developed in the past years with specific tools, each tool with its own qualities. Soon after the implementation of embolization for treatment of AVMs, this technique was used in combination with microsurgery; since the development of radiosurgery, treatment algorithms combining embolization with surgery and eventual subsequent radiosurgery, embolization with radiosurgery, or surgery with subsequent radiosurgery have been reported. ⋯ Institutions with an endovascular background embolize AVMs with the aim of maximal occlusion rates and view surgery or radiosurgery as a technique to be used if the goal of total endovascular occlusion cannot be achieved. Radiosurgeons receive patients after incomplete embolization or surgical extirpation or a combination of both.
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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.
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Endovascular neurosurgical procedures are complex, requiring significant planning, foresight, and coordination. The neuroanesthetist is an integral part of these procedures, organizing efforts of the technicians and nurses and responding to the needs of the neurointerventionalist. The purpose of this article is to review, in detail, the role of the neuroanesthetist in the endovascular operating room. An overview of all areas either partially or completely managed by the anesthetist is provided.