Neurosurgery
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There is no consensus regarding the optimal management of inoperable high-grade arteriovenous malformations (AVMs). This long-term study of 42 patients with high-grade AVMs reports obliteration and adverse event (AE) rates using planned multistage repeat stereotactic radiosurgery (SRS). ⋯ Treatment of high-grade AVMs with multistage SRS achieves AVM obliteration in a meaningful proportion of patients with acceptable AE rates. Lower obliteration rates were associated with higher S-M grade and pre-SRS embolization. This approach should be considered with caution, as partial obliteration does not protect from hemorrhage.
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Flow diversion is typically reserved for large, giant, or morphologically complex aneurysms. Coiling remains a first-line treatment for small, morphologically simple aneurysms. ⋯ This matched analysis suggests that flow diversion provides higher occlusion rates, lower retreatment rates, and no additional morbidity compared with coiling in small, simple aneurysms amenable to both techniques. These results suggest a potential benefit for flow diversion over coiling even in small, uncomplicated aneurysms.
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Ultrasonic flow meters and quantitative magnetic resonance angiography quantitatively assess flow during hemodynamic evaluation of cerebral ischemia. Although their reliability and reproducibility have been verified, their clinical impact in moyamoya disease has rarely been reported. ⋯ Ipsilateral hemispheric flow was increased during 6-mo follow-up, and posterior circulation flow burden was diminished. Abundant intraoperative bypass flow was associated with postoperative hemodynamic improvement. Low preoperative contralateral hemispheric flow was related with immediate postoperative ischemic stroke.
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Pineoblastomas are rare, supratentorial, primitive neuroectodermal tumors. ⋯ Poor prognostic variables for children with pineoblastoma include young age, metastatic disease at presentation, and tumor relapse. For patients older than 5 years with focal disease, maximal tumor resection should be the goal.
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The utility of oral 5-aminolevulinic acid (5-ALA)/protoporphyrin fluorescence for the resection of high-grade gliomas is well documented. This drug has received regulatory approval in Europe but awaits approval in the United States. ⋯ The use of 5-ALA for brain tumor fluorescence is safe and effective to a dose of 50 mg/kg. Dose-limiting toxicity was not reached in this study.