Neurosurgery
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The disciplines of microneurosurgery and cranial base surgery have reached maturity, and technical advances in the surgical management of aneurysms are limited. Although most aneurysms can be clipped microsurgically or coiled endovascularly, a subset of patients may require a combined approach. A consecutive series of patients with aneurysms in one surgeon's cerebrovascular practice was reviewed retrospectively to analyze strategies for integrating microsurgical and endovascular techniques in the management of complex aneurysms. ⋯ Evolving endovascular technologies need to be integrated into the microsurgical management of aneurysms. Multimodality approaches are best used with complex aneurysms in which conventional therapy with a single modality has failed. Revascularization remains a unique surgical contribution to the overall management of aneurysms with which current endovascular techniques cannot be used. Multimodality management should be considered an elegant addition to the therapeutic armamentarium that, through simplification and increased safety, improves the treatment of complex aneurysms beyond what is achievable by performing clipping or coiling alone.
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During the past decade, management of posterior circulation aneurysms has shifted away from microsurgery. Currently, microsurgical clipping is considered a primary, competitive alternative to endovascular coiling, or more commonly, a secondary alternative when endovascular therapy is unfavorable. We present a large, multidisciplinary team experience with posterior circulation aneurysms in an institution that continues to use microsurgery as a primary treatment modality for selected aneurysms. ⋯ Despite increasing reliance on endovascular therapy with posterior circulation aneurysms, there is a role for microsurgical therapy. Microsurgery remains a competitive, primary therapy for superior cerebellar artery, P1 posterior cerebral artery, distal anteroinferior cerebellar artery, and posteroinferior cerebellar artery aneurysms. Microsurgery has become a secondary therapy for P2 posterior cerebral artery, basilar trunk, proximal anteroinferior cerebellar artery, vertebrobasilar junction, and vertebral artery aneurysms when endovascular therapy is unfavorable. The preferred therapy for basilar bifurcation aneurysms remains unclear. Collaborative, multidisciplinary teams are strengthened and results are improved by offering competitive treatment alternatives for patients to consider and select. Rather than abandoning the posterior circulation prematurely, aneurysm surgeons should maintain technical proficiency with these lesions.
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Vestibular schwannomas (VS) are common, benign, VIIIth cranial nerve tumors. Treatment in patients with the genetic disorder neurofibromatosis type II (NF2) is complicated by their development of bilateral VS and risk of complete deafness. Intervention decisions consider several clinical factors including tumor size and growth rate evaluated using magnetic resonance imaging. The current study evaluated the relative sensitivity of volumetric versus linear diameter measurement for assessing VS growth rate and progression. ⋯ Linear measurements underestimate VS growth rate compared with volumetric measures in NF2 patients. These results provide clear, quantitative proof that diameter measures are not as sensitive to change as volumetric measurements and that volumetric measurements should be strongly considered when making VS treatment decisions.
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Biography Historical Article
The history of neurosurgery at Emory University in Atlanta, Georgia.
The development of neurosurgery at Emory University has paralleled the evolution of the science and practice of neurosurgery during the 20th century. This article features those individuals who have influenced and nurtured neurosurgery at Emory. ⋯ Those individuals who have led neurosurgery at Emory are emphasized. Finally, the current Emory Department of Neurosurgery is featured, including facilities, faculty, and areas of subspecialty expertise.
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To report our experience with the treatment of brain arteriovenous malformations (AVM) with microsurgical resection after embolization with Onyx liquid embolic agent (eV3, Irvine, CA). ⋯ Multimodality treatment with microsurgery is safe and effective after embolization with Onyx. High occlusion rates and low complication rates were observed after Onyx embolization and were comparable to those in previous reports. Superselective intranidal or perinidal catheter positions and slow, controlled injections that protect the draining veins make the therapy safe even in complex AVMs and critical locations. We recommend resection of the AVM despite apparently complete embolization with Onyx. Team work and coordination between the surgeon and the interventional neuroradiologist are important to achieve a good outcome.