Faculty Bibliography

The current role of CT perfusion (CTP) imaging in the diagnosis and treatment of vasospasm in the setting of aneurysmal subarachnoid hemorrhage is discussed in this article, with specific attention directed towards defining the terminology of vasospasm and delayed cerebral ischemia. A commonly used CTP technique in clinical practice is described. A review of the literature regarding the usefulness of CTP for the diagnosis of vasospasm and its role in guiding treatment are discussed. Recent research advances in the utilization of CTP and associated ongoing challenges are also presented.

SUMMARY: During the past few decades, there have been significant advances in the understanding of spinal vascular lesions, mainly because of the evolution of imaging technology and selective spinal angiography techniques. In this article, we discuss the classification, pathophysiology, and clinical manifestations of spinal vascular lesions other than DAVFs and provide a review of the endovascular approach to treat these lesions

OBJECT: The authors assessed the safety and maximum tolerated dose of superselective intraarterial cerebral infusion (SIACI) of bevacizumab after osmotic disruption of the blood-brain barrier (BBB) with mannitol in patients with recurrent malignant glioma. METHODS: A total of 30 patients with recurrent malignant glioma were included in the current study. RESULTS: The authors report no dose-limiting toxicity from a single dose of SIACI of bevacizumab up to 15 mg/kg after osmotic BBB disruption with mannitol. Two groups of patients were studied; those without prior bevacizumab exposure (naive patients; Group I) and those who had received previous intravenous bevacizumab (exposed patients; Group II). Radiographic changes demonstrated on MR imaging were assessed at 1 month postprocedure. In Group I patients, MR imaging at 1 month showed a median reduction in the area of tumor enhancement of 34.7%, a median reduction in the volume of tumor enhancement of 46.9%, a median MR perfusion (MRP) reduction of 32.14%, and a T2-weighted/FLAIR signal decrease in 9 (47.4%) of 19 patients. In Group II patients, MR imaging at 1 month showed a median reduction in the area of tumor enhancement of 15.2%, a median volume reduction of 8.3%, a median MRP reduction of 25.5%, and a T2-weighted FLAIR decrease in 0 (0%) of 11 patients. CONCLUSIONS: The authors conclude that SIACI of mannitol followed by bevacizumab (up to 15 mg/kg) for recurrent malignant glioma is safe and well tolerated. Magnetic resonance imaging shows that SIACI treatment with bevacizumab can lead to reduction in tumor area, volume, perfusion, and T2-weighted/FLAIR signal

Spinal dural arteriovenous fistulas (SDAVFs) represent the most frequent spinal arteriovenous malformation and have an ominous natural history if left untreated. In the present review, we describe the spinal vascular anatomy, pathophysiology and clinical manifestations of SDAVFs, and the current role of endovascular embolization in this type of lesion.

OBJECTIVE: To review notable aneurysm cases that required complex decision making from a single institution and to examine available literature when relevant to highlight evidence-based paradigms for treatment of complex aneurysms. METHODS: Case illustrations were used to highlight topics in complex aneurysm treatments. Reviews of the literature were conducted to evaluate the evidence for available treatment models. RESULTS: Current modalities for treating complex aneurysms involve endovascular and microsurgical tools. CONCLUSIONS: Innovations in both arms of the cerebrovascular field will continue to advance the field and provide novel approaches to these complex lesions.

BACKGROUND: The International Study of Intracranial Aneurysms found that for patients with no previous history of subarachnoid hemorrhage, small (< 7 mm) anterior circulation and posterior circulation aneurysms had a 0% and 2.5% risk of subarachnoid hemorrhage over 5 years, respectively. OBJECTIVE: To determine whether cerebral aneurysms shrink with rupture. METHODS: The clinical databases of 7 sites were screened for patients with imaging of cerebral aneurysms before and after rupture. Inclusion criteria included documented subarachnoid hemorrhage by imaging or lumbar puncture and intracranial imaging before and after cerebral aneurysm rupture. The patients were evaluated for aneurysm maximal height, maximal width, neck diameter, and other measurement parameters. Only a change of >/= 2 mm was considered a true change. RESULTS: Data on 13 patients who met inclusion criteria were collected. The median age was 60, and 11 of the 13 patients (84.6%) were female. Only 5 patients had posterior circulation aneurysms. None of the aneurysms had a significant decrease in size. One aneurysm decreased by 1.8 mm in maximum size after rupture (7.7%). Six aneurysms had an increase in maximum size of at least 2 mm after rupture (46.2%) with a mean increase of 3.5 mm (+/- 0.5 mm). CONCLUSION: Unruptured aneurysms do not shrink when they rupture. The large percentage of ruptured small aneurysms in previous studies were likely small before they ruptured

Purpose: To assess in vivo performance of new eCLIPs (ENDOVASCULAR CLIP SYSTEM) device for treatment of rabbit bifurcation and sidewall aneurysms. The device was evaluated for flow diversion and coil assist. Performance was evaluated during acute implant and 30 days follow up. Materials and Methods: 8 animals with 10 surgical aneurysms were treated with eCLIPs, 6 bifurcation and 4 sidewall. Three devices were evaluated: High density (HD) bifurcation, Low density (LD) bifurcation, Sidewall. Two bifurcation aneurysms treated with HD device; following implantation, 1 device crossed for coiling; the other aneurysm treated with eCLIPs alone. Four bifurcation aneurysms treated with LD device - following implantation, 1 device crossed for coiling; 2 aneurysms treated with 1 eCLIPs alone and another with 2 'overlapping' eCLIPs devices. Two sidewall aneurysms treated with eCLIPs and coiling; 2 sidewall aneurysms treated with eCLIPs alone. Results: eCLIPs was intuitive with ease of delivery and positioning across the necks of both bifurcation and sidewall aneurysms. Post implantation angiograms showed flow reduction. When chosen, eCLIPs was crossed for coiling, demonstrating stability and containment of the coils within the aneurysm. As a flow diverter, the device provided flow effect at the aneurysm neck and stasis. 30 day follow up angiographic results and histopathological healing response is pending. Conclusion: eCLIPs is an evolved endoluminal treatment device with unique ability to treat aneurysms arising at sidewall and bifurcation locations; it predominantly affects the neck of the aneurysm for closure, respecting adjacent perforators and side branches

BACKGROUND: Aneurysms of the anterior inferior cerebellar artery (AICA), especially those located in the distal portion of the AICA, are rare. There are few reported cases treated with surgery or endovascular embolization. CASE DESCRIPTION: We report two cases of fusiform distal AICA aneurysms presenting with subarachnoid hemorrhage. Parent artery occlusion with coils and n-butyl cyanoacrilate (n-BCA) resulted in complete aneurysm occlusion and prevented rebleeding. Both patients presented postprocedure neurological deficits, but have made a good recovery at 4 and 10 months, respectively. CONCLUSION: Occlusion of the parent artery for the treatment of ruptured fusiform distal AICA aneurysms is effective but has significant neurological risks.

Intra-arterial bevacizumab (IA BV) has been recently identified to be safe in the treatment of recurrent GBM. In this study, we sought to perform a cost analysis of IA BV versus IV BV especially also taking account of patient progression free survival (PFS) and overall survival (OS). We show that IA BV is significantly more cost effective than conventional IV therapy.

BACKGROUND: Sphenoid wing meningiomas are slow-growing, well-circumscribed, and histologically benign lesions. The recurrence rate is low if removed completely at the time of surgery. Adequate surgical exposure with minimal morbidity is a challenge for those treating these lateral skull base lesions. OBJECTIVE: To describe our experience with the lateral tranzygomatic approach for resection of sphenoid wing meningioms in which the entire zygoma is mobilized and remains vascularized by masseter muscle attachments. METHODS: A retrospective review of the records of 19 patients who underwent sphenoid wing meningioma resection via a lateral transzygomatic approach between 1997 and 2007 was performed. A confirmatory cadaver dissection was performed to illustrate the anatomic nature of the technique. To achieve maximal exposure and minimal brain retraction, a lateral transzygomatic approach with osteotomies of the entire zygoma, which remains pedicled on the masseter muscle, was used. RESULTS: Nineteen patients with sphenoid wing meningioma underwent resection via a lateral transzygomatic approach. Complete resection of the meningioma was achieved in 17 cases. Morbidity consisted of temporary frontal nerve weakness (57.9%), mild to moderate temporalis atrophy (36.8%), and diplopia (15.8%). There were no cases of wound infection, bone malunion, or resorption. A mean follow-up period of 33.1 months (range, 2-71 months) revealed no recurrences after surgery as demonstrated by computed tomography or magnetic resonance imaging. CONCLUSION: The lateral transzygomatic approach to the sphenoid wing can be performed safely with minimal morbidity and facilitates complete resection of the tumor. Complete removal at an early stage is the best prognostic factor in treating sphenoid wing meningioma. This approach belongs in the armamentarium of surgeons who are involved in the resection of skull base neoplasms