Controversies in Vascular Neurosurgery

Description:

This concise, easy-to-use book offers expert insights into current controversies in vascular neurosurgery with a view to providing the practitioner with authoritative practical guidance that will assist in the management of difficult disease entities. While vascular neurosurgery has undergone unprecedented advances during the past decade, enabling safer and easier access to previously untreatable pathology, this progress has been accompanied by confusion as to what constitutes best, or even acceptable, practice. Here, experts in the field discuss the various tools available and explain how best to use them when confronted by different pathologies, drawing upon their personal experience. Each chapter focuses on a specific case that is discussed by two experienced surgeons; a third author then evaluates the case, highlighting the available evidence and pearls in the treatment of that particular disease. The authors have been carefully chosen to provide a truly balanced viewpoint on paradigms that they themselves use. They therefore have a sound understanding of the thought processes of surgeons when dealing with challenging diseases for which there may be no single correct path. Furthermore, they are well placed to identify not only appropriate uses of new treatment options and technologies but also circumstances in which their use is best avoided. The ultimate benefactor of this book will be the patient: our biases as physicians should never become a patient’s morbidity.

Table of Contents:

1: Paraclinoid Aneurysms: Who to Treat with Craniotomy?

Introduction

Classification of Paraclinoid Aneurysms

Microsurgical Versus Endovascular Treatment

Surgical Treatment

Balloon Test Occlusion

Carotid Ligation

Microsurgical Management

Preoperative Planning

Intraoperative Neuromonitoring

Intraoperative Angiography

Surgical Exposure

Proximal Control

Techniques of Proximal Control/Methods to Reduce Aneurysm Size

Anterior Clinoidectomy

Extradural Clinoidectomy

Intradural Clinoidectomy

Subsequent Bony Exposure and Distal Dural Ring Dissection

Aneurysm Dissection/Clipping

Surgical Outcomes

Complications

Visual Outcomes

Intraoperative Aneurysm Rupture

Cranial Nerve Palsies

ICA Occlusion and Ischemia

Cerebrospinal Fluid Rhinorrhea

Mortality

Conclusions

References

2: Paraclinoid Aneurysms: Flow Diverters and Endovascular Treatment

Introduction

Anatomy and Classification Systems

Natural History, Treatment Indications, and Management Strategies

Treatment of Symptomatic Paraclinoid Aneurysms

Endovascular Considerations: Techniques, Results, and Outcomes

Historical Perspective

Therapeutic ICA Occlusion

Current Status

BTO Technique

Neurological Evaluation During BTO

Primary and Balloon-Assisted Coiling

Navigation of Microcatheters

Stent-Assisted Coiling

Flow Diversion

Strategies for Improving Results with the PED

Dual Antiplatelet Therapy

Correct Sizing

Optimal Deployment and Judicious Overlapping

Use of Coils

Indications

Complications

Radiological Outcomes

PED in Ruptured Aneurysms

Silk Stent

Other Flow Diverters

PED Flex

Flow-Redirection Endoluminal Device (FRED)

Surpass

Flow Diverters: The Future

References

3: Treatment Options for Paraclinoid Aneurysms: Discussion

4: Aneurysm Neck Remnants: A Strong Case Can Be Made for Re-treatment

Introduction

Incidence of the Aneurysm Neck Remnant (ANR)

Natural History of ANR

Re-treatment Risk

Advanced Imaging of ANR

Conclusion

References

5: Remnant Intracranial Aneurysms: Safety and Feasibility of Observation Over Retreatment

Introduction

Natural History of Intracranial Aneurysms

Remnant Aneurysms Following Surgical Clipping

Remnant Aneurysms Following Endovascular Coil Embolization

Retreatment Risks

Conclusion

References

6: Controversies in Vascular Neurosurgery: Aneurysm Remnants

Incidence

Natural History

Management

Conclusion

References

7: Basilar Artery Aneurysm: Role for Open Surgery

Introduction

Illustrative Case

Contemporary Surgical Series of Basilar Artery Aneurysms

Discussion

Conclusions

References

8: Craniotomy Is Over for Basilar Artery Aneurysms

Introduction

Basilar Apex Aneurysms

Novel Devices for Bifurcation Aneurysms

Aneurysm Recanalization and Coil Compaction

Basilar Trunk Aneurysms

Saccular Aneurysms

Fusiform Aneurysms

Vertebrobasilar Junction Aneurysms

References

9: Treatment of Basilar Artery Aneurysms: Natural Selection and Propagation of Endovascular Techn

Introduction

Discussion

Morbidity and Mortality of Treatment

Angioarchitectural Features Favoring Microsurgery

Intraprocedural Complications and Management

Treatment Decisions Based Upon Neurocognitive Outcome

Future Treatment Paradigms and Surgical Training

Conclusion

References

10: Surgical and Radiologic Intervention for Prevention of Ischemic Stroke

Extracranial Athero-occlusive Disease

Clinical Presentation and Natural Evolution of the Disease

Patient Evaluation

Management and Treatment

Conclusions

References

11: Whom I Stent

Introduction

Background

Current Evidence for Carotid Revascularization

Carotid Angioplasty and Stenting

The Carotid Angioplasty and Stenting Trials

Embolic Protection Options During Stenting Procedure

Consensus Recommendations for Treatment of Carotid Disease

Future of Therapy

Summary

References

12: Distal Protection for Carotid Artery Stenting: Where Is the Evidence?

Introduction

Distal Embolic Protection

The Evidence Against Distal Embolic Protection

Looking Beyond Distal Protection

Conclusions

References

13: Carotid Artery Stenosis: Discussion

Introduction

Carotid Endarterectomy

Carotid Artery Stenting

Carotid Endarterectomy Versus Carotid Artery Stenting

Stroke and Death

Myocardial Infarction

Restenosis

Other Complications

Cost-Effectiveness

Embolic Protection Devices

Conclusion

References

14: Arteriovenous Malformations: How We Changed Our Practice

Introduction

Anatomic Features

Epidemiology and Natural History

Clinical Presentation

Management

Surgery

Radiosurgery

Embolization

Medical Management With or Without Interventional Therapy for Unruptured Brain Arteriovenous Mal

The Treating Physicians

References

15: Discussion

References

16: Intra-arterial Treatment: Who and When

Who to Treat: Age

When to Treat: Time

When to Treat: Imaging

References

17: Acute Ischemic Stroke: Discussion

The Case Against Mechanical Thrombectomy of Acute Ischemic Strokes

The Case for Mechanical Thrombectomy of Acute Ischemic Strokes

References

18: Arterial Bypass

Introduction

Bypass Indications

Intracranial Aneurysms

Moyamoya Disease

Cerebral Ischemia

Skull Base Tumors

References

19: Cranial Dural AV Fistulas: Making Sense of Who to Treat and How

Introduction

Epidemiology

Clinical Presentation

Diagnostic Approach and Imaging

Grading

Natural History and Clinical Course

Treatment

Patient Selection for Treatment

Formulating a Treatment Strategy

Endovascular Management

Microsurgical Management

Stereotactic Radiosurgery

Cases

Conclusions

References

Index