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Endovascular Treatment of Cerebral Arteriovenous Malformations

Significant advancements in the management and treatment of cerebral arteriovenous malformations (AVMs) have been made over the last few years. Although surgical resection remains the most definitive treatment option in selected patients, both endovascular and radiosurgical techniques have been added to the arsenal available for the treatment of these lesions. These treatment modalities can be used individually or combined in a multimodality approach. This chapter takes…

Endovascular Treatment of Stroke

Background According to estimates by the World Health Organization (WHO), stroke is the second leading cause of death worldwide and is the third greatest contributor to lost disability-adjusted life years (DALYs) globally. There are approximately 17 million strokes worldwide each year, with a disproportionately high incidence in low-income countries. In the United States, approximately 795,000 patients have a stroke annually, and with a mortality rate of…

Endovascular Management of Intracranial Aneurysms

Microsurgical clipping has been the historical definitive standard for treatment of intracranial aneurysms, though several factors may put a patient at increased risk for morbidity and mortality. These factors include the aneurysm’s size, location, and morphology; the patient’s age; and their medical condition. To overcome some of the limitations of surgical clipping, endovascular treatments were developed. They have grown considerably since US Food and Drug Administration…

Surgical Management of Cerebral Arteriovenous Malformations

Introduction Intracranial vascular malformations represent approximately 6% of all diseases that affect the central nervous system. They are classified according to their hemodynamic patterns in terms of arterial malformations (aneurysms), arteriovenous shunts (cerebral arteriovenous malformations), dural and pial fistulae, venous malformations (cavernous and venous angiomas), and capillary malformations (telangiectasias). Another type of vascular malformations that involve different angioarchitecture and preponderance in the pediatric age group (although…

Surgical Management of Brainstem and Cerebellar Arteriovenous Malformations

Introduction Brainstem and cerebellar arteriovenous malformations (AVMs) are rare vascular lesions that represent a minority of all intracranial AVMs. Although they are often grouped together, their specific anatomic location within the posterior fossa has important clinical implications for prognosis and treatment. For example, while cerebellar and pial-based brainstem AVMs are frequently amenable to surgical resection, AVMs involving the deep cerebellar nuclei or located within the brainstem…

Surgical Management of Cavernous Malformations of the Nervous System

Cavernous malformations (CMs) have long been recognized as one of the major clinicopathologic categories of vascular malformations of the nervous system. CMs have been included in the descriptions of cryptic or occult vascular malformations , a term that has been used to describe any vascular malformation that cannot be seen on angiography. The term cavernous angioma was used by Russell and Rubinstein in their description of…

Surgical Management of Cranial Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous shunts within the dural leaflets. DAVFs have similar hemodynamics to brain arteriovenous malformations (AVMs), with low resistance, high-flow arteriovenous shunting, and a higher annual rupture risk than AVMs. They are usually located within or near the wall of a dural venous sinus, which is often narrowed or obstructed. The nidus of arteriovenous shunting is contained solely within the dural…

Far-Lateral Approach for Vertebral and Posterior Inferior Cerebellar Artery Aneurysms

Introduction Aneurysms of the intracranial vertebral artery (VA) and posterior inferior cerebellar artery (PICA) can be challenging to treat effectively, given the narrow surgical corridors of the posterior fossa, the presence of brainstem perforators, and the frequent need for advanced revascularization strategies. However, despite significant advances in endovascular techniques in recent years, open surgical repair remains a necessary and effective approach for these often-complex lesions. Aneurysms…

Surgical Management of Aneurysms of the Vertebral and Posterior Inferior Cerebellar Artery Complex

Aneurysms of the vertebral artery–posterior inferior cerebellar artery (VA-PICA) complex can originate from any portion of the intradural VA up to the vertebrobasilar junction and from one of the five PICA segments. During the past decade, the treatment of these aneurysms became more sophisticated due to significant developments in diagnostic methods, improvements in microsurgical technique, further development of skull base surgery, better understanding of the microsurgical…

Surgical Management of Midbasilar and Lower Basilar Aneurysms

Acknowledgments The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for their assistance with the preparation of this manuscript. Background Aneurysms of the midbasilar and lower basilar artery (BA) are located below the level of the superior cerebellar artery and involve the anterior inferior cerebellar artery (AICA), the inferior basilar trunk, and the vertebrobasilar junction (VBJ). Aneurysms of the midbasilar and lower BA…

Surgical Management of Terminal Basilar and Posterior Cerebral Artery Aneurysms

Background In the early 1940s, following surgery for a posterior fossa aneurysm that ultimately took the life of the patient, Walter Dandy stated, “I know of no successful outcome from operative attack upon an aneurysm of the posterior cranial fossa, but for those upon the vertebral and posterior inferior cerebellar arteries, which afford good exposure, cures will certainly come in time.” As time passed, Dandy’s prediction…

Surgical Management of Aneurysms of the Middle Cerebral Artery

Acknowledgment The authors wish to thank Anette Krueger and Luzie Hofman for her medical illustrations. The middle cerebral artery (MCA) is one of the most common sites for the formation of intracranial aneurysms (IAs). In Finland, middle cerebral artery aneurysms (MCAAs) represent 40% of all IAs. MCAAs are more frequent among unruptured aneurysms (48%) than among ruptured aneurysms (34%). Although MCAAs are so common, surprisingly few…

Surgical Management of Anterior Communicating and Anterior Cerebral Artery Aneurysms

The anterior communicating artery (ACoA) aneurysm is the most common aneurysm encountered in neurosurgical practice, accounting for one-quarter to one-third of all microsurgically treated aneurysms in published experiences and 18.4% of the senior author’s experience with 4545 aneurysms. This aneurysm has a propensity to hemorrhage, often at or less than size limits considered safe for conservative management and often in younger patients for whom microsurgical clipping…

Surgical Management of Posterior Communicating, Anterior Choroidal, and Carotid Bifurcation Aneurysms

Walter Dandy at the Johns Hopkins Hospital was the first to describe an aneurysm clipping. In 1938 a patient presented to him with complete palsy of the third cranial nerve along with periorbital headaches. Through clip application, Dandy achieved complete obliteration of the neck of the posterior communicating artery (PComA) aneurysm while preserving the parent vessel. Seven months following the procedure, the patient experienced full resolution…

Surgical Treatment of Paraclinoid Aneurysms

The portion of the proximal intradural internal carotid artery (ICA) adjacent to the anterior clinoid process (ACP) is called the paraclinoid segment. Aneurysms arising from the ICA between the roof of the cavernous sinus and the origin of the posterior communicating artery (PComA) are defined as paraclinoid aneurysms. These aneurysms are of considerable surgical interest due to their particular anatomic features and technical difficulties. Some of…

Surgical Treatment of Moyamoya Disease in Adults

Introduction Moyamoya disease is a chronic, occlusive cerebrovascular disease with unknown etiology characterized by steno-occlusive changes at the terminal portion of the internal carotid artery (ICA) and an abnormal vascular network at the base of the brain. These vessels are called “moyamoya vessels” because the angiographic appearance of these vessels resembles the “cloud” or “puff” of cigarette smoke, which is described as “moya-moya” in the Japanese…

Surgical Management of Cerebellar Stroke—Hemorrhage and Infarction

Introduction The clinical manifestations of supratentorial stroke, ischemic or hemorrhagic, are usually diagnosed in a timely fashion. However, infratentorial stroke can be indolent, and its diagnosis is often delayed until severe clinical symptoms are evident. The posterior fossa tolerates very little mass effect and can quickly lead to hydrocephalus or herniation. Thus cerebellar stroke, whether hemorrhagic or ischemic, must be managed in a quick and efficient…

Surgical Management of Intracerebral Hemorrhage

Epidemiology Hemorrhagic infarction, or intracerebral hemorrhages (ICHs), make up approximately 14% of all strokes. Within the United States, ICH occurs with an incidence estimated to range from 15 to 35 cases per 100,000 people per 1 year. Each year, approximately 37,000 to 52,000 people in the United States have an ICH. Unlike ischemic infarctions, for which studies have demonstrated a steady decline over the past two…

Management of Unruptured Intracranial Aneurysms

Subarachnoid hemorrhage, when caused by the rupture of an intracranial aneurysm, has a mortality rate near 50% at 30 days, and approximately half of the survivors sustain irreversible brain damage. To avoid such a catastrophic event, it is important to identify and treat patients who harbor aneurysms that carry a significant risk of rupture. With the increased use of brain imaging in recent medical practice, including…

Management of Dissections of the Carotid and Vertebral Arteries

Introduction Cervicocerebral arterial dissection is an important cause of stroke; however, the majority of dissections are asymptomatic and do not warrant invasive therapy. The treatment of carotid and vertebral artery dissections has evolved significantly since the early diagnosis and management descriptions by Fisher and colleagues in the 1970s. As surgical technology and our understanding of the natural histories of these entities have evolved, radical surgical interventions…