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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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.
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Direct surgical approaches to the posterior incisural space, including the pineal region, remain as challenges for neurosurgeons. The purposes of this study were 1) to compare the surgical views in the various posterior approaches to the posterior incisural space and 2) to propose a new approach, which is a modification of the occipital transtentorial approach. ⋯ Precise surgical anatomic knowledge of each approach is required for the treatment of lesions in the posterior incisural space, because the operative fields obtained with different approaches differ significantly. The occipital bi-transtentorial/falcine approach provides greater contralateral exposure of the posterior incisural space than does the occipital transtentorial approach.
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Although endovascular coiling has been used for 15 years in the treatment of intracranial aneurysms, fewer than 60 published studies have directly compared microsurgical clipping and endovascular coiling, and only two studies have used a randomized, prospective design. The objective of this review is to weigh evidence for the efficacy of endovascular coiling compared with microsurgical clipping based on published head-to-head comparisons. ⋯ The earliest randomized prospective study by Koivisto et al. found clinical and angiographic results between the two methodologies to be statistically equivalent. The more recent and larger randomized, prospective study from the International Subarachnoid Aneurysm Trial group suggests that endovascular coiling is statistically superior to microsurgical clipping in clinical outcomes, although the recently published long-term follow-up of International Subarachnoid Aneurysm Trial patients documents higher recurrence and rehemorrhage rates after endovascular coiling. Although there is no clear consensus in these two studies or in the 45 observational studies included, clinically useful information can be extracted to improve shared decision making and interaction between interventionalists and neurosurgeons, create more individualized treatment algorithms, and enhance future research.