Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Apr 2010
Review Historical ArticleSurgical management of aneurysmal subarachnoid hemorrhage.
Aneurysmal subarachnoid hemorrhage (aSAH) is a common and often devastating condition that requires prompt neurosurgical evaluation and intervention. Modern management of aSAH involves a multidisciplinary team of subspecialists, including vascular neurosurgeons, neurocritical care specialists and, frequently, neurointerventional radiologists. This team is responsible for stabilizing the patient on presentation, diagnosing the offending ruptured aneurysm, securing the aneurysm, and managing the patient through a typically prolonged and complicated hospital course. ⋯ Following a brief historical perspective on the origin of aneurysm surgery, the topics discussed include the timing of surgical intervention after aSAH, commonly used surgical approaches and craniotomies, fenestration of the lamina terminalis, intraoperative neurophysiological monitoring, intraoperative digital subtraction and fluorescent angiography, temporary clipping, deep hypothermic cardiopulmonary bypass, management of acute hydrocephalus, cerebral revascularization, and novel clip configurations and microsurgical techniques. Many of the topics highlighted in this report represent some of the more debated techniques in vascular neurosurgery. The popularity of such techniques is constantly evolving as new studies are performed and data about their utility become available.
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Endovascular reperfusion therapy is evolving as a promising treatment in the setting of acute ischemic stroke. Careful patient selection and angiographic evaluation of the location and extent of occlusion are necessary for the successful management of stroke patients. ⋯ Mechanical thrombolysis is becoming an adjunctive or alternative treatment therapy via novel clot dissolution and retrieval techniques. Existing and upcoming trials are investigating the safety and efficacy of neuroendovascular therapy while attempting to expand its indications in acute ischemic stroke.
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Neurosurg. Clin. N. Am. · Oct 2009
ReviewNeuroendovascular management of carotid cavernous fistulae.
Carotid-cavernous fistulae are abnormal arterial communications within the cavernous sinus. Endovascular obliteration is the mainstay therapy for the definitive treatment of these lesions. ⋯ These include transarterial or transvenous embolization with balloons, coils, particles, or covered stents, and arterial sacrifice. The preferred technique is based on the fistula type (direct or indirect), microanatomy, chronicity, and the extent of the arterial defect.
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Neurosurg. Clin. N. Am. · Oct 2009
ReviewNeuroendovascular management of vasospasm following aneurysmal subarachnoid hemorrhage.
Cerebral vasospasm continues to be the leading treatable cause of death and disability in patients with subarachnoid hemorrhage. Transluminal balloon angioplasty has been considered a safe and effective treatment for cerebral vasospasm resistant to maximal medical treatment. However, it should be performed in a timely manner, any delays could potentially increase the risk of hemorrhagic infarct. Angioplasty in the affected territory may be of benefit in improving not only the angiographic appearance but also the ultimate outcome for the patient, if performed in a timely fashion.