J Neurosurg Sci
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Review
Intra-arterial thrombolysis and thrombectomy for acute ischemic stroke: technique and results.
Endovascular intraarterial (IA) strategies have emerged as important treatment options for patients with acute ischemic stroke who are ineligible for intravenous (IV) tissue plasminogen activator (tPA) or in whom such therapy has failed. The goal of this article is to provide a comprehensive review of percutaneous IA endovascular techniques aimed at revascularization in the setting of acute ischemic stroke from IA thrombolysis, mechanical thrombectomy, and primary intracranial stenting to retrievable-stent technology. For each modality, we focus on the existing clinical data, including our institutional experience and techniques.
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Extracranial-intracranial (EC-IC) bypass remains an important revascularization technique for management of complex cerebrovascular disease. Despite evolving endovascular techniques, the role of bypass for the purpose of flow replacement prior to planned vessel sacrifice remains relevant for treatment of complex and fusiform aneurysms. The role of bypass for purposes of flow augmentation in the setting of cerebral ischemia is limited based on current data, but remains an important option for selected cases of athero-occlusive disease, in addition to a primary treatment for symptomatic moyamoya disease. An objective flow-based approach to EC-IC bypass can enhance decision-making in preoperative patient selection, intraoperative graft assessment, and postoperative follow-up.
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Multicenter Study
Microsurgical technique for previously coiled aneurysms.
Since the introduction of Guglielmi detachable coils to treat intracranial aneurysms in 1991, the number of patients undergoing endovascular coiling has continuously risen as well as the number of those residual and recurrent previously coiled aneurysms that necessitate a microsurgical occlusion. Between July 1995 and August 2009 we retrospectively analyzed 81 patients with 82 previously coiled aneurysms treated microsurgically at two Finnish Neurosurgical University Hospitals, Helsinki and Kuopio. Fifty-eight aneurysms (71%) were located at anterior circulation and 24 (29%) at posterior circulation. ⋯ Good clinical outcome, three months after surgery, was achieved in 71 patients (88%); four patients were severely disabled, and six patients died (three of them due to poor clinical condition). Complete microsurgical occlusion of the residual previously coiled aneurysm is a high-risk procedure in large and giant aneurysms, and these patients should be referred to a dedicated neurovascular center to minimize surgical complications. Bypass procedures may be the best option for demanding growing lesions, especially those in posterior circulation.
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Arteriovenous malformations (AVM) can occur in the entire central nervous system with a predilection of the supratentorial intracranial compartment. Intracerebral hemorrhage is the most common clinical presentation of AVM and associated with a high morbidity and mortality rate. ⋯ In this review, the authors present actual diagnostic and interdisciplinary treatment modalities based on their experience in a major neurovascular center and taking into consideration actual literature data. Different treatment strategies are discussed.
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Based on findings from the International Subarachnoid Aneurysm Trial (ISAT), coiling of ruptured cerebral aneurysms is associated with the lowest immediate morbidity and mortality rates compared to other treatment options.1, 2 Whenever anatomy permits, coiling is the preferred method for repair. Unfortunately, not all cerebral aneurysms are suitable for coiling, and the best treatment for aneurysms that cannot be coiled remains unclear. Adjunctive techniques such as surgical clipping, balloon remodeling,3 use of two microcatheters,4 and intracranial stents 5 can increase the likelihood of aneurysm thrombosis and parent vessel patency. The goal of this article is to describe our current practice using intracranial stents in appropriately selected patients with subarachnoid hemorrhage (SAH) as a result of aneurysm rupture.