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Vascular malformations of the brain and spine pose many management challenges. This text provides a comprehensive, state-of-the-art review of the natural history, treatment options, and outcomes of patients with these conditions. Despite their relative rarity, these lesions are responsible for devastating injury to individuals and can cause an enduring physical, psychological, and economic burden on patients and families. Many new therapeutic options are now available with the advent of novel surgical, endovascular, and radiosurgical techniques. The basic sciences have fuelled development of small molecule and biologic therapies targeting the molecular basis of disease. Authored by international experts in the fields of neurosurgery, neurology, radiology, and radiation oncology, this book provides state-of-the-art treatment plans and discussions of ideal therapy. This text is aimed at practitioners in the fields of neurology, neurosurgery, neuroradiology, radiation oncology, rehabilitation medicine and allied fields who care for patients with brain and spinal vascular malformations.
We have all – patients and physicians alike – come to take the capabilities of diagnostic imaging technology for granted; indeed, our expectations of that technology continue to increase – higher resolution, faster acquisition times, less artifact – the list of demands goes on and on. However, it is scarcely within the span of a generation that lesions considered occult in one imaging modality can now be diagnosed based on features that are pathognomonic in another modality. Young clinicians embarking on their careers at this time may be unaware, for example, that cerebral cavernous malformations with their distinctive appearance on magnetic resonance images were not that long ago considered to be angiographically occult arteriovenous malformations.
I offer this brief historical detail because readers of this volume are about to embark on an amazing three-dimensional visual journey of the circulation of the brain and neck that very few years ago would have been impossible. From the perspective of a neurosurgeon, the appreciation of the vascular system afforded by these images is priceless. Not only does three-dimensional rotational angiography improve the accuracy of diagnosis, it considerably enhances our ability to optimize treatment for patients with challenging neurovascular disorders. Preoperative planning is immeasurably improved by the ability to rotate these images in space to view the posterior regions of vessels that can even be difficult to view intra operatively.
To delineate factors associated with the successful endovascular treatment of extracranial carotid dissections, the authors review their management of 13 cases.
The records of 12 patients with 13 dissections were assessed with reference to mechanism of dissection, preoperative symptoms, presence of a pseudoaneurysm, treatment success, and etiology of treatment failure. Patients were followed prospectively and included six men and six women, ranging in age from 27 to 62 years.
Angioplasty and stenting were performed successfully in 11 of 13 procedures (10 of 12 patients). Follow-up in these 10 patients demonstrated excellent patency through the stented segment in nine of the 11 treated vessels. Two patients, both of whom suffered their original dissection as a result of endarterectomy, required further angioplasty and stenting for stenosis outside the previously treated arterial segment. Regarding the treatment failures, a stent deployment device could not navigate a tortuous loop in one, while a microwire could not be advanced beyond a pseudoaneurysm in the second. Six patients had pseudoaneurysms, four of which were treated only with stenting across the dissected arterial segment. All pseudoaneurysms treated in this fashion resolved. No permanent complications occurred as a result of endovascular therapy.
Angioplasty and stenting can be performed safely to manage carotid dissection. A pseudoaneurysm or tortuous anatomy can preclude therapy although the former typically resolves if angioplasty and stenting are feasible. Dissections secondary to endarterectomy may be associated with a higher rate of restenosis after stenting and may require further treatment.