ReviewCerebrovascular neurosurgery 2011
Introduction
In 2011, considerable advances in our understanding of the natural history and treatment of cerebrovascular disease were made. In particular, landmark prospective randomized trials such as the Barrow Ruptured Aneurysm Trial (BRAT),1 Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS)2 and Carotid Occlusion Surgery Study (COSS)3 were published (Table 1), as were numerous other manuscripts furthering our understanding of cerebral aneurysms and vascular malformations and their treatment.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 We briefly review these studies at the culmination of an exciting period in clinical cerebrovascular research.
Section snippets
Natural history
Hasan et al., who highlighted the potential pathophysiologic component of chronic inflammation in aneurysm rupture, demonstrated a beneficial effect of aspirin in reducing the risk of aneurysm rupture.4 This study evaluated 58 patients in the International Study of Unruptured Intracranial Aneurysms (ISUIA)21 with a proven subarachnoid hemorrhage (SAH), matching each to four controls by aneurysm location and size. In a multivariate analysis, patients who took aspirin at least 3 times weekly had
Arteriovenous malformations
Although the original study of Han et al.32 of grade IV and V AVMs suggested that these challenging neurosurgical lesions may have a more benign natural history than their lower grade counterparts, a subsequent study by Jayaraman et al.33 suggested a more malignant natural history with a 10.4% annual hemorrhage rate. Laakso et al. have now published the Finnish data for these lesions, suggesting that if ruptured, they may have a relatively malevolent course, with an overall 3.3% annual rupture
Cavernous malformations
The Helsinki group recently reviewed their surgical experience with 303 consecutive cavernous malformations (CM).19 Only lesion location and preadmission focal deficit affected long-term outcome. Patient age, sex, cavernoma size, preadmission epilepsy and history of hemorrhage did not. Based on this information, they devised a surgical CM grading scale. One point is assigned to supratentorial non-ganglionic CMs. Two points are assigned to infratentorial, ganglionic or spinal cord lesions. An
Cerebral ischemia
The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial demonstrated superiority of aggressive medical management to percutaneous transluminal angioplasty and stenting (PTAS, Wingspan stent; Boston Scientific, Natick MA, USA) for symptomatic intracranial stenosis.2 This prospective randomized trial comparing these two modalities randomized 451 patients with symptomatic, severe (70–99%) intracranial arterial stenosis. The 30-day
Conclusion
The year 2011 saw numerous advances in our understanding of the natural history of cerebral aneurysms, AVMs, CMs, and ischemic disease. Surgical and endovascular techniques continued to evolve, although the latter was curbed by reports of delayed hemorrhage after flow-diverting stent monotherapy for aneurysms. The true implications of the BRAT will follow as additional follow-up accrues and with subgroup analyses. Similarly, additional follow-up and subgroup analyses will prove useful for the
Conflicts of interest/disclosures
The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
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Cited by (5)
Cerebrovascular neurosurgery 2014
2015, Journal of Clinical NeuroscienceCitation Excerpt :It was suggested that delayed intervention (average 7 days between the qualifying event and randomization) may have increased the risk of the procedure [30]. Stratification of the stenting results by lesion location and length may have also impacted results [29,31]. A recent systematic review [32] of the use of stenting in the post-SAMMPRIS era demonstrated in 2196 patients with 2314 lesions a median success rate of 98%, stroke rate of 9.4%, and in-stent restenosis rate of 2.7%, though this was largely based on single center, retrospective, self-reported outcome results.
Angiotensin-converting enzyme-inhibitors, statins and the risk of hemorrhage from cerebral dural arteriovenous fistulae
2013, Journal of Clinical NeuroscienceCitation Excerpt :As few patients in our cohort were active smokers, an evaluation of this potential risk factor for dAVF hemorrhage was precluded. Although this small study will not modify current practice patterns in the management of cerebral dAVF, we hope it stimulates further study of these potentially modifiable risk factors across larger, multi-institutional databases; indeed, despite multiple advances in our understanding of the natural history of cerebral vascular malformations,7,23 to our knowledge such a study is yet to be undertaken. Our study demonstrated a lower rate of hemorrhagic presentation among patients with cerebral dAVF taking statins or ACE-inhibitors.
Preparedness of neurosurgery graduates for neuroendovascular fellowship: A national survey of fellowship programs
2015, Journal of NeurosurgeryQuality of life measures in Italian neurosurgical patients: validity of the EUROHIS-QOL 8-item index
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