Review
Cerebrovascular neurosurgery 2011

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Abstract

Several landmark studies in cerebrovascular neurosurgery were published in 2011. In this brief review, we highlight advances in our understanding of cerebral aneurysms, arteriovenous malformations (AVM), cavernous malformations (CM) and cerebral ischemia. Specifically, results from the Barrow Ruptured Aneurysm Trial (BRAT), the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial (SAMMPRIS) and the Carotid Occlusion Surgery Study (COSS) are highlighted. In addition, studies detailing the effect of aspirin on aneurysm rupture, the question of shrinking of ruptured aneurysms, and important endovascular reports including the Pipeline embolization device for the Intracranial Treatment of Aneurysms trial (PITA) are reviewed. New natural history results for high grade AVM from the Finnish database were reported, as were exciting advances in endovascular therapy and a compilation of results of radiosurgery. For CM, a new grading scheme was presented and the largest surgical series of brainstem CM was reported.

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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