(SPETZLER) Color Atlas of Microneurosurgery vol2.pdf

s
c
i
s
s
a
Color At las Koos/Sp et zler
of Micron eu r osu rger y

l
C
e
m
e
i
h
Microan atom y · Ap p roach es · Tech n iqu es
T
Secon d e d it ion
revised an d exp an d ed
Volu m e 2
Cerebrovascu lar
Lesion s
R. F. Sp et zler
W. T. Koos
B. Rich lin g
J. Lan g
Color Atlas
of Microneurosurgery
Volume 2
Second Edition
Microanatomy • Approaches • Techniques
Second edition, revised and expanded
Volume 2: Cerebrovascular Lesions
Robert F. Spetzler, M.D. Wolfgang T. Koos, M.D.

Professor and Director Professor and Director
Barrow Neurological Institute University Clinic of Neurosurgery
St. Joseph's Hospital and Medical Center Vienna, Austria
Phoenix, USA
Bernd Richling, M.D. Johannes Lang, M.D.

Professor Professor Emeritus and Former Director
University Clinic of Neurosurgery Anatomical Institute
Vienna, Austria University of Würzburg, Germany
2537 illustrations, most in color

Drawings by A. Conley, I. Dobsak, S. Phippen, M. Schornak
Thieme
Stuttgart • New York
iv
Robert F. Spetzler, M. D. Library of Congress Cataloging-in-Publication Data

Professor and Director Koos, Wolfgang, T.
Barrow Neurological Institute Color atlas of microneurosurgery : microanatomy, ap
St. Joseph's Hospital and Medical Center proaches, techniques / Wolfgang T. Koos, Robert F. Spetzler,
350 West Thomas Road Johannes Lang ; with contributions by G. Pendl and A. Per-
Phoenix, Arizona, USA neczky ; drawings by Ingrid Dobsak, Gerhard Spitzer, and Steven
Harrison. — 2nd ed. p. cm.
Wolfgang T. Koos, M.D.
Rev. ed. of: Color atlas of microneurosurgery / W. T. Koos
Professor and Director ...[et al.].1985.
University Clinic of Neurosurgery
Includes bibliographical references and index.
Währinger Gürtel 18–20
Contents: v. 1. Intracranial tumors.
A-1090 Vienna IX, Austria
1. Nervous system—Surgery—Atlases. 2. Microsurgery—
Atlases. I. Spetzler, Robert F. (Robert Friedrich), 1944 —. II.
Bernd Richling, M. D.
Lang, Johannes, 1923 —. III. Title.
Professor
[DNLM: 1. Microsurgery—atlases. 2. Neurosurgery—atlases.
University Clinic of Neurosurgery
WL 17 K82 1993]
Währinger Gürtel 18–20
RD593, C594 1993 617,4'8—dc20 DNLM/DLC
A-1090 Vienna IX, Austria
for Library of Congress 93-20014
CIP
Johannes Lang, M. D.
Professor Emeritus and Former Director
Anatomical Institute Important Note: Medicine is an ever-changing science undergoing
University of Würzburg continual development. Research and clinical experience are con
Koellikerstraße 6 tinually expanding our knowledge, in particular our knowledge of
97078 Würzburg, Germany proper treatment and drug therapy. Insofar as this book mentions
any dosage or application, readers may rest assured that the
Aileen Conley authors, editors and publishers have made every effort to ensure
Phoenix, USA that such references are in accordance with the state of knowledge at
the time of production of the book.
Ingrid Dobsak Nevertheless this does not involve, imply, or express any guarantee
Vienna, Austria or responsibility on the part of the publishers in respect of any
dosage instructions and forms of application stated in the book.
Spencer, Phippen Every user is requested to examine carefully the manufacturers'
Phoenix, USA leaflets accompanying each drug and to check, if necessary in con
sultation with a physician or specialist, whether the dosage sched
Mark Schornak ules mentioned therein or the contraindications stated by the man
Phoenix, USA ufacturers differ from the statements made in the present book.
Such examination is particularly important with drugs that are
either rarely used or have been newly released on the market. Every
dosage schedule or every form of application used is entirely at the
user's own risk and responsibility. The authors and publishers
Any reference to or mention of manufacturers or specific brand request every user to report to the publishers any discrepancies or
names should not be interpreted as an endorsement or advertise inaccuracies noticed.
ment for any company or product.
Some of the product names, patents and registered designs referred
to in this book are in fact registered trademarks or proprietary Cover drawing by Steven J. Harrison
names even though specific reference to this fact is not always made
in the text. Therefore, the appearance of a name without designa © 1997 Georg Thieme Verlag, Rüdigerstraße 14,
tion as proprietary is not to be construed as a representation by the 70469 Stuttgart, Germany
publisher that it is in the public domain. http://www.thieme.de
Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA
This book, including all parts thereof, is legally protected by copy http://www.thieme.com
right. Any use, exploitation or commercialization outside the nar
row limits set by copyright legislation, without the publisher's con Typesetting by primustype R. Hurler GmbH, Notzingen
sent, is illegal and liable to prosecution. This applies in particular to Printed in Germany by Grammlich, Pliezhausen
photostat reproduction, copying, mimeographing or duplication of
any kind, translating, preparation of microfilms, and electronic data ISBN 978-3-13-111102-9 (TPS)
processing and storage. ISBN 978-0-86577-478-0 (TPN) 3 4 5 6
EISBN: 978-3-13-173472-3
V
Preface
A few years ago, rapid improvements in technolo both straightforward and exceedingly complicated
gy and neurosurgical technique served as the cases, should interest readers at all levels of neuro
impetus and justification to revise this microsurgi surgical expertise — from the resident to the sea
cal atlas. The resulting volume was devoted solely soned expert. The overwhelming majority of the
to intracranial tumors. As originally planned, this cases are new, and the most innovative techniques,
second volume in the series was intended to com including hypothermic cardiac arrest, stereotactic
plete the revised edition by including intracranial guided imaging, and endovascular approaches,
and extracranial pathology. However, the number are liberally represented. As in the previous vol
of excellent clinical cases soon expanded with a umes, only the surgical details are presented.
logic of its own that dictated an alternative organi Diagnostics, indications, efficacy, and outcomes
zation. Consequently, Volume Two, which includes have been left to other texts so that the surgical
aneurysms, arteriovenous malformations (AVMs), detail necessary to complete a procedure could be
cerebrovascular malformations, and vascular com shown in as much pictorial detail as possible. As in
pression, now completes the presentation of cere the previous volumes, references have been omit
brovascular pathology. Extracranial neurovascular ted, so we must again acknowledge the colleagues,
pathology will form its own volume, as will the too many to be named, who have helped shape our
microsurgical treatment of all other disorders of ideas and techniques over the years.
the spine. What we hope readers will gain by both Several colleagues, however, lent their technical
the additional material and the wait for the newly expertise to many of the cases in this book and
planned volumes is the most comprehensive deserve special mention. Dr. Joseph Zabramski
instruction in microsurgical technique yet avail has provided both camaraderie and unlimited sup
able between the covers of a book. port in handling the demanding cerebrovascular
In this second volume, the intracranial anatomy is case load at the B NI . In Vienna, Drs. Monika Killer
detailed in its own chapter with almost 100 color and Andreas Gruber contributed greatly to the
plates, 40% of which are new. In the previous vol endovascular procedures. This volume also profit
ume, the surgical approaches corresponding to ed from the critical review of Dr. Christian Matula
each major anatomical area preceded the related from Vienna and Dr. Michael Lawton, Senior
clinical material. In this volume, however, the Resident, from Phoenix who good-humoredly
approaches are grouped together in their own challenged us to clarify thoughts too hastily com
chapter since the lesions involved respect no con posed and whose questions never failed to instruct
venient anatomical boundaries. This new arrange us. Suggestions from former B NI Neurovascular
ment should make it easier for the reader to locate Fellow, Jacques Morcos, M. D., helped to organize
a given approach and to study its preliminary oper the presentation of the surgical approaches.
ative steps independent of the type of pathology. The actual production of such an atlas begins in
Technical improvements to old approaches have the operating room where our medical photogra
been added, as has a new approach developed phers patiently withstood long hours of surgery to
since the first volume — the orbitozygomatic. shoot the hundreds of operative photographs that
Because excellent access to the clivus can be beautifully document the cases presented here. At
obtained by removing the roof of the orbit and the B N I , the bulk of this exacting work was performed
zygoma, this approach has become a personal by Ms. Pamela Smith with contributions later in
favorite of the senior author for exposing the the process by Ms. Stacy Ruzicka; Mrs. Margarethe
upper half of the basilar artery. Baumann performed this essential task in Vienna.
The abundance of clinical material, which includes Perhaps the biggest burden was borne by the med-
vi Preface
ical illustrators whose splendid line drawings sup We have been blessed with these silent partners
port the photographic record. These artful inter who have demonstrated the utmost dedication to
pretations are the product of countless hours spent our needs while toiling assiduously behind the
not only in drawing but also in conceptualizing scenes. It is no overstatement to say that this vol
and simplifying the operative photographs to ume simply could not have been completed with
enhance the reader's understanding of the often out the hard work of these members of the
complicated three-dimensional spatial relation Neuroscience Publications Office at the B NI ,
ships involved in neurosurgery. Mr. Mark directed by Senior Editor Shelley A. Kick, Ph. D.,
Schornak, M. S., B NI Medical Illustrator, pursued or without the help of the staff of the secretariat
artistic excellence with uncommon zeal on our for Scientific Affairs of the Department of
behalf. Besides personally producing much of the Neurosurgery in Vienna. To all, we extend our
artwork himself, he also coordinated the efforts of heartfelt appreciation.
the other Phoenix artists involved in the project. We also thank the team at Thieme, Mr. Achim
Assistant B NI Medical Illustrator, Ms. Aileen Menge, Mr. Gert Krüger, and Dr. Clifford
Conley, M. S., facilitated completion of this volume Bergman, and their colleagues for the superb qual
not only with her drawings, but also with her ity of the production and for their patient support
steadiness, calm, and persistence when it seemed in the production of this volume.
impossible to meet the deadline. Freelancer The willingness and patience of our families to
Spencer Phippen, M. S., contributed numerous support us in these time-consuming projects bor
drawings in his fluid style with unflagging enthusi der on saintliness. No words can ever thank them
asm and the highest artistic standards. In Vienna, sufficiently for their unquestioning support. Over
Mrs. Ingrid Dobsak reprised the outstanding artis the years, our residents, too, have contributed
tic performance she gave in the previous volume. greatly to our professional satisfaction, and we
Perhaps the extent of their hard work can better thank them for the pleasure and privilege of shar
be appreciated by revealing that the majority of ing our neurosurgical heritage.
the hundreds of excellent illustrations in this vol We hope that this volume will further contribute to
ume were completed in less than a year. our common mission of providing the best possible
B NI Assistant Editor, Cynthia A. Sanner, Ph. D., care to patients suffering from neurological disor
admirably executed the monumental task of ders. For surely the information presented here
developing this volume. She worked tirelessly to has value only if it fulfills that goal. Our patients
coordinate and track the project from its inception remain our most valued teachers, and this vol
to the final details, and her excellent skills in elec ume's success will best be measured by how well
tronic publishing eased the task for all. Judy we have shared the lessons they have taught us.
Wilson and Eve DeShazer word processed the text
accurately and often, so it seemed, instantaneous
ly. Dawn Mutchler, B NI Editorial Intern, also pro
vided valuable assistance in many aspects of the Fall 1996
project. Robert F. Spetzler, W. T. Koos, B. Richling, J. Lang
vii
Contents
1 An a t om y 3
2 Ap p r oa ch es 71
Aneurysms — Anterior Circulation 122

3 An eu r ysm s of t h e Br ain 121 Aneurysms — Posterior Circulation 248
Introduction 346
Supratentorial AVMs 348
4 Ar t er ioven ou s Malfor mations Infratentorial AVMs 478
of the Br ain 345 Dural Vascular Malformations 499
5 Ca ver nous Malfor mations

of the Br ain 525
6 Vascular C om p r ession 575

I n d ex 587
viii
Abbreviations
Gener al Anatomy Terms Vessels
a., aa. artery, arteries A1, A2 Segments of the ACA

ant. anterior ACA Anterior cerebral artery
inf. inferior ACoA; Anterior communicating artery
int. interior AComA
L. left AICA Anterior inferior cerebellar artery
lat. lateral BA Basilar artery
m. muscle C1 , C2 , Segments of the carotid artery
n., nn. nerve, nerves C3, C 4
post. posterior ECA External carotid artery
R. right ICA Internal carotid artery
sup. superior M1, M2, M3 Segments of the MCA
temp. temporal MCA Middle cerebral artery
v. vein Ophth. A. Ophthalmic artery
P1, P2 Segments of the PCA
PCA Posterior cerebral artery
Cranial Ner ves PCoA; Posterior communicating artery
PComA
CN I Olfactory PICA Posterior inferior cerebellar artery
CN II Optic Saph Saphenous
CN III Oculomotor STA Superficial temporal artery
CN IV Trochlear VA Vertebral artery
CN V Trigeminal
CN VI Abducent
CN VII Facial Other
CN VIII Vestibulocochlear
CN IX Glossopharyngeal AVM Arteriovenous malformation
CN X Vagus C1, C 2 , C3 Nerve roots of the first cervical
CN XI Spinal accessory nerve roots vertebra, second cervical vertebra,
CN XII Hypoglossal and third cervical vertebra
CT Computed tomography
MR Magnetic resonance
1
Org a n iza tio n of Volume Two
This volume is divided into three major sections. the chapter on cavernous malformations. The
The first chapter is devoted to anatomy, the sec cases presented in the chapter on vascular com
ond chapter to surgical approaches, and the last pression move down the brainstem from superi
four chapters to type of pathology as demon or to inferior.
strated by the clinical material. The anatomy To ease identification of sections, color bars have
chapter begins at the skull base and follows the been added to the edges of the pages in the
internal carotid artery to its bifurcation. The chapters on anatomy and surgical approaches, as
anterior cerebral artery, middle cerebral artery, well as in each chapter of the clinical material.
and circle of Willis are explored before moving A schematic sketch of the orientation of the
down the basilar artery to the vertebral artery. lesion—either along the vasculature or in an
The chapter on surgical approaches is divided anatomical plane as appropriate—and a
into approaches of the anterior fossa; approach schematic sketch of the patient's position on the
es of the middle cranial fossa and combined mid operating table are shown at the top of each case
dle and posterior cranial fossae; approaches of to help orient the reader immediately. To further
the posterior fossa and craniocervical junction; facilitate cross-referencing for the reader, the
and, finally, approaches of the vein of Galen and page numbers corresponding to the relevant
pineal region. This chapter provides an overview anatomy and surgical approaches are also listed
of the approaches used in the clinical cases at the top of each case.
throughout the remainder of the book.
Each chapter of clinical material is devoted to a
major category of vascular disease: aneurysms,
arteriovenous malformations, cavernous malfor
mations, and vascular compression from a variety
of specific etiologies. Paralleling the organization
of the anatomy chapter, aneurysms of the anteri
or circulation are presented first, starting with
the internal carotid artery, moving up toward the
circle of Willis, and branching first to the anteri
or cerebral artery and then to the middle cere
bral artery. Aneurysms of the posterior circula
tion follow, moving down from the circle of Willis
to the basilar artery and then to the vertebral
arteries. Supratentorial arteriovenous malforma
tions are presented followed by those of the pos
terior fossa and then by dural and vein of Galen
malformations. Within these two major sections,
the arteriovenous malformations are subdivided
by their Spetzler-Martin grade, progressing from
simple (Grade I) to complex (Grade V). Within a
grade of arteriovenous malformation, the lesions
are presented along a superoanterior to pos-
teroinferior axis—a schema that is maintained in
3
4 Anatomy
Introduction brobasilar artery junction. Clearly, there is con

siderable overlap as these territories are viewed
This section starts with the internal carotid arter from many different perspectives. The purpose of
ies as they enter the skull base then continues to providing so many different views of the same
the internal carotid artery bifurcation. Next the vascular structures is to enhance the reader's
anterior cerebral artery territory is explored, fol ability to conceptualize these vessels three
lowed by the middle cerebral artery territory and dimensionally. Figures related to a surgical
the circle of Willis, from which it moves down the approach have been printed in surgical orienta
basilar artery and its branches and on to the verte tion.
1-1 Corrosion cast of the internal carotid arteries as they enter

the skull base and course intracranially. The arteries are injected
with red and the veins with blue acrylate.
Anatomy 5
1-2 A slice through the internal ca rotid artery as it

courses through the petrous bone. The relationship
of the inner ear structures and the trigeminal nerve
can be appre ciated. When the petrous portion of the
internal carotid artery is e xpos e d, it is exposed
between these structures.
6 Anatomy
1-3 Anatomical exposure of the petrous and intracavernous por

tions of the internal carotid artery. This surgical exposure is obtained
through a transpetrosal approach and demonstrates the relation
ship of the artery and the various cranial nerves.
1-4 A slightly more lateral view of the course of the internal carotid
artery with the trigeminal nerve retracted interiorly.
Anatomy 7
1-5 The intrapetrous portion of the

internal carotid artery is exposed
through a subtemporal transapical
approa ch. Note the extent of the
exposure of the intrapetrous portion
of the internal carotid artery, which is
used for access to perform venous
bypasses.
1-6 A frontobasal view of the internal carotid artery as it courses

through the cavernous sinus. Corrosion preparation after injection
of arteries with red and veins with blue acrylate.
8 Ana tomy
1-7 Oblique view of the cavernous sinus de mon

strates the relationships among the internal carotid
artery, basilar artery, and the oculomotor and trochlear
nerves. The lateral wall of the cavernous sinus and
the posterior clinoid have been removed. The blue
de picts the area of Parkinson's triangle.
Anatomy 9
1-8 Microanatomy of the cavernous sinus (viewed

from behind). This coronal section demonstrates the
proximity of the internal ca rotid artery within the
subarachnoid space to its proximal intracavernous
position. With a section straight through the infundib-
ulum, the anatomical arrangement of the nerves
and the intracavernous portion of the internal carotid
artery can be visualized.
10 Anatomy
1-9 Higher magnification demonstrates the rela

tionship of the internal ca rotid artery between the
subarachnoid and intracavernous portions.
Anatomy 11
1-10 The posterior cavernous sinus is opened

exposing the intracavernous internal carotid artery.
The dura of the clivus is also reflected, exposing the
inferior petrosal sinus as it courses from the ca ve rn
ous sinus to the jugular bulb.
12 Anatomy
1-11 Further exposure of the intracavernous

portion of the left internal ca rotid artery shows its
S-shaped course.
Anatomy 13
1-12 The cavernous sinus has been dissected fur

ther, and the oculomotor and trochlear nerves and
first division of the trigeminal nerve have been reflect
ed interiorly. The entire intracavernous course of the
internal carotid artery can be a pprecia te d. The
abducent nerve is seen throughout its entire intra
cavernous course. Notice the relationship of the
subarachnoid internal ca rotid artery, the optic nerve,
the anterior clinoid process, and the intracavernous
portion of the internal carotid artery.
14 Anatomy
1-13 The cavernous sinus has been disse cted still

further, and the anterior clinoid process has been
removed. The relationship of the subarachnoid intra-
cavernous portion of the internal ca rotid artery to
the cavernous sinus is visible. The fibrous ring sur
rounding the internal carotid artery at its junction
with the cavernous sinus is clearly demonstrated.
Anatomy 15
1-14 In this view of the cavernous sinus, the inter

nal ca rotid artery is pulled down, allowing excellent
visualization of the intracavernous branches of the
internal ca rotid artery.
16 Anatomy
1-15 By opening the lateral wall of the pituitary

fos s a , the relationship of the pituitary gland and
intracavernous portion of the internal carotid artery
can be appreciated. Note the vascular supply of the
internal carotid artery to the pituitary gland, and the
relationship of the fibrous ring at the junction of the
subarachnoid and the intracavernous portions of the
internal carotid artery.
Ana tomy 17
1-16 The left optic nerve entering the optic foramen is com
pressed from below by the ophthalmic artery and from above by
the membranous roof of the optic canal.
1-17 A fetal posterior cerebral artery

arises from the internal carotid artery.
Note the many branches coming off the
proximal portion of the posterior ce re
bral artery. This view can be seen surgi
cally through a subte mporal a pproa ch.
18 Ana tomy
1-18 The entire course of the posterior communi

cating artery is seen between the internal carotid
artery and the posterior cerebral artery. Surgically,
this view can be obtained through a subtemporal
approach and can be enhanced with an orbitozy-
gomatic resection.
Ana tomy 19
1-19 Midsagittal section through the pituitary and third ventricle

exposes the anterior cerebral artery, basilar artery comple x, and
posterior communicating artery.
1-20 A paramedian section shows posterior communicating

artery.
20 Ana tomy
1-21 Inferior view of the posterior communica ting artery. Also

notice the course of the anterior choroidal artery.
1-22 The posterior communica ting artery is visualized in relation

ship to its surrounding structures as most often seen through a
pterional approach with some inferior retraction of the tempora l
lobe. The anterior choroidal artery is dissected free and its relation
ship to the right optic tra ct can be appre cia ted.
Ana tomy 21
1-23 Lateral view of the course of the anterior choroidal artery

along with the posterior communicating artery.
1-24 Inferior diencephalic branches

from posterior communicating artery and
anterior choroidal artery (medial view).
22 Ana tomy
1-25 The anterior choroidal artery is exposed completely from the

internal carotid artery to the choroid plexus of the temporal horn of
the lateral ventricles. The branches can be appreciated as they
course towa rd the optic tra ct, internal capsule, and the choroid
plexus of the te mporal horn.
Ana tomy 23
1-26 Through a section of the trigone, the anterior

choroidal artery is seen as it courses along the cho
roid plexus where it communicates with the medial
and lateral posterior choroidal arteries.
24 Ana tomy
1-27 Trigone of the right lateral ventricle.

Ana tomy 25
1-28 The choroid plexus is elevated exposing the

vasculature.
26 Ana tomy
1-29 Choroid plexus of tempora l horn of the lateral

ventricle (right side).
1-30 Cortical branch of anterior choroidal artery from below.

Ana tomy 27
1-31 In a view obtained through a bilateral s ub-

frontal a pproa ch, both internal carotid artery bifurca
tions are visualized. Note the pituitary stalk between
the optic nerves as the stalk enters the diaphragma
sella.
28 Ana tomy
1-32 With further retraction, the entire course of

the A1 segments of the anterior cerebral arteries is
seen. The anterior communicating artery complex
with the bilateral recurrent arteries of Heubner can
be appreciated.
Ana tomy 29
1-33 The anterior communicating artery complex is exposed from

a right pterional a pproa ch.
1-34 From an inferior view, the right anterior cerebral artery and
anterior communica ting artery complex is e xpos e d. Note the origin
of the recurrent artery of Heubner as it arises from A2 just past
the anterior communicating artery. This is the most common origin
of the recurrent artery of Heubner, although it can also arise from
the anterior communicating artery or from the A1 segment of the
anterior cerebral artery.
30 Ana tomy
1-35 Superior view of the anterior communica ting artery complex.
1-36 A midsagittal section through the

third ventricle demonstrates the anterior
communica ting artery and anterior cere
bral artery. Notice the basilar bifurcation
and the posterior communicating artery
with its multiple perforating branches.
Ana tomy 31
1-37 In an exposure obtained with a bilat

eral subfrontal a pproa ch, the entire optic
chiasm and anterior communicating artery
complex can be a pprecia te d. The distal
anterior cerebral arteries are exposed in a
territory where pericallosal artery aneurysms
frequently are encountered.
1-38 Branches of the anterior cerebral arteries within the inter-

hemispheric fissure as they course around the genu of the corpus
callosum, viewed from above and rostrally in anatomical orientation.
32 Ana tomy
1-39 The anterior cerebral artery as it courses around the genu of

the corpus callosum.
1-40 The middle cerebral artery, as it lies in the Sylvian fissure, is

dissected free. Note the lenticulostriate branches.
Ana tomy 33
1-41 Frontolateral exposure of the parasellar and

Sylvian cisterns. The middle cerebral artery following
resection of the te mporal and frontal lobes de mon
strates the many perforators off the main trunk.
34 Anatomy
1-42 The distal middle cerebral artery branches are

exposed in the insular region with further dissection
of the Sylvian fissure.
Ana tomy 35
1-43 Inferior view of the middle cerebral artery

along its entire course after the Sylvian fissure is
ope ne d.
36 Ana tomy
1-44 Overview of the entire course of the middle

cerebral artery as exposed through a pterional
a pproa ch.
Ana tomy 37
1-45 View of the circle of Willis after the brain is removed. Note
the dominant left vertebral artery.
1-46 A midsagittal section through the third ventricle and basilar

artery beautifully demonstrates the many perforators to the brain
stem within the interpeduncular fossa.
38 Ana tomy
1-47 A good demonstration of the medial aspect of Lilliequist's

membrane. The basilar artery and its branches are visualized in the
interpeduncular fossa.
Ana tomy 39
1-48 Close-up paramedian section through the

pituitary region and the third ventricle demonstrates
the relationship of the internal carotid artery and
basilar artery with emphasis on all the perforators
from the P1 segment.
40 Ana tomy
1-49 The interpeduncular fossa is exposed through

a paramedian sagittal section demonstrating the va s
culature around the oculomotor nerve.
Ana tomy 41
1-50 This perspective of the circle of Willis, viewed

through the skull base, de picts the relationship
between the vessels and the mamillary bodies. Note
the luxurious perforators from the P1 segment that
are so critical to preserve when operating in this
region. The right posterior communica ting artery is
hypopla stic.
42 Ana tomy
1-51 Transverse section through the cerebral peduncles and the

third ventricle viewed from above. The anterior and lateral sections
of the circle of Willis are visualized. Note the relationship between
the anterior cerebral arteries and the lamina terminalis.
Ana tomy 43
1-52 Midsagittal section through the circle of Willis

demonstrates the proximity of the anterior cerebral
artery complex to the tip of the basilar artery as well
as the relationships of the blood vessels to the third
ventricle.
44 Ana tomy
1-53 Midsagittal section of the

hypophyseal area viewed from medially.
A1 and A2 sections of the right anterior
cerebral artery, the anterior communi
cating artery, and various branches are
visualized on the lower medial anterior
surface of the right frontal lobe.
1-54 A horizontal section at the level of the oculomotor nerves

and through the pituitary gland demonstrates the basilar artery as it
bifurcates into the two posterior cerebral arteries. The perforating
branches from the P 1 segments are visible.
Ana tomy 45
1-55 View of the ambient cistern

along the edge of the te ntorium as
seen through a subtemporal approach
visualizes the origin of the posterior
cerebral artery as it courses through
the ambient cis te rn. In this anatomical
variation, the posterior cerebral artery
emerges directly from the internal
carotid artery in the absence of a
posterior communicating artery.
1-56 With further retraction, the rela

tionships of the superior cerebellar
artery and posterior cerebral artery to
the entire subarachnoid course of the
oculomotor nerve can be a ppre cia te d.
Note the right cerebral peduncle.
46 Anatomy
1-57 Through a dorsolateral view with the tentorium pulled back,

the posterior cerebral artery can be seen. Note the relationship of
the trochlear nerve and superior cerebellar artery.
1-58 The vascularization of the internal

capsule and adjacent nuclei from a lateral
view. Notice the many perforating branch
es originating from the posterior communi
cating, posterior cerebral and anterior
choroidal arteries.
Ana tomy 47
1-59 Dentate gyrus viewed from below. Numerous hippocampal

branches of the posterior cerebral artery supply this gyrus.
1-60 Branches of the posterior cere

bral artery. The posterior cerebral artery
is shown as it enters the calcarine fis
sure. The cingulate gyrus and splenium
of the corpus callosum have been
displaced upwa rd.
48 Ana tomy
1-61 Paramedian sagittal section through the pineal

region and the splenium of the corpus callosum.
Note the branches of the posterior cerebral artery to
the corpus callosum.
Ana tomy 49
1-62 Midsagittal se ction demonstrates the deep

venous system that drains into the great vein of
Galen.
50 Ana tomy
1-63 Superior view of the lateral ventricles, bilateral choroid

plexus, and the venous vasculature. The transverse cisternal fissure
is e xpos e d.
1-64 A slightly more superior view of the vein of Galen as it enters

the straight sinus. The conte nts of the transverse cisternal fissure
are illustrated.
Ana tomy 51
1-65 Through a midsagittal section through the basilar artery, the

posterior cerebral artery is seen above the te ntorium and the s upe
rior cerebellar artery runs below.
1-66 The superior cerebellar artery is

visualized as it courses through the
ambient cis te rn.
52 Ana tomy
1-67 From a lateral and slightly superior

view after resection of the te ntorium, the
superior cerebellar artery is followed to
above the collicular plate. Note the
extensive course of the trochlear nerve.
1-68 The ambient cistern has been opened widely exposing the
distal superior cerebellar artery as well as the vein of Galen.
Ana tomy 53
1-69 Cerebellopontine angle from above, the tentorium has been

turne d laterally. The superior cerebellar artery as it courses around
the midbrain. Notice the loop of the anterior inferior cerebellar arte
ry going behind the trigeminal, facial and acoustic nerves. The pe
trosal veins are well illustrated.
1-70 View of the vasculature of the cerebellopontine angle.

54 Ana tomy
1-71 View of the superior cerebellar artery and the

anterior inferior cerebellar artery and their relationship
to the trigeminal nerve.
Ana tomy 55
1-72 Anatomic specimen showing compression of

the trigeminal nerve by a loop of the superior cere
bellar artery at the entry zone of the nerve root.
1-73 After the loop of the superior cerebellar artery has been dis
pla ce d, the groove from the compression of this loop can be seen
in the trigeminal nerve.
56 Ana tomy
1-74 Diencephalon, midbrain and cerebellum viewed from above. The

distal segment of the superior cerebellar artery is visualized from the s upe
rior lateral aspect along with the vein of Galen and its tributaries.
1-75 Lateral view of the right cerebellar

hemisphere shows the cortica l cerebellar
branches of the superior cerebellar
artery.
Ana tomy 57
1-76 A lateral view of the cerebellum and temporal lobe after the
tentorium has been removed. Branches of the superior cerebellar
artery and the basilar artery can be seen.
1-77 An overview of the clivus, brainstem, cerebellum, and cranial

nerves as would be seen through the combined supratentorial and
infratentorial a pproa ch.
58 Ana tomy
1-78 Inferolateral view of the pons demonstrates the course of

the basilar artery and its branches.
1-79 Superior view of the basilar artery and the

course of the anterior inferior cerebellar artery
can be a ppre cia te d.
Ana tomy 59
1-80 Through a midsagittal section of the pons

and the pituitary and hypothalamic region, the
courses of the basilar artery and its branches are seen.
60 Ana tomy
1-81 Total view of the basilar artery system.
1-82 View of the vertebrobasilar junction, the origin of the pos te

rior inferior cerebellar arteries, and the branches to the anterior
spinal artery.
Ana tomy 61
1-83 The relationships of the vertebral and basilar arteries with all
their branches are s hown.
1-84 The vertebrobasilar junction and the origin of the posterior

inferior cerebellar arteries are visualized.
62 Ana tomy
1-85 After the brainstem has been resecte d, the

course of the vertebral and basilar arteries can be
seen in relation to the exits of the cranial nerves. The
entire clivus is visible.
Ana tomy 63
1-86 Close-up view of the vertebrobasilar junction

with a hypoplastic right vertebral artery.
64 Ana tomy
1-87 Pons and medulla with nerves and vessels viewed from the
basal as pe ct. Anterior inferior cerebellar artery and posterior inferior
cerebellar artery exhibit a common origin at the vertebrobasilar
junction on the right side.
1-88 An anatomical specimen of the cerebellopontine angle

indicates the cranial extent of the loop of the posterior inferior cere
bellar artery.
Ana tomy 65
1-89 A dorsolateral view of the posterior inferior cerebellar artery

and lower cranial nerves.
1-90 The cerebellar tonsils and the cerebellum have been resect
ed to the region of the former foramen of Luschka. The course of
the posterior inferior cerebellar arteries can be followe d around the
medulla to the region of the former foramen of Magendie and the
fourth ventricle.
66 Ana tomy
1-91 A loop of the posterior inferior cerebellar artery can be visu

alized within the right cerebellopontine angle.
1-92 Right far-lateral view of the vertebral artery, the posterior

inferior cerebellar artery, and the anterior inferior cerebellar artery.
Ana tomy 67
1-93 The caudal loop of the posterior

inferior cerebellar artery is visualized
through a suboccipital exposure.
1-94 With the tonsils retracted laterally and upwa rd, both intra
cranial vertebral arteries and the loop of the right posterior inferior
cerebellar artery can be seen as they course along the medial
aspect of the tons il.
68 Ana tomy
1-95 A lateral view of the lower cranial nerves and their relation
ship to the intradural and extradural vertebral artery.
1-96 Anterior view of the extradural and intradural portions of the

vertebral artery.
Ana tomy 69
1-97 Lateral view of the extradural vertebral artery with its sur
rounding venous plexus.
1-98 The vertebral venous plexus has been removed, exposing

the loop of the vertebral artery around the atlas and its entry
through the dura.
71
72 Cortica l a nd Tra ns cortica l Approa che s
Pos ition a n d Approa che s

For exposure of hemispheric and intrahemispher-
ic lesions, the patient should be positioned in such
a way that access from a vertical direction is pos
sible. The relationship between the craniotomy
and the lesion should allow the surgeon to
assume a comfortable sitting position to mini
mize fatigue. The head is placed so that the lesion
is easily exposed for the surgical approach. The
exposed brain is routinely covered with a moist
ened thin Gelfoam to prevent drying. Strict
hemostasis is an important and obvious criterion
for any microsurgical procedure. For cavernous
malformations located deep in the hemisphere,
frameless stereotaxy is of great assistance.
Cortica l a nd Tra ns cortica l Approa che s

• Tra ns fronta l
• Tra ns pa rie ta l tra ns ve ntricula r

(P a rie tote mpora l)
P a rie ta l
Tran s frontal Tra n s c o rtic a l Trans ventricular Ap p ro a c h

to th e La te ra l Ve n tric le and Fo ra m en o f Mon ro
2-2a For the transfrontal transcortical approach to the

lateral ventricle and to the foramen of Monro, the head is
rotated 30 degrees off the vertical axis.
2 -2 b The scalp incision, burr hole, and craniotomy. 2-2c The relationship between the craniotomy, the cere
bral hemisphere, and the ventricular syste m.
Cortica l a nd Tra ns cortica l Approa che s 73
2-3a The foramen of Monro can be located by drawing

a line 1 cm in front of the coronal suture to the external
meatus.
2-3b When the line is 3.5 cm from midline and aimed

towa rd the inner canthus of the contralateral eye, it will tra
verse the foramen of Monro.
2-3c This coronal diagram shows the line pointing

towa rd a lesion in the third ventricle.
Trans frontal Tra n s c o rtic a l Ap p ro a c h to th e La te ra l

Ve n tric le
2-3d A view through the transcortica l a pproa ch into the

lateral ventricle. The anatomical structures are easily ide nti
fied and provide a reliable pathway to the foramen of
Monro. The choroid plexus or thalamostriate vein is fol
lowed anteriorly until it enters the foramen of Monro. To
enlarge the foramen of Monro, we prefer opening the
choroidal fissure instead of sacrificing the fornix. This
enlargement is best a ccomplished by coagulating the
choroid plexus right at the foramen of Monro. This maneu
ver exposes the choroidal fissure and provides easy access
to the anterior portion of the third ventricle.
74 Cortica l a nd Tra ns cortica l Approa che s
Tra n s c o rtic a l Ap p ro a c h to th e Trigone Region o f th e

La te ra l Ven tric le
2-4a The patient is placed supine on the operating table

with one shoulder elevated and the head horizontal.
2-4b Scalp incision and craniotomy for exposure of the 2-4c Relationship of craniotomy to the lateral ventricle.
angular gyrus.
Inte rhe mis phe ric a nd Tra ns ca llos a l Approa che s 75
Inte rhe mis phe ric a nd Tra ns ca llos a l

Approa che s
• Inte rhe mis phe ric a pp ro a ch
Ante rior
P os te rior
• Tra ns ca llos a l
Ante rior
P os te rior
The interhemispheric approach exposes the peri-

callosal and callosomarginal arteries. If the cor
pus callosum is opened, the lateral and third ven
tricles are exposed.
In te rh e m is p h e ric Ap p ro a c h in th e Ve rtic a l Pos ition
2-5b The craniotomy is schematically outlined to

demonstrate the relationship of the ventricles to the corpus
callosum.
2-5a Skin incision and craniotomy. A small burr hole is

placed lateral to the midline or in the posterior inferior cor
ner. Through the small burr hole, the craniotomy is drilled
anteriorly, with the Midas Rex footpla te towa rd the superior
sagittal sinus. Immediately before the sagittal sinus is
reached, the drill is s toppe d and pulled back slightly, and
the bone dust is irrigated out. While the light is directly
above the bone cut, the dura is inspected to ascertain that
the footpla te is located extradurally. The cut is then con
tinued across the sagittal sinus. This maneuver is repeated 2-5c Scalp incision and standard placement of multiple
again just prior to crossing the sagittal sinus the second burr holes. Using this technique, the sagittal sinus gradual
time . ly is e xpos e d.
76 Inte rhe mis phe ric a nd Tra ns ca llos a l Approa che s
An te rio r Trans c allos a l Ap p ro a c h in th e Ho rizo n ta l

Pos ition
2-6 a , b With the body supine and the appropriate to work in the same horizontal plane along the interhemi
shoulder slightly elevated, the head is placed in the hori spheric fissure, rather than in an awkward vertical relation
zontal position and raised 30 to 45 degrees from the ship. S e cond, it allows the ipsilateral hemisphere to be
ta ble . This position offers several advantages and is much retracted by gravity, thereby reducing the need for retrac
preferred by the senior author. First, it allows both hands tors .
2-6c The skin incision, burr hole, and craniotomy. 2-6d The relationship of the craniotomy to the corpus
callosum and ventricular s ys tem.
Inte rhe mis phe ric a nd Tra ns ca llos a l Approa che s 77
Pos terior Trans ca llos al Ap p ro a c h
2-7a The craniotomy and scalp incision are used for the 2-7b Relationship between the craniotomy and ve ntricu
a pproach to the splenium of the corpus ca llosum. P a rticu lar syste m.
lar care must be taken to separate this critical portion of
the superior sagittal sinus from any adherence to overlying
bone when performing the craniotomy.
78 Inte rhe mis phe ric a nd Tra ns ca llos a l Approa che s
Tra ns callos al Ap p ro a c h to th e La te ra l Ve ntricle
2-8a The transcallosal approach to the ipsilateral lateral 2-8b Contralateral midline transcallosal approach to the
ventricle between the two hemispheres. The contralateral lateral ventricle. Particularly for left lateral ventricular
hemisphere is minimally retracted along with the falx, with lesions, a contralateral midline approach may be cons id
care being taken not to compress and occlude the s upe ri e red. The ipsilateral sinus and falx are re tra cte d, and the
or sagittal sinus. The ipsilateral hemisphere is gently ipsilateral corpus callosum is approache d from the oppo
retracted between the draining veins. The exact point of site side. If extensive exposure is required and maximum
retractor placement depends on the venous drainage, visualization is needed, an approach on both sides of the
choosing the portion of hemisphere that is most a ppropri sagittal sinus can be us ed. Sometimes a portion of the falx
ate for the location of the lesion and tha t has no major may need to be resected.
draining veins that join the sagittal sinus.
2-8c The interhemispheric transcallosal approach to

both lateral ventricles. This approach may be considered in
cases of bilateral ventricular lesions and lesions that extend
from the third ventricle through both foramina of Monro.
Ante rior Skull Base Approa che s 79
2-9 An terior s kull ba s e a p p ro a c h e s . This schematic

diagram depicts the anterior skull base approaches includ
ing the bilateral subfrontal, the unilateral subfrontal or
frontolateral, the pterional, the orbitopte riona l, and finally
the orbitozygoma tic. The medial resection of the petrous
bone is outlined as the transapical.
80 Anterior Skull Base Approaches
Ch o ic e of Ap p ro a c h
2-10a The arrows indicate the various approaches tha t 2-10b Similarly, head positioning depends not only on
are available to the surgeon for exposure of the neurovas the approach se lected, but also on the specific area of
cular structures of the sellar and parasellar region. The interest. This diagram illustrates how the surgeon would
specific area of interest obviously plays an important role in position the patient's head so that the vision through the
the choice of a pproa ch. microscope is in the vertical axis in relationship to the
exposure. With a 45-degree rotation off the vertical axis, a
frontolateral or pterional approach would give excellent
visualization of the sellar region. However, if the surgeon
were interested in a region lateral to the sella, such as the
sphenoid wing, less rotation would be desired. Alternatively,
if the area of interest were the tuberculum sellae, more
rotation would be required.
2-10c , d These diagrams show the many routes that located only a centimeter below the optic nerve and the
can be used to approach the neurovascular structures of internal carotid artery were to be e xpos e d. For such a
the parasellar region. The specific topogra phy of the lesion lesion, a lateral pterional approach allowing visualization
to be visualized plays a significant role in selecting which below the optic nerve and internal carotid artery would be
approach is most suitable (e.g., a lesion located between the exposure of choice . It is the ability to determine the
the optic nerves in the plane of the optic nerves and location of the lesion preoperatively, combined with the
chiasm is best approached through an exposure as close experience of what each approach affords, that is the criti
to the vertical axis as possible) in order to allow visualiza cal fa ctor in the decision-making process leading to the
tion between the optic nerves without requiring any retrac proper exposure in any individual case.
tion. Yet, this a pproa ch would be undesirable if a lesion
Un ila te ra l o r Bila te ra l S u b fro n ta l Ap p ro a c h
2-11a For the unilateral subfrontal a pproa ch, the head is

turne d slightly from midline. The option of using a bifrontal
approach still remains.
2-11b Outline of unilateral and bifrontal craniotomy and

the relationship to the underlying frontal lobes, optic chiasm,
and optic nerves.
Un ila te ra l o r Fro n to la te ra l Ap p ro a c h
2-12 a The patient is rotated 30 degrees off the vertical
axis, with the head slightly e xte nde d. The incision is made
behind the hairline from the midline to the zygomatic
process. A craniotomy is performed along the floor of the
frontal fossa, extending to the pte rion. Every a tte mpt is
made to expose the floor of the fossa without leaving a rim
of bone .
2-12b The relationship between the craniotomy and the

underlying neural structures is presented.
82 Ante rior Skull Base Approa che s
P te rio n a l Ap p ro a c h
2-13a The scalp incision a nd craniotomy for the s ta n 2-13b Relationship between the craniotomy and the
dard pterional approach to the parasellar region are shown underlying Sylvian fissure, pituitary gla nd, and ventricular
here. Extensive drilling of the sphenoid wing and the a nte system.
rior sphenoid process can be performed extradurally.
Pos ition and Ap p ro a c h
2-13c An operative photogra ph of the head pos i

tion for the pterional a pproach. The frontal and
parietal branches of the superficial temporal artery
have been demarcated and the scalp incision has
been delineated, saving the main trunk of the
superficial te mporal artery.
2-13d The pterion has been resected with

a drill.
2-13e The resection of the pterion can

now proceed further to the anterior clinoid
process by utilizing the diamond bit drill.
2-13f By continuing the resection of the 2-13g The Sylvian fissure is visible follow
pterion to the anterior clinoid, one can appre ing the dural ope ning. Without any retraction
ciate the advantage in exposure which this the entire Sylvian fissure is e xpos e d.
maneuver affords. Also notice that the cra ni
otomy is flush with the floor of the frontal
fossa.
2-13h The arachnoid at the base of the Sylvian cistern is opened

sharply, exposing the underlying middle cerebral artery.
2-13i The posterior communica ting artery (which is still rium. The location of the trochlear nerve is critical when the
retracted towa rd the middle cerebral artery) is visualized tentorial edge requires incision in order to avoid injury to
as it emerges from the internal carotid artery. Following this fragile s tructure .
the course of the oculomotor nerve, the basilar artery
branches into the superior cerebellar artery as it courses 2-13k Both optic nerves, chia sm, and optic tra ct are
below the nerve. On the other side, just below the pos te visualized along with the internal carotid artery giving off a
rior clinoid process, the basilar-superior cerebellar junction small posterior communica ting artery, which travels deep
a nd, a little farther up, the posterior cerebral artery on the to anastomose with the posterior cerebral artery. The ocu
contralateral side can be seen. lomotor nerve is located between the superior cerebellar
artery and posterior cerebral artery. The basilar artery junc
2-13j The te ntorium has been elevated to reveal the tion can be seen, and the relationships of these structures
course of the trochlear nerve below the edge of the te nto to the tentorial edge can be a pprecia te d.
86 Anterior Skull Base Approaches
Orb ito p te rio n a l Ap p ro a c h
2-14a The scalp incision and craniotomy of the

orbitopterional approach are de picte d.
2-14b A skull specimen demonstrates the saw cuts for

the orbitopterional craniotomy.
2-14 c The orbitopterional craniotomy is

outlined in black on this skull.
2-14d The parasellar and sellar region are

visualized after an orbitopterional craniotomy.
2-14e The extent of the removal of the

orbital wall can best be appreciated from this
anterior view.
Orb ito zyg o m a tic Ap p ro a c h
2-15a The scalp incision is outlined along with the vari 2-15b A pterional craniotomy has been turned and the
ous saw cuts . next cuts to be performed with an oscillating saw are
de picte d. Shaded areas are drilled.
2-15c The comple te d orbitozygomatic approach pro 2-15d The relationship of the craniotomy to the basilar
vides a view to the upper clivus. artery is de picte d.
2-15e The three arrows on this schematic representa 2-15g The orbitozygomatic transapical exposure is
tion depict the angle to the upper basilar artery obtained s hown. The medial apex of the petrous bone is drilled off,
through a subfrontal a pproa ch, a pterional a pproa ch, and increasing the exposure to the clivus and allowing ready
an orbitozygomatic a pproa ch. The additional room gained exposure of the upper half of the basilar artery.
from removing the roof of the orbit and the zygoma has
made it the favorite approach of the senior author to
obtain maximum exposure of the upper basilar artery.
2-15f Anatomical landmarks tha t guide drilling for the

orbitozygomatic transapical exposure. The anterior margin
is the trigeminal nerve, the lateral margin is the greater
superficial petrosal nerve, the inferior margin is the internal
carotid artery, and the medial margin is the inferior petrosal
sinus. Posteriorly, the cochle a should be avoided.
2-15h Skull specimen after a routine pte ri- 2-15i A more posterior angulation shows
onal bone flap has been turne d. The black the deeper saw cuts that are performed with
lines are drawn in preparation for an orbito- an oscillating saw.
zygomatic resection.
2-15j Higher magnification view shows the

medial saw cut to the inferior orbital fissure.
2-15 k A more inferior posterolateral view

demonstrates a portion of the lateral wall of the
orbit to be removed.
2-15l An anteroposterior view after resec 2-15m A lateral view demonstrates the
tion of the orbitozygomatic process. exposure gained through an orbitozygomatic
craniotomy.
2-15n A posterolateral view after an

orbitozygomatic craniotomy visualizes the top
of the clivus and posterior clinoid.
92 Middle Cra nia l Fossa a nd Combine d Middle a nd Posterior Cra nia l Fossae Skull Base Approa che s
2-16 Middle cranial fossa and combine d middle and approach exposes the midclival region of the posterior
posterior fossae skull base approaches are de picte d in this foss a . If the s ubte mporal and transpetrosal approaches
schematic drawing. The subtemporal approach is used to are combine d, the result is the combine d supra- and
access the structures of the middle cranial fossa. The s ub infratentorial a pproa ch. The transpetrosal approaches
tempora l petrosal approach exposes the petrous portion of have been divided into the retrolabyrinthine, tra ns
the internal carotid artery. The subtemporal transapical labyrinthine, and transcochlear.
Middle Cra nia l Fossa a nd Combine d Middle a nd Posterior Cra nia l Fossae Skull Base Approa che s 93
S u b te m p o ra l Ap p ro a c h
2-17a The patient is placed in the supine pos ition, with 2-17b The scalp incision and craniotomy. It is essential
the appropriate shoulder elevated and the head in the hori to extend the craniotomy inferiorly until it is flush with the
zontal position and slightly exte nded. floor of the middle fossa.
2-17c The relationship between the craniotomy and the 2-17d The subtemporal transapical exposure is s hown.
temporal lobe and midbra in.
94 Combine d Middle a nd Posterior Fossae Skull Base Approa che s
Introduction a nd Technique
The combined supratentorial and infratentorial
approach is recommended for any lesion that is
situated above and below the tentorium along
the petrous ridge, the clivus, or both. The rela
tionship between the vascular and neural struc 2-18a The position for the combine d supratentorial and
tures is so important that the surgeon who is infratentorial a pproa ch. This position is the most common,
unfamiliar with this region is urged to dissect sev unless an extensive posterior foss a craniotomy is also nec
essary.
eral cadavers before attempting surgery. A team
approach including a neurosurgeon and a neuro-
otologist is highly advantageous.
The incision begins in front of the ear below the
zygomatic arch, above and behind the frontalis
branch of the facial nerve. The incision curves
over the ear to end behind and below the tip of
the auditory meatus. Variations on this incision
depend on the particular exposure desired.
The scalp and underlying muscle are mobilized in
two directions. The first is retraction of the scalp
and temporalis muscle anteriorly to expose a sig
nificant portion of the zygomatic process and a
portion of the middle fossa. This is best accom
plished with scalp hooks attached to rubber
bands and fixed by a Leyla bar. The other direc
tion of retraction runs interiorly, exposing the rim
of the external auditory canal and the entire audi 2-18b This modified park-bench position is particularly
useful if the combine d supratentorial and infratentorial
tory meatus. Again, scalp hooks, rubber bands, approach is combine d with the far-lateral transcondylar
and a Leyla bar are advantageous. foramen magnum a pproa ch.
The petrous bone is drilled initially, exposing the
dura and sigmoid sinus. This opening is used to
perform a craniotomy. The extent of petrous
bone resection depends on the desired exposure.
The resection, and therefore the exposure, can
be extensive even if hearing needs to be pre
served. If, however, the entire inner ear can be
sacrificed, the petrous bone resection can be
maximized after mobilizing the facial nerve,
thereby gaining a generous view of the base of
the skull. When this approach is combined with
the subtemporal and posterior fossa approach,
the entire extent of the base of the skull can be
visualized from the foramen magnum to the tip
2-18c The modified semi-sitting position may also be
of the temporal fossa. used for the combine d supratentorial and infratentorial
a pproa ch.
The important vascular relationship to be borne
in mind after the craniotomy is that of the dural
sinuses and the inferior anastomotic vein of
Labbé. The vein of Labbé enters the transverse
sinus proximal to the junction of the sigmoid and
superior petrosal sinuses. Recognizing this rela
tionship is important because it allows the entire
Combine d Middle a nd Posterior Fossae Skull Base Approa che s 95
width of the tentorium to be split below this junc The technique of presigmoidal incision of the
tion, sacrificing the superior petrosal sinus while dura of the posterior cranial fossa is an alterna
preserving the important drainage of the vein of tive to the supratentorial and infratentorial
Labbé into the lateral sinus. approach described above, which involves tran
After ensuring that bilateral sigmoid sinus section of the sigmoid sinus. The advantage of this
drainage is present, or that the venous drainage is technique is the preservation of the sigmoid
primarily through the contralateral sigmoid sinus, sinus. The jugular bulb forms the caudal limit of
the ipsilateral sigmoid sinus can be sacrificed. this approach. The sigmoid sinus rarely needs to
This maneuver allows almost unlimited retrac be transected.
tion of the incised tentorium, along with the lat The combined approach has been divided into
eral sinus, the vein of Labbé, and the base of the three variations. The first is the r etr olabyr inthine
temporal lobe. The need for this retraction is, exposure, which maintains the labyrinth intact
however, considerably reduced because the during the drilling of the petrous ridge, thus pre
petrous bone resection provides considerable serving hearing. The second is the translaby-
exposure. If the facial nerve is completely drilled r inthine exposure, in which the labyrinth is
out of its canal, facial paresis that can persist for removed and ipsilateral hearing is thereby sacri
6–12 months must be anticipated. If slightly less ficed. The third and most extensive approach is
exposure is adequate, the facial nerve can be pro the tr anscochlear , in which the entire cochlea and
tected with a rim of bone and left in its normal the remainder of the petrous pyramid are sacri
anatomical course to avoid facial palsy. The ficed. The facial nerve is severed from its super
petrous portion of the internal carotid artery can ficial petrosal branch and transposed from its
be readily exposed; if direct exposure is not canal.
required, a bony rim can be left to protect it.
2-19 a The venous vasculature is emphasized here. 2-19 b Knowledge of the anatomy of the cochlea within
Because the vein of Labbé drains into the transverse the petrous bone is extremely important if hearing is to be
sinus above the junction of the superior petrosal sinus and preserved. Obviously, if hearing can be sacrificed and the
sigmoid sinus, the sigmoid sinus and superior petrosal facial nerve mobilized, a much greater degree of petrous
sinus can be sacrificed. The vein of Labbe will then drain bone can be resected to gain further exposure
into the transverse sinus and empty through the contra lat (transcochlear exposure).
eral side.
2-19c The scalp incision usually extends below the 2-19d The craniotomy and its relationship to the cere
zygomatic arch in front of the ear between the frontalis bellopontine angle.
branch of the facial nerve and the tra gus of the ear. The
posterior rim of the incision extends down to the mastoid
tip or beyond, and depending on the extent, the mastoid
and petrous bones are re sected.
2-20a These illustrations have been deliberately placed 2-20b A lateral diagram summarizes the three
upright to emphasize the anatomical relationship when the approaches: the supra-infratentorial retrolabyrinthine
sitting position is used. a A petrous resection that spares approach (yellow), the translabyrinthine approach (blue)
the labyrinth. A translabyrinthine petrous resection would and the transcochlear approach (green).
include the blue shading; the transcochlear approach
would additionally include the green shading.
2-20c , d The retrolabyrinthine petrosal resection.
2-20e The extended retrolabyrinthine a pproa ch, with

skeletonized posterior and superior semicircular canals
and mastoidectomy.
98 Combined Middle and Posterior Fossae Skull Base Approaches
2-20 f, g The translabyrinthine petrosal rese ction.
2-20h , i The transcochlea r petrosal resection.
2-20j Anatomical relationships whe n the patient is pos i 2-20k Extent of the bone resection in an e xte nde d
tione d supine on the operating table with the head turne d combine d supratentorial and infratentorial a pproa ch. The
parallel to the floor, inclined slightly downwa rd. The illustra larger exposure in the s ubte mpora l region affords the two
tions are prese nted in the ups ide -down pos ition. angles of a pproa ch to the petrous tip a nd the clivus.
2-20l This dural incision is presigmoid and crosses the 2-20m The craniotomy, with an orange line indicating
superior petrosal sinus to join the dural incision over the the presigmoidal dural incision with preservation of the s ig
temporal lobe. moid sinus, and clips across the superior petrosal sinus.
The labyrinthine segment of the facial nerve is exposed
after removing the roof of its bony canal.
2-20n Two separate dural incisions, in front of and 2-20o The dural incision crosses the superior petrosal
behind the sigmoid sinus, preserve the integrity of the sinus as well as the sigmoid sinus and extends in a retro
sigmoid sinus. sigmoid fashion for a maximal dural ope ning. The sigmoid
sinus can only be sacrificed after bilateral patency of the
transverse sinuses has been established.
2-20q The temporal lobe and the incised te ntorium, pro

2-20p Extended retrolabyrinthine a pproa ch with e xpo te cte d by a retractor. The base of the tempora l lobe, along
sure of the labyrinthine segment of the facial nerve and with the incised tentorium is elevated without stretching
the dural incision crossing the superior petrosal sinus. A the great anastomotic vein (Labbé). The ipsilateral petrous
Y-shaped retrosigmoid dural incision allows access in front region, the entire clivus, and the cranial nerves are
of and behind the sinus. exposed (with pe rmis s ion of Ba rrow Ne urologica l Ins titute ).
2-21a A postoperative three-dimensional 2-21b In contra s t, the entire petrous ridge

CT reconstruction of a retrolabyrinthine has been drilled away in this transcochlear
approach demonstrates significant preserva CT re construction.
tion of the petrous ridge to preserve hearing.
2-21c The same CT reconstruction as in 2-21d The same patient as in 2-21b ,

2-21a , seen from the side, demonstrates the showing removal of the entire petrous ridge,
preserved labyrinth. viewed from the side.
2-21 e An oblique view of a thre e -dime n 2-21 f An oblique view of a CT reconstruc

sional CT reconstruction of the skull tion after a transcochlear a pproa ch. These
base after a retrolabyrinthine a pproa ch, CT reconstructions dramatically illustrate the
demonstrating the extent of petrous bone degree of petrous ridge resection tha t is pos
resection. sible, depending on the approach use d.
Posterior Fossa a nd Cra nioce rvica l J unction Approa che s 101
Midline
suboccipital
2-22 The posterior fossa and craniocervical junction skull s igmoid, far-lateral, and transpetrosal approaches are
base approaches are outlined in this schematic dia gra m. de picte d in various colors .
The midline s uboccipita l, paramedian s uboccipita l, retro-
102 Posterior Fossa a nd Cra nioce rvica l J unction Approa che s
Pos ition and Approac h to th e Pos terior Fos s a

S itting a n d S e m is ittin g P os ition Pos terior Fos s a a nd Cranioce rvic al
J unction App roa c he s
• Mid lin e s u b o c c ip ita l
s u b o c c ip ita l s pina l
• P a ra m e d ia n
s u b o c c ip ita l
c e re b e lla r
• P e tro s a l
re tro la byrin th in e
tra n s la b yrin th in e
tra n s c o c h le a r
re tro s ig m o id
fa r-la te ra l
2-23 a The sitting position, with head moderately flexe d.
2-23b The neck is flexed maximally in this semisitting 2-23c The amount of flexion of the head required
pos ition, requiring attention to prevent compromise of the depends on the relationship of the lesion to the straight
endotracheal tube . sinus. The straight sinus (blue line) is indicated to illustrate
the amount of flexion required so that it is parallel to the
floor.
Prone a n d S e m ip ro n e Pos ition
2-23 d -f These three illustrations show the approach

using the prone or semiprone positions. The amount of
head flexion and rotation depends on the area within the
posterior fos s a tha t requires exposure.
P a rk-Be nch P os ition La te ra l P os ition
2-23g This position allows good exposure of the cere 2-23h This position is only useful for a cerebellar hemi
bellopontine angle or midline structures. It is important to sphere lesion located laterally and near the surface. It is
pull the ipsilateral shoulder interiorly and to extend the not appropriate for the cerebellopontine exposure.
head in the oppos ite dire ction, rotating the head 15 to 30
degrees and flexing it maximally. This allows clear access
above and behind the ipsilateral shoulder.
Midlin e S u b o c c ip ita l Ap p ro a c h
2-24a A skin incision starting several centimeters above adequate residual nuchal ligament attached to the bone to
the inion and extending down to C2 may be use d. permit complete closure of this layer at the end of the pro
cedure. This closure is made possible by extending the
2-24b The nuchal ligament and midline are identified flexed neck at the end of the intracranial procedure, follow
and then cut in a modified T-shaped incision, allowing ing dural closure and prior to muscle closure.
2-24 c Midline craniotomy, with removal of the arch of

the atlas and a proposed dural opening.
2-24 d The relationship between the craniotomy and the

underlying neural structures .
2-24e Alternative ope ning, with the atlas kept intact.

Also, the foramen magnum may or may not be resected,
depending on the location of the lesion to be e xpos e d.
2-24f This view relates the craniotomy to the underlying

neural structures , with the atlas kept intact.
Views from above and from the side demonstrat

ing how to approach the variously located lesions
through a midline exposure.
2-24g , h Midline approach to cavernous malformations

or arteriovenous malformations in and near the midline of
the cerebellum.
106 Posterior Fossa and Craniocervical Junction Approaches
Mid lin e S u b o c c ip ita l Spina l Ap p ro a c h
2-25a The s ca lp incision overlies the posterior fos s a a nd 2-25b The dural ope ning.
cervical spine to a pproa ch this group of lesions. The inci
sion needs to be modified de pending on the lateral extent
of the lesion. Although this picture is represented with the
patient in the sitting pos ition, a prone position is equally
suitable.
2-25c A dorsal view into the craniocervical junction and

the upper cervical spinal canal (laminae C1 to C3 have
been removed).
P a ra m e d ia n P o s te rio r Fos s a Ap p ro a c h
2-26a The scalp incision used with the paramedian pos 2-26b The propos e d dural incision.
terior fossa a pproa ch,
2-26c The cerebellum e xpos ed using the paramedian

posterior fos s a a pproa ch.
Pos ition and Appro ac h

Re tro s ig m o id Ap p ro a c h
2 -27 a -c The three most common positions used to

approach the cerebellopontine angle. The supine pos ition,
with the head turne d and fle xe d, is particularly useful for
the translabyrinthine a pproa ch. The modified pa rk-be nch
or semisitting pos ition is best for the retrosigmoid
a pproa ch.
2-27d A paramedian incision is made from the level of 2-27e The underlying musculature.
C2 overlying the ma stoid to extend above the nuchal line
with a slight curve anteriorly.
2-27f The craniotomy. Care must be take n to expose 2-27g The craniotomy a nd its relationship to the cere
the sigmoid sinus which may require resection of mastoid bellum and brain s te m.
air cells. These should be sealed appropriately.
Pos ition and Approac h

Fa r-La te ra l P os te rio r Fos s a Ap p ro a c h Pos ition
2-28a A semisitting pos ition, with the head turne d for

the far-lateral a pproa ch.
2-28b A modified pa rk-be nch pos ition, for the far-lateral

a pproa ch.
2-28c A modifie d pa rk-be nch pos ition, with the ipsilater-

al shoulder ta pe d down and the patient ta pe d securely to
the opera ting ta ble . This position allows use of the full
range of the ope rating table's lateral rota tion.
2-28d The scalp incision for the far-lateral a pproa ch. 2-28e The underlying cervical musculature can be
a pprecia ted in this schematic dra wing.
2-28f The propos e d cra niotomy overlies the lower bor 2-28g The cra niotomy a nd its relationship to the cere
der of the transverse sinus and courses along the sigmoid bellum and brains tem.
sinus.
Fa r-La te ra l Po s te rior Fos s a Ap p ro a c h
2-28h An alternative propos e d skin incision for the far- 2-28i The underlying cervical musculature.
lateral a pproa ch.
2-28j The craniotomy and a C1-C2 laminectomy 2-28k Extension of s uboccipita l bone removal.
(including partial resection of the occipita l and C1
condyles).
Technique
The patient is placed in a modified park-bench
position. The head is rotated downward (away
from the lesion), positioning the inferior clivus
perpendicular to the floor, and maximally open
ing the posterior cervical-to-suboccipital angle.
An inverted hockey-stick incision starts at the
mastoid prominence and proceeds under the
superior nuchal line to the midline (Figs. 2-28l,
2-28o). The muscle mass is freed from along the
nuchal line, leaving a one-centimeter edge of
nuchal fascia and muscle for closure (Fig.
2-28m). During closure, the neck is extended, to
help reapproximate the cervical musculature to
the nuchal fascia. The incision continues caudally
in the midline down to the C6 spinous process.
The paraspinous muscles are split until the spi
nous processes of C1 and C2 are exposed. The
muscle flap is dissected from the suboccipital
bone and the laminae of C1 and C2. The muscle
flap is retracted inferiorly and laterally with fish
hooks attached to a Leyla bar. The midline flap
can be retracted contralateraly with fish hooks
from a second Leyla bar.
The lateral mass of C1 and the vertebral artery
from C1 to its dural entry are exposed. A C1
laminotomy is performed with a Midas Rex drill.
The contralateral lamina is cut across the midline,
and the ipsilateral lamina is cut at the sulcus for
the vertebral artery (Figs. 2-28n, 2-28 p). The lam
ina is saved and replaced at closure.
A suboccipital craniotomy performed with the

same drill is begun at the foramen magnum in
young patients, or with a small keyhole in older
patients. The craniotomy extends contralateraly
across the midline and ipsilaterally as far-lateral-
ly as possible. The craniotomy proceeds back to
the foramen magnum and exits medially to the
entry of the vertebral artery. The ipsilateral rim of
the foramen magnum is removed to the lateral
mass of C1 and the occipital condyle (Figs. 2-28 n,
2-28 q).
The important aspect of this modified approach
is the removal of the posterior condyle and the
lateral mass of C1. With the high-speed drill, the
posterior occipital condyle and the superior lat linear fashion, hinged laterally, and tented up
eral mass and facet of C1 are removed. Drilling with sutures.
away the inner portion of the condyle until only a The extensive removal of the condyle and lateral
thin shell of cortical bone remains will protect the mass of C1 eliminates the last osseous shelf
surrounding structures in this restricted space. obstructing direct vision to the clivus and anteri
The shell is then removed with microcurettes. or brain stem and allows lateral movement of the
Since the hypoglossal canal is situated in the extradural vertebral artery when the dura is tent
anterior medial third of the occipital condyle, it is ed. The extensive bone removal and the ability to
never threatened by removal of the posterior lat move the artery, combined with lateral and infe
eral third of the condyle. The extradural vertebral rior retraction of the muscle mass with fish hooks,
artery should be protected with a small dissector significantly enhance the direct exposure of the
while the condyle is drilled. The bone is removed lower clivus, the anterior foramen magnum, ante
to create a one-centimeter gap between the dural rior brain stem, and upper cervical spinal cord.
entry of the vertebral artery and the resected Minimal elevation of the cerebellar tonsil and
occipital condyle. The dura is opened in a curvi hemisphere also improves the exposure.
114 Vein of Ga le n a nd Pineal Region Approa che s
Overview of Approa c he s
Approac he s to th e Vein of Galen a nd
Pineal Region
• P o s te rio r tra n s c a llo s a l
• S u p ra te n to ria l tra n s te n to ria l
• In fra te n to ria l s u p ra c e re b e lla r
2-29 The various approaches to the vein of Galen region,

posterior third ventricle, and midbrain. These three
approaches include the posterior transcallosal approach
through the splenium, the supratentorial transtentorial
a pproa ch, and the infratentorial supracerebellar a pproa ch.
Each approach is detailed in the following pages.
P os terio r Trans callos al Ap p ro a c h
2-30a The craniotomy and scalp incision are used for 2-30b Relationship between the craniotomy, ventricular
the approach to the splenium of the corpus callosum. Par system, and pineal region.
ticular care must be taken to separate this critical portion
of the superior sagittal sinus from any adherence to overly
ing bone, when performing the craniotomy.
Vein of Ga le n a nd Pineal Region Approa che s 115
2-30c The approach along the falx exposes 2-30d The falx and tentorial junction have 2-30e An incision into the splenium of the
the corpus cailos um. The falx and he mi been ope ne d, exposing the pineal region with corpus cailosum anteriorly allows sharp de
sphere have been re tra cte d, exposing the its a rachnoid membranes. lineation of the pineal gla nd between the two
splenium of the corpus ca ilos um. internal cerebral veins as they coalesce with
the basal vein of Rosenthal and medial occi
pital veins to form the vein of Galen.
116 Vein of Ga le n a nd Pineal Region Approa che s
S u p ra te n to ria l Tra n s te n to ria l Ap p ro a c h
2-30f With the patient in the sitting position or in the

prone pos ition, the skin incision and craniotomy are
schematically outline d.
2-30g Relationship between the craniotomy, hemi

spheres, ventricular s ys te m, and pineal region.
2-30h This anatomical preparation is included here to de mon

strate the exposure of the occipita l lobe as seen by the s urge on.
Vein of Ga le n a nd Pineal Re gion Approa che s 117
2-30i The splenium of the corpus callosum 2-30j After the tentorium has been 2-30k After the arachnoidal planes have
is visualized following the retraction of the ope ne d, the tip of the vermis a nd the a ra ch been ope ne d, the pineal gla nd, precentral
occipital lobe. noidal membrane of the pineal region are cerebellar vein, vein of Galen, and both basal
e xpos e d. veins of Rosenthal are clearly visible. This
approach - as oppos e d to the previous one -
allows good exposure of the pineal area even
with small lesions. The precentral cerebellar
vein can be sacrificed for the exposure if nec
essary.
118 Vein of Ga le n a nd Pineal Re gion Approa che s
In fra te n to ria l S u p ra c e re b e lla r Ap p ro a c h
2-31a The prone position is one of three positions used 2-31b With the patient in the prone position and the
to expose the vein of Galen and midbrain region through head slightly tlexed, an excellent exposure of the vein of
an infratentorial supracerebellar a pproa ch. Galen region and midbrain can be achieved.
2-31c The bone flap is outlined. It is important to take 2-31d Schematic representation of the a pproa ch.
the bone flap far above the transverse sinuses in order to
elevate these sinuses and the tentorium maximally.
Vein of Ga le n a nd Pineal Re gion Approa che s 119
2-31e The BNI – modification of the Concord position is 2-31f A comforta ble sitting position for the surgeon can
used, and the patient is placed prone with the head flexed be maintained by tilting the operating table towa rd the sur
and turne d towa rd the contralateral shoulder. This position ge on.
allows the surgeon to stand behind the ipsilateral s houl
der. This a pproa ch is useful for the pineal region, as well
as for lesions of the cerebellum or occipital lobes. The
appropriate degree of head flexion and head rotation
depends on the location of the lesion.
2-31g Anatomical specimen of the vasculature encount

ered through the infratentorial supracerebellar a pproa ch.
120 Vein of Ga le n a nd Pineal Re gion Approa che s
2-31h The cerebellar hemispheres and ver 2-31i Following dissection of the a ra ch 2-31j Further inferior dissection reveals the
mis are gently retracted or more commonly noid, the anatomy of the pineal region pineal gland and its surrounding vasculature.
will fall away sufficiently to allow access to becomes apparent. The pale white structure Most interiorly the superior colliculi are visible
the pineal region. The arachnoidal me m is the splenium of the corpus callosum with projecting from the quadrigeminal plate.
branes cover the underlying pineal region. the vein of Galen and its tributaries in the
midline.
121
122 Ane urys ms of the Brain
An e u rys m s —An te rio r Circ u la tio n
Introduction
Aneurysms of the anterior circulation are pre
sented first and followed by those of the posteri
or circulation. Within that schema, we first follow
the internal carotid artery up from the skull base
and then explore the branches of the anterior
cerebral and pericallosal arteries. The territory of
the middle cerebral artery is covered next. The
section concludes by moving from the top of the
basilar artery down to the vertebral artery.
Endovascular techniques partner with neurosur
gical open procedures or are the definitive treat
ment for certain lesions and are therefore repre
sented in this section.
3-a The locations of intracranial aneurysms as they

appear in this te xt. The cases represent common
locations for aneurysms in the anterior (red) and posterior
(green) circulation.
Ane urys ms –Ante rior Circula tion 123
3-b Surgical approaches to revascularization of the bypass or, alternatively, with an anterior temporal artery
anterior and posterior circulation. Overview shows the (Ant. Te mp. A)-to-MCA in situ bypass.
common intracranial locations for aneurysms of the ante ri Overview s hows the common intracranial locations for
or circulation and the corresponding treatment strategies aneurysms of the posterior circulation and the corre s pond
as detailed in a -d .(a ) Cavernous internal carotid artery ing treatment strategies as detailed in e and f. (e) Midbasi-
(ICA) aneurysm is tra ppe d and revascularized with a lar artery is occlude d proximally or distally to the aneurysm
pe trous -to-s upra clinoid (C5 to C3) ca rotid bypass with a and revascularized with a STA-to-posterior cerebral artery
saphenous (S a ph) vein graft or, alternatively, with a ce rvi- (PCA) bypass. (AICA, anterior inferior cerebellar artery;
ca l-to-supra clinoid ca rotid artery bypass. (Ophth. A., Ve rt A, vertebral artery; S CA, superior cerebellar artery).
ophthalmic artery; ECA, external carotid artery). (b) Supra- (f) Aneurysm is tra ppe d between a clip on the proximal Vert
clinoid ICA is tra ppe d and revascularized with a superficial A and distal endovascular coils. Revascularization was
temporal a rte ry-to-middle cerebral artery (STA-to-MCA) accomplished with a posterior inferior cerebellar-to-posteri-
bypass with a S a ph vein graft. (P ComA, posterior commu or inferior cerebellar artery (PICA-to-PICA) in situ bypass.
nicating artery; ACA, anterior cerebral artery). The clip at the origin of the PICA prevents retrograde filling
(c) ACA aneurysm is tra ppe d and revascularized with an of the aneurysm. Alternatively, an occipital artery-to-PICA
A2-to-A2 in situ bypass. (Re c. A., recurrent artery; AComA, bypass is s hown. Re printe d with pe rmis s ion of Ba rrow
anterior communicating artery). (d) Aneurysm is tra ppe d Ne urologica l Ins titute ®.
and revascularized with a double-barrel STA-to-MCA
124 Aneurysms of the Brain
Case 3–1
Diagnosis: Right intracavernous sinus aneurysm (related anatomy:
pp 8, 10-15, 20, 32)
Approach: Right intracavernous pterional with clipping (rel. approaches:
pp 80, 82-85)
3-1a Compute d tomogra phic (CT)

scan shows an enlarged cavernous sinus
with calcification.
3-1b and c Anteroposterior and lateral

angiograms demonstrate a large multilobulat-
ed intracavernous sinus aneurysm on the
right that was responsible for the patient's
progressive ophthalmoparesis.
3-1d The intracavernous sinus aneurysm is

e xpos e d.
3-1e The course of the internal carotid artery as

it enters the cavernous sinus and the entry of the
oculomotor nerve are visible.
3-1f After the cavernous sinus has been ope ne d,

the cranial nerves as well as the dome and neck of
the aneurysm are visible.
3-1g and h Postoperative anteroposterior

and lateral angiograms demonstrate clipping
of the intracavernous sinus aneurysm with
good preservation of the internal carotid
artery. The patient's preoperative ophtha lmo-
paresis became complete after surgery but
had resolved entirely at 6 months.
Case 3–2
Diagnosis: Giant intracavernous sinus aneurysm (rel. anatomy:
pp 5-8, 10-15, 20)
Approach: Right pterional and extradural subtemporal petrosal with
carotid-to-carotid saphenous-vein bypass (rel. approaches:
pp 80, 82-85, 92, 93)
3-2a and b Anteroposterior and lateral

angiograms of a giant intracavernous sinus and
sphenoid aneurysm. The patient presented with
severe epistaxis and partial oculomotor nerve palsy.
3-2c Exposure of the right tempora l fossa

reveals that the dura of the cavernous sinus is
stretched because of the giant aneurysm.
3-2d Utilizing the landmark of the middle

meningeal artery medially and the foramen ovale
anteriorly, the petrous bone is drilled to expose the
internal carotid artery.
3-2e With a clip on the internal carotid artery as

it enters the cavernous sinus and a balloon placed
proximally into the ca rotid canal for occlusion of the
internal carotid artery, an anastomosis is per
forme d, e nd-to-s ide , between a saphenous-vein
graft and the internal carotid artery.
3-2f Close-up view of the anastomosis between

the petrous internal carotid artery and the saphe
nous-vein graft.
3-2g The internal carotid artery is exposed in its

subarachnoid course and the saphenous-vein graft
placed where the anastomosis is to be pe rforme d.
3-2h In this case the internal ca rotid artery was

tra ns e cte d and an e nd-to-e nd anastomosis,
between the saphenous-vein graft and the internal
carotid artery, proximal to the posterior communi
cating artery, was performe d.
3-2i Direct anastomosis between the saphe

nous-vein graft to the internal carotid artery. A
piece of Gelfoam covers the base of the frontal
lobe for protection during the operative manipula
tion.
3-2j Overview demonstrates the graft connecting

the petrous internal carotid artery to the subara ch
noid internal carotid artery.
3-2k Postoperative angiogram demonstrates the

venous graft and the two clips that exclude the
giant aneurysm from the circulation. Within 5 months ,
the patient recovered completely from his oculomotor
nerve paresis.
Case 3–3
Diagnosis: Bilateral intracavernous sinus aneurysms (rel. anatomy:
pp 5-8, 10-15, 17, 20)
Approach: Right pterional and intradural subtemporal petrosal
with right carotid-to-carotid saphenous-vein bypass
(rel. approaches: pp 80, 82-85, 92, 93)
3-3a Schematic demonstration of the

anatomy of the internal carotid artery as it
courses through the cavernous sinus. The C3
and C5 portions of the internal carotid artery
are identified, a nd the necessary exposure of
the internal carotid artery adjacent to the cav
ernous sinus proximally and distally is de lin
eated by the triangles. V1 , V2 , V3 are the
three branches of the trigeminal nerve.
Re printe d with pe rmis s ion from J ourna l of
Ne uros urge ry.
3-3b Magnetic resonance (MR) image 3-3c and d Right and left lateral sinus aneurysm that was responsible for pro
demonstrates bilateral intracavernous sinus angiograms demonstrate the bilateral gressive ophthalmoparesis.
aneurysms. aneurysms with a large right intracavernous
3-3e Intradural approach to the temporal foss a .

The dura along the foramen ovale and medial to
the middle meningeal artery is ope ne d, exposing
the petrous bone covering the internal ca rotid
artery. The microDoppler flow probe is useful for
locating the middle meningeal artery as it exits the
foramen spinosum.
3-3f The petrous bone has been removed,

exposing the petrous internal ca rotid artery. The
greater and lesser superficial petrosal nerves are
typically sectioned with an extradural exposure.
This sacrifice can be avoided with the intradural
exposure. The middle meningeal artery also can be
spared with an intradural exposure. The petrous
bone medial to the carotid artery can be drilled
extensively to allow excellent exposure of the inter
nal carotid artery. Lateral drilling along the internal
ca rotid artery risks damage to the eustachian tube .
Posterior drilling encroaches on the cochlea with
risk of loss of hearing.
3-3g A 2-French Fogarty balloon catheter (photo)

can be inserted into the pe trous ca rotid canal for
proximal control of the internal ca rotid artery
(s che ma tic ove rvie w).
3-3h The inflated balloon partially protrudes from

the ca rotid ca na l, occluding the internal ca rotid
artery. The advantage of using the balloon is the
elimination of a s e cond clip to control the internal
ca rotid artery proximally, allowing more fre e dom of
movement for performing the a nastomos is. A per
manent clip is placed distally on the expose d inter
nal ca rotid artery. A saphenous-vein graft wa s
inserted as in the previous case.
3-3i Postoperative angiogram demonstrates

elimination of the aneurysm with good internal
carotid artery flow through the saphenous-vein
graft.
3-3j Schematic presentation of a complete d

saphenous-vein graft bypass between the C5 and
C3 portions of the internal carotid artery. The two
aneurysm clips are positioned close to the oph
thalmic artery and proximal ana stomotic s ite ,
respectively, to eliminate any vascular dead spa ce.
Re printe d with pe rmis s ion from J ourna l of Ne uro-
s urge ry.
Case 3–4
Diagnosis: Right ophthalmic artery aneurysm (rel. anatomy: pp 17, 20)
Approach: Right subfrontal frontolateral with clipping (rel. approaches:
pp 80, 81)
3-4a A subfrontal frontolateral approach to 3-4b A clip has been placed on the neck
the optic chiasm (following elevation of the of the aneurysm following dissection of the
fronta l lobe) allows visualization of the elevat right anterior clinoid process.
ed optic nerve from the underlying oph
thalmic artery aneurysm. A relatively thin
internal ca rotid artery is seen on the left.
Ca s e 3–5
Diagnosis: Giant left ophthalmic artery aneurysm (rel. anatomy: pp 17, 20, 32)
Approach: Left pterional with clipping (rel. approaches: pp 80, 82-85)
3-5a and b CT scan of the left ophthalmic

aneurysm.
3-5c and d Angiograms demonstrate the

giant ophthalmic aneurysm.
3-5e Through a pterional a pproa ch the S yl 3-5f After extensive dissection along the 3-5g The aneurysm has been compres sed
vian fissure has been ope ne d, exposing a arachnoidal planes and resection of a dhe by vascular force ps in order to allow the
giant aneurysm. The aneurysm has been sions, the internal ca rotid artery is seen at the application of large aneurysm clips.
mobilized from the middle fos s a , visualizing base of the aneurysm dome . The junction of
the middle cerebral artery as it emerges the posterior communicating artery is visible.
below the edge of the aneurysm sac.
3-5h The wall of the aneurysm has been 3-5i After partial thrombe ctomy of the 3-5j Following complete removal of the
incised, releasing thrombus and blood, in aneurysm, the three clips occlude the neck of aneurysm, an additional clip was placed
order to allow additional clip applications. the aneurysm. across the other clips for reinforcement.
3-5k Schematic presentation of the clip

ping technique used in this case.
Aneurysms–Anterior Circula tion 139
3-5l, m, and n Postoperative angiograms.

Case 3–6
Diagnosis: Large left ophthalmic artery aneurysm (rel. anatomy: pp 14, 15,17,
20, 32)
3-6a Left lateral angiogram demonstrates a large

ophthalmic artery aneurysm.
3-6b The ophthalmic artery aneurysm is visual

ized through a pterional a pproa ch.
3-6c The clinoid is removed with a drill.

3-6d After the clinoid has been resected, the

extradural course of the internal carotid artery is
visualized.
3-6e The internal carotid artery dural ring is cut.
3-6f An extra bulge of the ophthalmic artery

aneurysm is visible inferior to its main body.
3-6g An additional clip placed along the remaining

neck of the aneurysm obliterates the entire
aneurysm.
3-6h Overview after comple te obliteration of the

aneurysm shows separation of the red blood cells
from the serum in the aneurysm sac.
3-6i Postoperative angiogram de mon

strates good preservation of the internal
carotid artery and ophthalmic artery with
complete obliteration of the aneurysm.
Case 3–7
Diagnosis: Giant left ophthalmic artery aneurysm (rel. anatomy:
pp 17, 20, 32, 34-36)
Approach: Left pterional STA-to-MCA bypass using a saphenous-vein
graft for trapping of the aneurysm (rel. approaches:
pp 80, 82-85)

angiograms demonstra te a giant left oph
thalmic artery aneurysm. The patient's com
plaints were progressive visual loss and tra n
sient ischemic atta cks of the left hemisphere.
3-7c The saphenous-vein gra ft-to-middle cere

bral artery branch anastomosis is half comple te d.
3-7d After the vein graft has been completely

anastomosed to the middle cerebral artery branch,
back flow expands the vein graft.
3-7e Overview of the vein graft as it enters the

Sylvian fissure.
3-7f Postoperative angiogram demonstrates

good flow through the left middle cerebral artery
territory down to the distal end of the tra ppe d
aneurysm.
Case 3–8
Diagnosis: Large left ophthalmic artery aneurysm (rel. anatomy:
PP 17, 20)
3-8a Angiographic demonstration of large 3-8b CT scan of aneurysm.

left ophthalmic artery aneurysm.
3-8c The left optic nerve is visualized fol

lowing a pterional exposure. The internal
carotid artery emerges under the rim of the
anterior clinoid process. The neck of the
aneurysm can be appreciated medially.
3-8d A clip was placed over the neck of 3-8e Because a single, large clip was not 3-8f Postoperative angiogram de mon
the aneurysm following partial anterior clinoid capable of permanently occluding the neck of strates occlusion of the neck of the
resection and the enlargement of the optic the aneurysm (opening with each arterial pul aneurysm.
fora men. sation), a se cond clip was placed over the
first to get complete neck obliteration.
Despite the obvious distortion of the optic
nerve, no visual deficit was present postoper
atively.
Case 3–9
Diagnosis: Right ophthalmic artery aneurysm (rel. anatomy: pp 17, 20)
Approach: Endovascular

internal carotid artery angiograms show a
small ophthalmic artery aneurysm that pro
je cts medially.
3-9c and d Oblique internal carotid artery

angiograms before and after coiling (a rrows )
of the small-necked ophthalmic artery
aneurysm.
3-9e and f Anteroposterior and lateral

angiograms demonstrate the obliteration of
the aneurysm by coils.
3-9g Twelve-month follow-up angiogram

demonstrates continue d obliteration of the
ophthalmic artery aneurysm (arrow) by the
coils.
Case 3–10
Diagnosis: Paraclinoid aneurysm (cave aneurysm) (rel. anatomy:
pp 13,14, 19, 20, 29, 32)
Approach: Right pterional with clipping (rel. approaches: pp 80, 82-85)
3-10a and b Two lateral angiograms de mon

strate a small aneurysm on the internal carotid
artery adjacent to the cavernous sinus. Previously,
this aneurysm had been misdiagnosed as being
within the cavernous sinus. It is important to re cog
nize that this aneurysm is within the subarachnoid
space and frequently becomes symptomatic with a
subarachnoid hemorrhage. The inexperienced ne u
rosurgeon will fail to see this aneurysm when first
observing the internal carotid artery at surgery
because the lesion is hidden by that vessel and the
anterior clinoid.
3-10c The internal carotid artery and optic

nerve are exposed through a right pterional
craniotomy. Partial drilling has progressed. It is
easy to see why the aneurysm can be missed
upon initial inspection.
3-10d Retracting the internal ca rotid artery later

ally exposes the medial portion of the aneurysm.
3-10f The origin of the ophthalmic artery on the

internal carotid artery is e xpos e d.
3-10g With the internal carotid artery retracted

medially, the proximal portion of the aneurysm neck
is being exposed after the dural ring has been par
tially cut.
3-10h After the ring of the internal carotid artery

has been cut further along its lateral portion, the
proximal neck of the aneurysm is visible.
Dura
3-10i With the internal carotid artery retracted

laterally, the aneurysm and the hypophyseal artery
are visible.
3-10 j With a fenestrated clip, the neck of the

aneurysm is oblite ra te d.
3-10k With the clip rotated laterally, the tip of the

aneurysm clip is visible as it crosses the proximal
neck of the aneurysm.
3-10l Postoperative angiogram demonstrates

clip placement and obliteration of the aneurysm
proximal to the posterior communica ting artery.
Case 3–11
Diagnosis: Paraclinoid aneurysm (rel. anatomy: pp 13,14, 19, 20, 29, 32)
3-11a , b, and c Lateral and two oblique angiograms

of a large-based paraclinoid aneurysm on the left.
3-11d Through a pterional a pproa ch, the internal

carotid artery, optic nerve, and anterior clinoid are
visible.
3-11e The anterior clinoid is drilled.
3-11f The remnant of the anterior clinoid is being

removed.
3-11g The aneurysm is visible medial to the optic

nerve.
3-11h The aneurysm is being clippe d with a fe n

e strate d clip after proximal control of the internal
ca rotid artery in the neck and distal control of the
internal ca rotid artery with a te mpora ry clip has
been obta ine d.
3-11i Additional clips are a pplie d. Note the nar

rowing of the internal ca rotid artery.
3-11j A microDoppler flow probe is used to verify

patency of the internal ca rotid artery. Poor flow dic
ta te d reapplication of the clips .
3-11k Close -up of the obliterated aneurysm

neck after final clip placement. Note tha t the caliber
of the internal carotid artery is normal compared to
its appearance in Figure i.
3-11l and m Ante ropos

terior and lateral angio
grams show obliteration of
the aneurysm with good
preservation of the internal
carotid artery and anterior
choroidal artery.
Case 3–12
Diagnosis: Giant paraclinoid aneurysm (rel. anatomy: pp 13,14, 19, 20,
29, 32)

MR images demonstrate the giant mass that
caused the patient to develop dementia and
secondary obstructive hydrocephalus.
3-12c Exposure of the right Sylvian fissure

demonstrates the internal carotid artery, the optic
nerve, and the base of the aneurysm. Much to the
surgeon's delight, there was a distinct aneurysm
neck below the right optic nerve.
3-12d A clip now occludes the aneurysm neck.

The internal carotid artery, middle cerebral artery,
and anterior cerebral artery are visible and the
aneurysm protrudes through the lamina terminalis.
The right optic tra ct is dis torte d laterally.
3-12e After the aneurysm was ope ned through

the lamina terminalis, an ultrasonic aspirator is used
to debulk the mass. The anterior cerebral artery is
elevated. The patient's preoperative neurological
deficit improved dramatically. This case nicely
emphasizes tha t many giant aneurysms must be
explored surgically to determine their clipability.
Case 3–13
Diagnosis: Right complex paraclinoid aneurysm (rel. anatomy:
pp 13, 14, 17, 19, 20, 28, 29, 32, 35, 36)
Approach: Right pterional with STA-to-MCA saphenous-vein bypass
(rel. approaches: pp 80, 82-85)
3-13a and b Anteroposterior and lateral angiograms demonstrate posterior cerebral artery (double a rrow). The patient presented with a
a complex internal carotid artery aneurysm with severe stenosis of subarachnoid hemorrhage as well as with progressive ischemic
the internal ca rotid artery (arrow). Note the fetal origin of the right s ymptoms .
3-13c and d Left anteroposterior and lateral internal ca rotid artery A posterior fossa injection (not s hown) revealed no filling of the right
angiograms demonstrate no cross-filling to the right hemisphere. hemisphere.
3-13e Through a right pterional a pproa ch, the

right Sylvian fissure is expose d. Evidence of the
previous subarachnoid hemorrhage is present.
3-13f The Sylvian fissure is partially dis s e cte d,

exposing the middle cerebral artery and aneurysm.
3-13g With further exposure, the middle cerebral

artery, anterior cerebral artery, and internal ca rotid
artery are visible. The large, calcified fusiform
aneurysm on the internal carotid artery is apparent
along with the fetal posterior cerebral artery, the
anterior choroidal artery, and the bifurcation.
3-13h The anterior clinoid is removed, exposing

the base of the aneurysm.
3-13i Higher magnification view demonstrates

the ophthalmic artery as it exits from the internal
carotid artery.
3-13j A clip is placed distal to the exit of the

ophthalmic artery on the internal carotid artery.
3-13k A major middle cerebral artery bifurcation

is isolated between temporary aneurysm clips. The
artery is ope ne d, and the posterior wall of the
saphenous-vein graft is comple ted.
3-13l The bypass is comple te d.
3-13m The proximal end of the saphenous-vein

graft is inserted into the bifurcation of the superficial
temporal artery.
3-13n Several clips are utilized to occlude the

internal ca rotid artery, distal to the aneurysm and
just proximal to the posterior communicating artery.
3-13o Left internal carotid artery

angiogram shows slight filling of the right
posterior cerebral artery without any filling of
the right middle cerebral artery.
3-13p and q Anteroposterior and lateral

angiograms of the superficial temporal artery-
to-middle cerebral artery bypass demonstrate
patency of the saphenous-vein graft, filling
the middle cerebral artery territory.
Case 3–14
Diagnosis: Left PComA aneurysm (rel. anatomy: pp 17-22)
3-14a Left internal carotid artery angiogram

shows a posterior communicating artery aneurysm.
3-14b Through a left pterional a pproa ch, the pos

terior communicating artery aneurysm is identified.
3-14c A clip is placed on the aneurysm, which is

jus t distal to the posterior communica ting artery
and proximal to the anterior choroidal artery.
3-14d The aneurysm is retracted ba ckwa rd

showing its relationship to the posterior communi
cating artery.
3-14e The aneurysm is retracted anteriorly,

exposing the anterior choroidal artery.
3-14f The aneurysm is deflate d.

3-14g Postoperative angiogram demonstrates

complete obliteration of the aneurysm with pre
served flow through the posterior communicating
and anterior choroidal arteries.
Case 3–15
Diagnosis: Left PComA aneurysm (rel. anatomy: pp 18-21)
3-15a Left lateral internal carotid artery 3-15b Because the neck of the aneurysm
angiographic injection reveals a posterior was small, GDC coils were pla ced.
communicating artery aneurysm in this elderly
patient who presented with a subarachnoid
hemorrhage.
3-15 c Six-month follow-up angiogram

demonstrates good obliteration of the
aneurysm.
Case 3–16
Diagnosis: PComA aneurysm (rel. anatomy: pp 18-21)
3-16a Preoperative lateral angiogram

demonstrates a posterior communicating
artery aneurysm.

postoperative angiograms demonstrate oblit
eration of the posterior communicating artery
aneurysm.
3-16d and e Late follow-up lateral

angiograms confirm continued endovascular
occlusion of the posterior communicating
artery aneurysm.
Case 3–17
Diagnosis: Aneurysm of the bifurcation of the left ICA (rel. anatomy:
pp 20, 28, 29, 32)
3-17a The left internal carotid artery is 3-17b After the Sylvian fissure has been 3-17c A clip has been placed on the neck
visualized. The anterior cerebral artery is seen partially ope ne d, the aneurysm is clearly vis u of the aneurysm, and the sac of the
coursing over the left optic nerve. alized between the junction of the middle aneurysm has been aspirated.
cerebral and anterior cerebral arteries. Notice
the large choroidal artery.
Case 3–18
Diagnosis: Right carotid bifurcation aneurysm (rel. anatomy: pp 20, 28,
29, 32)
Approach: Right orbitopterional with clipping (rel. approaches: pp 86, 87)
3-18a Anteroposterior angiogram demonstrates

a multilobulated right bifurcation aneurysm.
3-18b Through the Sylvian fissure, the bifurcation

is e xpos e d, revealing the base of the aneurysm.
3-18c After further exposure, the bilobulated

dome of the aneurysm is apparent.
3-18d When the neck of the aneurysm is retract

ed laterally, the lenticulostriate perforators are visi
ble.
3-18e When the right middle cerebral artery is

pulled away from the aneurysm, the perforators
can be seen behind the aneurysm.
3-18f The clip is applied to the aneurysm neck

and its dome is deflated. Careful inspection reveals
patency of all the perforating branches.
3-18g Postoperative angiogram demonstrates

elimination of the aneurysm. The patient experi
enced no surgical complica tions.
Case 3–19
Diagnosis: Two aneurysms of the right ICA bifurcation (rel. anatomy:
pp 27-29, 32, 33)
pp 80, 81)
3-19a The internal carotid artery is 3-19b With a little deeper exposure, the 3-19c With further dis section, the recurrent
exposed following a right frontolateral posterior communica ting artery is visualized artery of Heubner is seen above the retractor.
a pproa ch. The Sylvian fissure has been off to the left. A small aneurysm is seen aris
ope ne d. ing between the anterior and middle cerebral
artery bifurcation, and an aneurysm going
deep into the Sylvian fissure can be a ppre ci
a te d.
3-19d With the judicious use of the mirror, 3-19e The aneurysm clip with the jaws 3-19f A small clip is placed on the small
the undersurface of the internal carotid artery open is being applied to the deep aneurysm. superficial aneurysm following the previous
bifurcation can be examined to assure free placement of the clip on the larger aneurysm
dom of adhesions prior to aneurysm clip
placement.
Case 3–20
Diagnosis: Left bifurcation aneurysm (rel. anatomy: pp 20, 28, 29, 32)
Approach: Left orbitozygomatic with clipping (rel. approaches:
pp 88–91)
3-20a CT scan performed because of per

sistent headaches in a 10-year-old patient
demonstrates a large aneurysm.

angiograms demonstrate a fusiform
aneurysm of the left internal carotid artery-
middle cerebral artery bifurcation.
3-20d Low-powe r view after the Sylvian fissure

has been split demonstrates the internal carotid
artery and the fusiform aneurysm on the middle
cerebral artery.
3-20e High-power view demonstrates the

aneurysm.
3-20 f A temporary clip is applied to the internal

carotid artery, proximal to the aneurysm, to soften
its dome .
Te mpora ry clip
3-20g A long curved clip was applied along the

bifurcation of the internal ca rotid artery and middle
cerebral artery after ascertaining tha t all the perfo
rators at the bifurcation and the anterior cerebral
artery have been spared.
3-20h High-power view demonstrates the lentic-

ulostriate perforators, which are outside the clip
blades, arising from the bifurcation.
3-20i The internal carotid artery is pulled gently

upwa rd, exposing the junction of the anterior cere
bral artery.
3-20j An additional clip is placed at the tip of the

long curved blade to obliterate a small remnant of
the aneurysm's neck. Also, a small clip is placed
proximal at the internal ca rotid artery to eliminate
the proximal base of the neck.
3-20k and I Left anteroposterior and oblique

internal carotid artery angiograms demonstrate
good preservation of the bifurcation with complete
elimination of the fusiform aneurysm.
Case 3–21
Diagnosis: Fusiform aneurysm on the ICA-MCA bifurcation
(rel. anatomy: pp 20, 29, 32, 33, 36)
Approach: Right pterional with trapping and STA-to-MCA
saphenous-vein bypass (rel. approaches: pp 80, 82-85)
3-21a CT scan demonstrates acute s ub

arachnoid hemorrhage.
Fig.3-21b CT scan at a higher level

demonstrates infarction of the right internal
capsule and stria tum.
3-21c and d MR images demonstrate an

aneurysm as well as the area of infarction.
This young man presented with acute s ub
arachnoid hemorrhage and progressive
stroke with significant left hemiparesis.
180 Ane urysms of the Brain

angiograms demonstrate a fusiform middle cerebral
artery aneurysm and severe stenosis of the internal
carotid artery just proximal to the anterior choroidal
artery.
3-21g Through a right pterional approach, the

internal carotid artery and middle cerebral artery
are exposed. The giant fusiform aneurysm is visible.
The internal carotid artery was mobilized, exposing
the posterior communicating and anterior choroidal
arteries.
3-21h After a superficial temporal a rte ry-to-mid

dle cerebral artery bypass with a saphenous-vein
graft is comple te d, a clip is placed proximal to the
aneurysm but distal to the origin of the anterior
choroidal artery. A s e cond clip is applied to the dis
tal aneurysm on the middle cerebral artery tra pping
the lesion.
3-21i and j Postoperative angiograms de mon

strate the bypass filling the territory of the right
middle cerebral artery. The anterior choroidal artery
(a rrows ) is filled from the internal ca rotid artery. The
clips tha t have tra ppe d the aneurysm are visible.
Despite evidence of infarction on magnetic reso
nance imaging, the patient could walk almost nor
mally and was left with a minor weakness of the
left upper extremity.
Case 3–22
Diagnosis: Right aneurysm of the ACA (A1 segment) (rel. anatomy:
pp 20, 27-30, 32, 35, 42)
3-22a Following the exposure of the inter- 3-22b A clip has been placed on the neck
nal carotid artery and its bifurcation through a of the aneurysm.
right pterional a pproa ch, the neck and dome
of the aneurysm are visible just below the
anterior tha lamoperfora tors.
Case 3–23
Diagnosis: Left giant aneurysm of the ACA (A1 segment) (rel. anatomy:
pp 20, 27-30, 32, 35, 42)
Approach: Left orbitozygomatic with clipping (rel. approaches: pp 88-91)
3-23a and b Ante ro

posterior and lateral angio
grams show a left giant
aneurysm located on the
A1 segment.
3-23c The internal carotid artery has been

exposed through an orbitozygomatic approach and
a split Sylvian fissure.
3-23d With further dis se ction, the bifurcation of

the internal carotid artery and the A1 artery is iden
tified along with the large aneurysm.
3-23e Two temporary clips are placed on either

side of the aneurysm.
3-23f The aneurysm is deflated with needle s uc

tion.
3-23g The aneurysm is deflated.

3-23h Multiple clips are applied to reconstruct

the parent vessel and to preserve all of the perfo
rating arteries.
3-23i and j Postoperative angiograms demon

strate patency of the parent vessels as well as
comple te obliteration of the aneurysm.
Case 3–24
Diagnosis: AComA aneurysm (rel. anatomy: pp 19, 27-31, 44)
pp 80, 81)
3-24a Through the right frontolateral 3-24b The optic nerve is exposed by
a pproa ch, dense arachnoid due to multiple opening the a ra chnoid. Previous hemorrhage
previous hemorrhages can be seen. The can be identified within the gyrus rectus.
olfactory tra ct is elevated along with the
retractor. Care is taken to preserve this nerve
in every case. Cutting the arachnoid along
the olfactory tra ct will allow sufficient room for
adequate retraction.
3-24c The anterior cerebral artery is identified

after the gyrus rectus has been resected. The
adhesions around the neck of the aneurysms are
virtually removed. The clot is visible in the back
ground.
3-24d The clip has been applied to the neck of

the aneurysm and the dome has been resected.
The clot has been removed.
Case 3–25
Diagnosis: Right AComA aneurysm (rel. anatomy: pp 19, 27-31, 44)
pp 80, 81)
3-25a The optic nerves and chiasm are 3-25b An angled clip has been applied to
expose d. The anterior communicating artery the neck of the aneurysm.
and aneurysm are visible.
Case 3–26
Diagnosis: Giant AComA aneurysm (rel. anatomy: pp 19, 27-31, 44)
Approach: Right orbitopterional with clipping (rel. approaches:
pp 86, 87)
3-26a and b CT scans show the giant ca l

cified aneurysm with only a small filling
de fe ct.
3-26c and d Left anteroposterior and lateral

internal ca rotid artery angiograms reveal vessel dis
placement but no aneurysm.
3-26e and f Right anteroposterior and lateral

angiograms demonstrate an anterior communica t
ing artery aneurysm.
3-26g The aneurysm is exposed through an

orbitopterional a pproa ch.
3-26h The aneurysm dome was opened and the

thrombus evacuated until active bleeding was
e ncounte re d. Temporary intra-aneurysmal ta mpon
ade was pe rformed. The dome of the aneurysm
was then cut circumferentially from the neck,
exposing the anterior communicating artery com
plex. After the feeding vessels were temporarily
occlude d, a clip was applied across the neck of the
aneurysm
.
3-26i and j Postoperative angiograms de mon

strate obliteration of the aneurysm with good filling
of the normal vasculature. This young business
man, who initially presented with progressive
dementia, recovered completely.
Case 3–27
Diagnosis: Giant AComA aneurysm (rel. anatomy: pp 19, 27-31, 44)
Approach: Right orbitopterional with clipping (rel. approaches: pp 86, 87)
3-27a and b Anteroposterior and lateral internal

carotid artery angiograms demonstrate a giant
anterior communicating artery aneurysm.
3-27c Through a right orbitopterional a pproa ch,

the right Sylvian fissure is e xpose d.
3-27d After the Sylvian fissure is split, the middle

cerebral and internal carotid arteries are completely
visible.
3-27e Both anterior cerebral arteries and the

ipsilateral A2 segment are visible. The lamina te rmi
na ls bulges between the two anterior cerebral
arteries. The recurrent artery of Heubner is seen as
it exits near the anterior cerebral artery junction on
A2 running along the ipsilateral A1 artery.
3-27f Clips are placed across the neck of the

aneurysm and the aneurysm is tilte d upwa rd. The
anterior cerebral artery and both A2 segments are
visible as well as all of the perforators from the
anterior communica ting artery.
3-27g Overview after the aneurysm has been

clippe d.
3-27h Postoperative angiogram demonstrates

obliteration of the aneurysm. The patient had no
postoperative deficits.
Case 3–28
Diagnosis: AComA aneurysm (rel. anatomy: pp 19, 27-31, 44)
3-28a and b Left anteroposterior and

oblique internal carotid artery angiograms
demonstrate the anterior communicating
artery aneurysm.
3-28c Through a left pterional a pproa ch,

the dome of the aneurysm is identified. The
recurrent artery of Heubner lies adjacent to
the left A1 segment, and the origin of the A2
segment is visible.
3-28d Using a right-angle aperture clip, the 3-28e Final operative view shows comple te 3-28f Late follow-up anteroposterior
base of the aneurysm is occlude d. A sec occlusion of the aneurysm by three clips and angiogram confirms complete occlusion of
ondary clip is inserted below a frontopolar preservation of the recurrent artery of Heub- the aneurysm.
branch for reinforcement. ner and the left frontopolar bra nch.
Case 3–29
Diagnosis: AComA aneurysm (rel. anatomy: pp 28-30, 44)
3-29a Right oblique internal ca rotid artery 3-29b Angiogram after obliteration of the 3-29c Six-month follow-up angiogram
angiogram demonstrates an anterior commu aneurysm with GDC coils. demonstrates continue d obliteration of the
nicating artery aneurysm. anterior communica ting artery aneurysm.
198 Ane urys ms of the Bra in
Case 3–30
Diagnosis: Pericallosal aneurysm (rel. anatomy: pp 31, 32)
Approach: Interhemispheric with clipping (rel. approach: p 75)
3-30a Lateral internal carotid artery 3-30b Through an interhemispheric 3-30c Higher magnification view visualizes
angiogram shows a right pericallosal a pproa ch, the aneurysm is e xpose d. the neck of the aneurysm.
aneurysm at the bifurcation of the callosal
and pericallosal marginal branches.
3-30d Two clips placed at the neck of the 3-30e Postoperative angiogram shows
aneurysm spare A2, the pericallosal, and the good visualization of A2, the pericallosal, and
callosomarginal branches. callosomarginal branches. The aneurysm is
oblitera te d.
Case 3–31
Diagnosis: Fusiform pericallosal callosomarginal aneurysm (rel. anatomy:
pp 31, 32)
Approach: Interhemispheric with wrap clipping (rel. approach: p 75)
3-31a Internal carotid artery angiogram shows

an ectatic pericallosal aneurysm.
3-31b The aneurysm is e xpos e d.
3-31c Muslin is wra ppe d around the aneurysm.

3-31d The muslin is wra ppe d snugly around the

aneurysm, and a clip is placed across the length of
the muslin obliterating the aneurysm.
3-31e Postoperative angiogram shows

good obliteration of the aneurysm.
Case 3–32
Diagnosis: Mycotic aneurysm of the distal pericallosal artery (rel. anatomy:
p 31)
Approach: Interhemispheric with aneurysm resection and reanastomosis
(rel. approach: p 75)
3-32a CT scan demonstrates subarachnoid

hemorrhage conce ntra te d in the region of the cor
pus callosum.
3-32b A lateral internal carotid artery angiogram

demonstrates a small mycotic aneurysm (a rrow)
along the pericallosal bra nch.
3-32c Exposure of the callosomarginal artery

reveals an aneurysm that involves the entire arterial
wall.
3-32d The aneurysm is resected, and an e nd-to-

end anastomosis is performe d.
3-32e Postoperative angiogram reveals patency

of the pericallosal bra nch.
Case 3–33
Diagnosis: Giant left fusiform aneurysm on the ACA (A 2 segment)
(rel. anatomy: pp 30, 31, 43, 44)
Approach: Bifrontal interhemispheric with trapping of aneurysm
and side-to-side anastomosis of pericallosal arteries
3-33a CT scan reveals a giant aneurysm. 3-33b and c Angiograms demonstrate a

fusiform aneurysm in a patient who present
ed with intermittent ischemic s ymptoms
involving the right lower extremity.
3-33d The distal segment of the aneurysm is vis

ible as it emerges from the aneurysm and divides
into pericallosal and callosomarginal branches. A
thrombus can be seen within the lumen of the
artery.
3-33e A clip applied on A2 tra ps the aneurysm

distally. A2 has been divided and the extruding
thrombus is visible.
3-33f Once the thrombus is removed, back-

bleeding occurs .
3-33g The two pericallosai arteries are placed

side to side and temporarily occlude d using ba rbi
turate prote ction.
3-33h A s ide -to-s ide anastomosis is performe d.
3-33i and j Postopera

tive anteroposterior and
lateral angiograms reveal
obliteration of the
aneurysm and filling of the
territories of both distal
anterior cerebral arteries.
Case 3–34
Diagnosis: MCA bifurcation aneurysm (rel. anatomy: pp 32-36)
3-34a Anteroposterior angiogram de mon 3-34b Selective angiogram reveals the

strates middle cerebral artery bifurcation close proximity of one of the middle cerebral
aneurysm. artery branches to the aneurysm.
3-34d After the right Sylvian fissure has

been split, the middle cerebral artery and
bifurcation are visible.
3-34c CT angiogram de picts a similar

situation.
3-34e The neck of the aneurysm is 3-34f A clip is placed across the neck of 3-34g Postoperative angiogram reveals
exposed as it arises from the bifurcation. the aneurysm and the dome deflated. obliteration of the middle cerebral artery.
Case 3–35
Diagnosis: Right MCA bifurcation aneurysm (rel. anatomy: pp 32-36)

angiograms of the right internal carotid artery
demonstrate a middle cerebral artery aneurysm.
3-35c After the Sylvian fissure has been split,

the aneurysm is visible. A small perforating vessel
is adherent to the neck of the aneurysm.
3-35d With further disse ction, the distal neck of

the aneurysm becomes clear.
3-35e A 9-mm clip has been applied across the

base of the aneurysm, which is then de flate d. Note
the preservation of the perforating bra nch, which
was dissected from the neck of one aneurysm. The
aneurysm has been rotate d, exposing the posterior
aspect of the middle cerebral artery bifurcation.
3-35f A se cond clip obliterates a portion of the

aneurysm neck.
3-35g and h Postoperative lateral and oblique

angiograms reveal obliteration of the aneurysm with
preservation of the middle cerebral artery branches.
Case 3–36
Diagnosis: Aneurysm on distal branch of the left MCA (rel. anatomy:
pp 34-36)
3-36a and b MR images reveal a small

vascular mass in the insula.
3-36c After the distal Sylvian fissure has 3-36d The aneurysm is exposed comple te 3-36e The aneurysm is excluded from the
been opened completely, the aneurysm is ly. circulation with two small temporary clips and
visible on one of the insular branches of the ope ne d.
middle cerebral artery.
3-36f The aneurysm is deflated and a por

tion of the dome is re s e cte d.
3-36g A combina tion of ta nde m clips obliterates

the neck of the aneurysm to preserve flow through
the parent vessel.
3-36h Intraoperatively, a microDoppler flow

probe is used to verify patency of the parent
vessel.
Case 3–37
Diagnosis: Left peripheral MCA aneurysm (rel. anatomy: pp 34-36)
Approach: Left pterional (Sylvian) with clipping (rel. approaches:
pp 80, 82-85)
3-37a and b Left anteroposterior and

oblique angiograms demonstrate the
aneurysm.
3-37c and d Superselective injection close

to the bifurcation of M2 and M3 . The flow of
the dye simulates an intact vessel wall and a
small neck. Further advancement of the
microcatheter and dye injection reveals a
broad aneurysm neck tha t makes endovas-
cular treatment impossible.
3-37e After the Sylvian fissure has been 3-37f The broad aneurysm neck is closed 3-37g Surgical perspective after successful
ope ne d, the aneurysm is e xpos e d. The with two angled clips that are moved aside clipping.
microsurgical perspective proves the to visualize the clip location.
microangiographical aspect (Figs. c and d).
3-37h Postoperative angiogram reveals

excellent clipping of the aneurysm.
Case 3–38
Diagnosis: Right mycotic MCA aneurysm (rel. anatomy: pp 32-36)
3-38a The right Sylvian fissure is e xpos e d, 3-38b A clip has been applied to the neck 3-38c Before the resection of the
and the Sylvian ciste rn is partially ope ne d, of the aneurysm. The mycotic nature is aneurysm, it is being mobilized to visualize
revealing the middle cerebral artery. apparent in the abnormal consistency of the the underlying branches.
aneurysm.
Case 3–39
Diagnosis: Large fusiform aneurysm on the left MCA (rel. anatomy: pp 32-36)
Approach: Left pterional with clip reconstruction of MCA (rel. approaches:
pp 80, 82-85)
3-39a Contrast-enhance d CT scan

demonstrates a fusiform aneurysm of the left
3-39b and c Anteroposterior and oblique

angiograms of the left internal ca rotid artery
demonstrate a fusiform aneurysm of the left
3-39d Through a left Sylvian split, the left internal

ca rotid artery becomes visible.
3-39e After the Sylvian fissure is opened com

pletely, the fusiform aneurysm is e xpos e d.
3-39 f Clips applied along the length of the

aneurysm reconstruct the left middle cerebral
artery.
3-39g A clip is applied to a s econd fusiform

aneurysm on one of the left middle cerebral artery
branches.
3-39h Overview diagram clarifies clip placement

(courte s y of Ba rrow Ne urologica l Ins titute ).
3-39i, j, and k Multiple angiographic views

of the left internal carotid artery demonstrate
obliteration of the aneurysm with preservation
of the involved arteries.
Case 3–40
Diagnosis: Right giant MCA aneurysm (rel. anatomy: pp 32-36)
Approach: Right pterional with excision of aneurysm and parent-vessel
reconstruction (rel. approaches: pp 80, 82-85)
3-40a CT scan reveals a large mass com

patible with a giant aneurysm of the middle
cerebral artery.
3-40b and c Right anteroposterior and lat

eral internal ca rotid artery angiograms
demonstrate the filling portion of the middle
cerebral artery aneurysm. An incidental oph
thalmic artery aneurysm is present.
3-40d After the Sylvian fissure has been split, the

middle cerebral artery branches involved with the
aneurysm become visible.
3-40e Temporary clips are applied proximal and

distal to the neck of the aneurysm.
3-40f and g The tra ppe d aneurysm is ope ne d, exposing

a large amount of thrombus .
3-40h The aneurysm dome and the involved por

tion of the middle cerebral artery have been resect
ed except for a portion of the dome that is firmly
adherent to an adjacent branch of the middle cere
bral artery. The two ends of the middle cerebral
artery are visible in the fie ld.
3-40i The aneurysm specimen shows multiple

laminations, which are common in giant
aneurysms. The pathological specimen nicely
demonstrates the cause of the ischemic s ymptoms
from which the patient suffered.
3-40 j After mobilization of the middle cerebral

artery branches, the cut ends of the artery are
anastomosed e nd-to-e nd with 10-0 suture.
3-40k and I Postoperative anteroposterior and

lateral angiograms demonstrate patency through
the reanastomosed middle cerebral artery bra nch.
The incidental ophthalmic artery aneurysm has
been obliterated with a clip.
Case 3–41
Diagnosis: Giant fusiform aneurysm of the left MCA (rel. anatomy:
pp 34-36)
Approach: Left pterional with excision of aneurysm and parent-vessel
reconstruction (rel. approaches: pp 80, 82-85)
3-41a MR image reveals a giant middle

cerebral artery aneurysm tha t has largely
thrombos e d.
3-41b and c Anteroposterior (b, le ft),

oblique (b, right), and lateral angiograms (c)
demonstrate the complex middle cerebral
artery aneurysm.
3-41 d Opening the Sylvian fissure demonstrates

the middle cerebral artery and a branch firmly
adherent to the wall of the aneurysm.
3-41e Further exposure of the aneurysm reveals

the branch entering the aneurysm.
3-41f Temporary clips applied proximally and dis -

tally tra p the aneurysm. The aneurysm is being
resected, along with the involved artery.
3-41g The cut ends of the vessel have been

a na stomos ed.
3-41h Pathological specimen shows the

entry and exit of the middle cerebral artery
vessel.
3-41 i and j Postoperative angiograms

demonstrate patency of the anastomosed
vessel.
Case 3–42
Diagnosis: Left giant MCA aneurysm (rel. anatomy: pp 34-36)
Approach: Left pterional with trapping of aneurysm and anterior
temporal artery-to-MCA bypass (rel. approaches:
pp 80, 82-85)
3-42 a and b MR images

reveal a large mass in the ter
ritory of the left middle cere
bral artery in a 17-year-old
patient who presented with
transient ischemic attacks
and a small stroke. Figure a,
re printe d with pe rmis s ion of
J ourna l of Ne uros urge ry.
3-42c Anteroposterior angiogram de mon 3-42d Lateral angiogram demonstrates the

strates severe stenosis along the left middle delayed filling of the middle cerebral artery
cerebral artery proximal to the bifurcation. territory. Re printe d with pe rmis s ion of J ourna l
of Ne uros urge ry.
3-42 e The left Sylvian fissure has been split,

exposing the distal end of the aneurysm. The anteri
or temporal bra nch, which arises proximal to the
aneurysm, is visible in the Sylvian fissure.
3-42f With temporary occlusion of the anterior

te mporal branch and a middle cerebral artery
branch distal to the aneurysm, the vessels are pre
pared for a s ide -to-s ide anastomosis.
3-42g The back wall of the anastomosis is com

ple te d.
3-42h The front wall of the anastomosis is com

ple te d.
3-42i When the te mpora ry clips are released,

patency of the anastomosis is appa rent.
3-42j Immediate (le ft) anteroposterior pos t

operative angiogram de mons tra te s filling of
the distal middle cerebral artery branches
through the anterior te mpora l anastomosis
(arrow). One month later (right), a repeat
angiogram de monstra te s dilation of the a nte
rior te mpora l bra nch. Re printe d with pe rmis -
s ion of J ourna l of Ne uros urge ry.
3-42k Lateral postoperative angiogram

now demonstrates rapid filling of the middle
cerebral artery. The patient has had no further
ischemic events during a 5-year follow-up.
3-42l Five-year follow-up angiogram

demonstrates continued patency of the
bypass with excellent filling of the left middle
cerebral artery territory.
3-42m Schematic illustration of anterior tempora l

artery-to-middle cerebral artery s ide -to-s ide bypass.
Re printe d with pe rmis s ion of J ourna l of Ne uros urge ry.
Case 3–43
Diagnosis: Left giant MCA aneurysm (rel. anatomy: pp 32-36)
Approach: Left pterional with neck reconstruction and STA-to-
MCA bypass (rel. approaches: pp 80, 82-85)
3-43a CT scan shows a large mass in the

left Sylvian fissure.
3-43b and c Anteroposterior and oblique

views of the left internal ca rotid artery injec
tion reveal a complex left middle cerebral
artery aneurysm.
3-43d After the Sylvian fissure has been split, a

giant aneurysm involving the major trunk of the
middle cerebral artery just distal to the branch of
the tempora l artery is visible.
3-43e While the middle cerebral artery branch is

temporarily occlude d, the aneurysm is exposed fur
ther.
3-43f Close-up view after the aneurysm was

opened and the thrombus removed. The proximal
and distal middle cerebral artery orifices are visible.
3-43g Direct middle cerebral artery reconstruc

tion caused a thrombus to form, occluding the
middle cerebral artery. Therefore, the distal portion
of the middle cerebral artery was reconstructed
with suture (10–0), and the remainder of the
aneurysm neck was occlude d proximally and dis -
tally. A superficial tempora l a rtery-to-distal middle
cerebral artery bypass was used to perfuse the dis
tal middle cerebral artery.
Ane urysms–Ante rior Circula tion 235
3-43h Rotating the distal reconstructed middle

cerebral artery reveals a large perforating branch
tha t is perfused by retrograde flow through the
superficial te mporal artery.
3-43i and j Anteroposterior and lateral

angiograms demonstrate good filling of the
left anterior te mporal artery through the inter
nal carotid artery. The remaining middle ce re
bral artery branches fill through the superficial
temporal artery bypass.
Case 3–44
Diagnosis: Fusiform aneurysm of the left MCA with mass effect
(rel. anatomy: pp 34-36)
Approach: Left frontoparietal craniotomy with STA-to-MCA bypass
and endovascular (rel. approach: p 72)
3-44a and b MR images demonstrate

mass effect from a fusiform aneurysm on the
left middle cerebral artery. This probable dis
secting aneurysm had been followe d for 7
years with recent growth over a 6-month
pe riod. The patient's symptoms included fluc
tuating periodic aphasia.
3-44c Angiogram demonstrates a fusiform

vessel in the distribution of the left middle
cerebral artery.
Ane urysms –Ante rior Circula tion 237
3-44d , e , and f A superficial tempora l a rte ry-to-

middle cerebral artery bypass is performed on the
distal segment of the middle cerebral artery
involved with the aneurysm.
3-44g Selective injection of the external 3-44h Selective catheterization of the mid 3-44i Postoperative internal carotid artery
vessels on the left demonstrates patency of dle cerebral artery branch involved in the angiogram demonstrates the absence of the
the bypass. aneurysm is performed. Coils were placed aneurysm. The patient had no neurologic
into the vessel until it was obs tructe d com deficit.
pletely.
Case 3–45
Diagnosis: Giant serpentine MCA aneurysm (rel. anatomy:
pp 32-36)
Approach: Left pterional, two-stage, with STA-to-MCA bypass and
aneurysmorrhaphy with clipping and trapping
3-45a MR image demonstrates a giant ser

pentine middle cerebral artery aneurysm in a
14-year-old boy who was asymptomatic
except for headaches.
3-45b CT scan with contrast demonstrates

some of the serpentine characteristics of this
aneurysm. Re printe d with pe rmis s ion of J our-
na l of Ne uros urge ry.
3-45c Left lateral internal ca rotid artery

angiographic injection reveals very slow filling
of the large middle cerebral artery aneurysm
with serpentine channel.
3-45d Anteroposterior angiographic injec

tion demonstrates tha t the bulbus portion of
the middle cerebral artery aneurysm has
been shifted far to the right, with a serpentine
channel coursing through the large throm
bosed aneurysm tha t feeds the distal middle
cerebral artery branches (arrow). Re printe d
with pe rmis s ion of J ourna l of Ne uros urge ry.
3-45e After the Sylvian fissure has been split, the

distal end of the middle cerebral artery aneurysm is
exposed and one of the two branches exiting from
the aneurysm is visible.
3-45f One of the two middle cerebral artery

branches has been sectioned and anastomosed to
one branch of the superficial temporal artery. The
other branch of the superficial tempora l artery is
being prepared for the se cond anastomosis.
3-45g Close-up view of the anastomosis

between the superficial tempora l artery branch and
the distal left middle cerebral artery branch.
3-45h The s econd anastomosis is comple te d.

The two aneurysm clips occlude the cut ends of
the middle cerebral artery branches as they exit the
aneurysm.
3-45i Overview of the double-barrel bypass

to the middle cerebral artery branches.
3-45j Postoperative
angiogram of the left internal
carotid artery demonstrates
continued filling of the bulbus
portion of the middle cerebral
artery aneurysm. The s e rpe n
tine portion no longer fills.
Re printe d with pe rmis s ion of
3-45k During a se cond-stage

procedure 1 week later, the
aneurysm was exposed and
incised. The two aneurysm
clips placed during the first
stage were removed and the
anastomosis (a rrow) is s hown.
3-45l Debulking creates sufficient room to

expose the internal carotid artery and its bifurca
tion.
3-45m After the aneurysm has been debulked

and the aneurysmal wall re tra cted, the internal
carotid artery and its bifurcation are visible.
3-45n With further dis se ction, the anterior cere

bral artery and the proximal middle cerebral artery
be come visible.
3-45o A clip is applied across the middle cere

bral artery at the base of the aneurysm just distal to
the perforating branches, which have been carefully
preserved.
3-45p The aneurysm is debulked further, leaving

the wall of the aneurysm undis turbe d.
3-45q A large gaping hole is visible where the

thrombus has been removed from within the
aneurysm. The previously performed bypass is vis i-
3-45r Left internal carotid artery angiographic injection reveals filling of

the proximal middle cerebral artery and its perforators. Re printe d with
pe rmis s ion of J ourna l of Ne uros urge ry.
3-45s Left lateral internal carotid artery angiogram demonstrates

preservation of the middle cerebral artery perforators and a clip at the
base of aneurysm (a rrow). Re printe d with pe rmis s ion of J ourna l of Ne uro-
s urge ry.
3-45t An external carotid artery angiographic injection demonstrates

the double-barrel bypass (a rrow) filling the left middle cerebral artery te rri
tory. This patient had no postoperative neurological deficit and has been
free of headaches for 4 years. Re printe d with pe rmis s ion of J ourna l of
Ne uros urge ry.
Ane urys ms–Ante rior Circula tion 245
Case 3–46
Diagnosis: Left MCA aneurysm (rel. anatomy: pp 34-36)
3-46a Left internal carotid artery

angiogram demonstrates a middle cerebral
artery aneurysm with a small neck.
3-46b The aneurysm is obliterated with

GDC coils.
3-46c S ix-month follow-up left internal

carotid artery angiogram reveals continued
obliteration of the aneurysm.
3-46d Twelve-month follow-up angiogram

reveals continue d obliteration of the
aneurysm.
Case 3–47
Diagnosis: Giant left MCA aneurysm (rel. anatomy: pp 32-36)
Approach: STA bypass and MCA balloon occlusion
3-47a MR image demonstrates a giant left

middle cerebral artery aneurysm.
3-47b and c Left anteroposterior and later

al angiograms demonstrate the giant middle
cerebral artery aneurysm with a small satellite
aneurysm. The drawing illustrates the positior
of an occlusive detachable balloon jus t before
entering the aneurysm. This M1 occlusion
was done after a left extracranial-intracranial
bypass operation performed 1 week previ
ously.
3-47d and e Postocclusion angiograms

reveal the total occlusion of the giant
aneurysm. The middle cerebral artery territory
is supplied via the extracranial-intracranial
bypass; the satellite aneurysm is filled via ret
rograde flow.
3-47f Six-month follow-up MR image

demonstrates complete thrombosis of the
aneurysm.
3-47g and h A 1 -year follow-up angiogram

demonstrates the permanent and total occlu
sion of the giant aneurysm and the satellite
aneurysm and perfect filling of the middle
cerebral artery territory by the extracrania l-
intracranial bypass.
An e u rys m s —P o s te rio r Circ u la tio n

Ca s e 3–48
Diagnosis: Basilar tip aneurysm (rel. anatomy: pp 18-21, 30, 37-39, 41, 43,
44, 51, 59)
Approach: Right orbitozygomatic with clipping (rel. approaches: pp 88-91)
3-48a CT scan demonstrates extensive

subarachnoid hemorrhage from a ruptured
basilar artery aneurysm.

angiograms demons trate the basilar tip
aneurysm, riding high above the posterior
clinoid.
3-48d The craniotomy flap has been reflected.

The temporalis muscle is divided and elevated,
leaving a cuff for later reattachment.
Ane urys ms –P os te rior Circula tion 249
3-48e The lateral orbit and the zygomatic

process are e xpos e d. The fat pa d, which prote cts
the frontalis branch of the facial nerve, is preserved
on the side of the scalp fla p.
3-48 f The pterional craniotomy is comple te . The

orbital roof and zygoma are e xpose d.
3-48g The zygomatic bone is cut using the

Midas Rex® drill (Midas Rex Pneumatic Tools,
Inc., Fort Worth, TX). An oscillating saw is pre
ferred.
3 -4 8 h With the pe riorbita re tra cte d, the orbita l

roof is re move d.
3-48i The dura is used to retract the orbit, and

the Sylvian fissure is e xpose d. Notice the additional
exposure gained from the orbitozygomatic
approach.
3-48j The posterior clinoid obscures the base of

the aneurysm.
3-48k The posterior clinoid is being removed

with the diamond drill. Remember that the internal
ca rotid artery may erode the base of the posterior
clinoid when drilling.
3-48l With the posterior clinoid removed, the

base of the aneurysm is visible.
3-48m A clip has been placed across the neck

of the aneurysm. The superior cerebellar and both
posterior cerebral arteries are visible. Great care
must be ta ken so that no perforators from the P1
segments are caught within the clip.
3-48n and o Postoperative angiograms de mon

strate that the basilar artery aneurysm has been
eliminated. A se cond clip is visible on an incidental
posterior communicating artery aneurysm.
Case 3–49
Diagnosis: BA aneurysm (rel. anatomy: pp 18-21, 30, 37-39, 41, 43,
44, 51, 59)
Approach: Right orbitozygomatic between CN II and ICA with
clipping (rel. approaches: pp 88-91)
3-49a Lateral vertebral artery angiogram

shows a basilar artery aneurysm in associa
tion with a large posterior cerebral artery that
fe d an arteriovenous malformation.
3-49b Through a n orbitozygomatic a pproa ch,

the optic nerve, internal carotid artery, and tip of
the aneurysm are e xpos e d.
3-49c With further disse ction, the internal carotid

artery and posterior communicating artery are
retracted laterally, exposing the lateral portion of
the aneurysm dome .
3-49d After further microsurgical dissection, the

entire aneurysm is visible between the optic nerve
and the internal carotid artery.
3-49e A clip has been applied to the base of the

aneurysm eliminating it from circulation.
3-49f Postoperative angiogram shows clip

ping of the aneurysm.
Case 3–50
Diagnosis: Giant BA aneurysm (high riding) (rel. anatomy:
pp 18-21, 30, 37-39, 41, 43, 44, 51, 59)
Approach: Right orbitozygomatic with clipping under hypothermic
circulatory arrest (rel. approaches: pp 88-91)
3-50a Lateral angiogram demonstrates a giant

basilar artery aneurysm far above the posterior cli-
noid process.
3-50b The patient is dra pe d for the craniotomy

and hypothermic circulatory arrest with access to
both groins as well as to the chest.
3-50c The scalp has been retracted along with

the fat pad to protect the frontalis branch of the
facial nerve. The temporalis muscle has been ele
va te d.
3-50d The pterional craniotomy is comple te d.
3-50e After the orbitozygomatic approach is

comple te d, the frontal and tempora l fossae and the
orbit are visible.
3-50f After the Sylvian fissure has been split, the

internal ca rotid artery, middle cerebral artery, anteri
or cerebral artery, and posterior clinoid process are
visible.
3-50g By dissecting the arachnoid planes along

the course of the anterior choroidal artery, the
exposure of the basilar artery comple x is ma xi
mized.
3-50b The catheters are inserted into the femoral

artery and vein in preparation for hypothermic cir
culatory arrest.
3-50i The heart a nd lung machine is now used

to s upport the circulation during active cooling of
the patient.
3-50j Under hypothermic circulatory arrest, the

vessels are collapsed and the basilar artery is
retracted downwa rd, allowing the clip to be applied
to the neck of the aneurysm.
3-50k Reclosure of the craniotomy site with

microplates and reapproximation of the temporalis
muscle.
3-50l and m Postoperative angiograms de mon

strate elimination of the aneurysm and preservation
of the normal vasculature.
Case 3–51
Diagnosis: Giant BA aneurysm associated with an AVM
(rel. anatomy: pp 18-21, 30, 37-39, 41, 43, 44, 51, 59)
Approach: Right orbitozygomatic with clipping of aneurysm under
hypothermic circulatory arrest (rel. approach: pp 88-91)
3-51a and b Two midline sagittal MR images

performed 2 years apart in the same patient show
dramatic growth of a basilar artery aneurysm. This
patient presented with progressive brainstem dys
function. Before the imaging study, it wa s assumed
that the arteriovenous malformation had hemor
rhaged.
3-51c and d Lateral vertebral artery angiographic

injections performed 2 years apart show the dra
matic growth of the basilar artery aneurysm. The
smaller posterior cerebral artery aneurysm has not
grown.
3-51e Through a right orbitozygomatic 3-51f During a brief period of hypothermic

a pproa ch, the aneurysm is e xpos e d. Both circulatory arrest, the perforators can be dis
posterior cerebral arteries and the perforating sected safely from the dome of the
branches are visible. aneurysm, allowing a clip to be applied
across the neck of the aneurysm.
S upe rior
ce re be lla r
a rte ry
3-51g and h Postoperative angiograms

reveal obliteration of the giant basilar artery
aneurysm. The patient's arteriovenous malfor
mation was resected at a later date.
Case 3–52
Diagnosis: Giant BA aneurysm (rel. anatomy: pp 17-21, 37-39, 41,
43-45, 51, 59)
Approach: Right subtemporal with clipping and hypothermic
circulatory arrest (rel. approach: p 93)
3-52a MR image reveals a giant basilar 3-52b and c Anteroposterior and lateral
artery aneurysm indenting the midbrain. vertebral artery angiograms demonstrate
giant basilar artery aneurysm.
3-52d and e Position of the patient on the opera ting-

room ta ble .
3-52f Fish-hook retraction of the temporalis mus

cle interiorly and anteriorly exposes the root of the
zygomatic process.
3-52g A temporal craniotomy is performed using

the Midas Rex® drill.
3-52h The lateral tempora l wall and root of the

zygoma are drilled down to the floor of the te mpo
ral fossa.
3-52i The removal of the base of the temporal

fos sa along with the zygomatic process gives a flat
approach to the temporal fossa.
3-52 j After the dura has been ope ne d, the floor

of the temporal fossa is visible. This approach
remains an excellent choice for basilar artery
aneurysms. However, the wide exposures obtained
through the orbltozygoma tic a pproa ch—with its
advantages of being able to clip associated
aneurysms of the anterior circulation as well as
minimizing trauma to the oculomotor nerve—make
it the senior author's preferred exposure for basilar
aneurysms.
3-52k The edge of the te ntorium, the trochlear

nerve, and the ambient cistern are visible.
3-52l The oculomotor nerve and ipsilateral pos

terior cerebral artery with its perforators are
e xpos e d.
3-52m After the tentorium has been cut and its

edge retracted with a suture, the basilar artery and
both posterior cerebral arteries are visible.
3-52n The posterior communica ting artery, as it

enters the posterior cerebral artery, is visible by
angling the microscope.
3-52o and p Hypothermic circulatory arrest is ini

tia te d through a transfemoral a pproa ch.
3-52q and r The clip is applied across the base

of the aneurysm, preserving the perforating bra nch
es.
3-52s and t Anteroposterior and lateral

vertebral artery angiograms demons tra te
elimination of the aneurysm and preservation
of the normal branches.
Case 3–53
Diagnosis: Giant calcified and thrombosed BA aneurysm
(rel. anatomy: pp 18-21, 30, 37-39, 41, 43, 44, 51, 59)
Approach: Right orbitozygomatic with Hunterian ligature and
aneurysmorrhaphy and second stage subtemporal
approach (rel. approaches: pp 88-91)
3-53a , b, and c MR images demonstrate

giant thrombos e d basilar artery aneurysm
with a flow defect. The patient presented with
progressive quadriparesis.
3-53d Anteroposterior vertebral artery

angiogram shows only a minor portion of the
giant basilar artery aneurysm. The left supe ri
or cerebellar artery (arrow) is draped around
the mass of the aneurysm.
3-53e Through a n orbitozygomatic a pproa ch,

the base of the aneurysm is e xpos e d. The superior
cerebellar artery and the posterior cerebral artery
are emerging from the aneurysm.
3-53g Despite hypothermic circulatory arrest, no

aneurysmal neck could be created for safe clip
ping.
3-53h A Hunterian tourniquet is placed around

the basilar artery proximal to the aneurysm.
3-53i Vertebral artery angiogram with ligature

closed 90% shows that the filling of the basilar
artery aneurysm has been eliminated.
3-53j Six weeks later through an anterior s ub

temporal a pproa ch, the aneurysm is de bulke d.
3-53k Thrombus is seen within the wall of the

aneurysm.
3-53l The debulked aneurysm.

Case 3–54
Diagnosis: BA aneurysm, regrowth after endovascular treatment
(rel. anatomy: pp 18-21, 30, 37-39, 41, 43, 44, 51, 59)
Approach: Right orbitozygomatic with clipping (rel. approaches:
pp 88-91)

vertebral artery angiograms show regrowth of
basilar artery aneurysm with compa ction of
the coils.
3-54c Through an orbitozygomatic a pproa ch,

the internal carotid artery is e xpos e d.
3-54d Coils are visible through the wall of the

aneurysm. One coil has migrated through the wall
of the aneurysm.
3-54e A clip is placed across the neck of the

aneurysm.
3-54f Overview shows the clippe d aneurysm as

well as the internal and middle cerebral arteries and
the optic nerve.
3-54g and h Postoperative angiograms

demonstrate good obliteration of the
aneurysm.
Case 3–55
Diagnosis: Basilar tip aneurysm (rel. anatomy: pp 19, 37-39, 41, 59)

vertebral artery angiograms demonstrate a
basilar tip aneurysm. This 69-year-old female
who presented with a subarachnoid hemor
rhage, was a poor operative risk a nd the re
fore was selected for treatment with GDC
coils.
3-55c and d The transfemoral route was

not possible. Exposure of the vertebral artery
in the neck allowed insertion of the catheter,
which was the n navigated to the base of the
aneurysm. The aneurysm was coiled to the
point of obliterating the dome .
3-55 e and f Twelve-month follow-up ve rte

bral artery angiograms after placement of the
GDC coils demonstrate continued obliteration
of the dome of the aneurysm with some
residual base.
Case 3–56
Diagnosis: Basilar tip aneurysm (rel. anatomy: pp 19, 37-39, 41, 59)

basilar tip aneurysm in this 80-year-old
patient who presented with a subarachnoid
hemorrhage.
3-56c and d Immediate follow-up

angiograms demonstrate good obliteration of
the dome of the aneurysm, with preservation
of both posterior cerebral arteries.
3-56 e and f S ix-month follow-up

angiograms demonstrate continue d oblitera
tion of the aneurysm.
Case 3–57
Diagnosis: Left PCA aneurysm (rel. anatomy: pp 21, 37, 46, 51, 52)

angiograms demonstrate a giant posterior
cerebral artery aneurysm arising on the left
P2 segment in a patient who presented with
progressive hemiparesis from mass effect.
This obese patient was considered a poor
surgical risk and therefore was treate d with
GDC coils.
3-57c and d The aneurysm is loosely

packed with GDC coils to avoid further bra in
stem compre ssion.
3-57e and f Six-month follow-up

tion of most of the aneurysm.
3-57g and h Twelve-month follow-up

angiograms reveal no increase in the size of
the residual filling.
Case 3–58
Diagnosis: Left PCA aneurysm (rel. anatomy: pp 42, 46, 47, 52)
3-58a and b Lateral and oblique vertebral

artery angiograms demonstrate a left P3 seg
ment aneurysm in a patient who presented
with subarachnoid hemorrhage.
3-58c and d Angiograms performed before

embolization demonstrate the growth of the
aneurysm 3 weeks after the angiograms in
Figures a and b were pe rformed.
3-58e Superselective angiography demon

strates the catheter at the mouth of the
aneurysm. Note tha t the aneurysm is bilobu-
lated with the posterior cerebral artery form
ing part of the comple x. A balloon placed into
the posterior cerebral artery at this point
obliterated the artery and the aneurysm.
Ane urysms–Posterior Circula tion 279
3-58f and g Anteroposterior and lateral

skull radiographs demonstrate the position of
the balloon.
3-58h and i Six-month follow-up

angiograms demonstrate the reduction in the
size of the posterior cerebral artery with no
recurrence of the aneurysm.
3-58j Twelve-month follow-up angiogram

shows the continued absence of the
aneurysm. Also, note the marked diminution
of the posterior cerebral artery. The large ves
sel on the right is the superior cerebellar
artery.
Case 3–59
Diagnosis: Left superior cerebellar artery aneurysm (rel. anatomy:
pp 20, 37, 41, 51, 60)
3-59a and b Vertebral artery angiograms

demonstrate a superior cerebellar artery
aneurysm.
3-59c Through a left pterional a pproa ch,

the internal carotid artery is visualized.
3-59d After the membrane of Lilliequist is

ope ne d, the superior cerebellar artery and
aneurysm are visible.
3-59e With further dis se ction, the other 3-59f Overview demonstrates the location 3-59g Postoperative angiogram de mon
side of the neck of the aneurysm, which is of the clip in relation to the internal ca rotid strates obliteration of the aneurysm.
adjacent to the posterior cerebral artery, is artery. The optic nerve is covered with a cot-
seen. tonoid.
Case 3–60
Diagnosis: Right giant superior cerebellar artery aneurysm
(rel. anatomy: pp 37, 41, 45, 46, 51, 52, 60)
Approach: Right subtemporal with aneurysmorrhaphy and clip
reconstruction (rel. approach: p 93)
3-60a MR image demonstrates a giant

thrombos e d superior cerebellar artery
aneurysm.

angiograms demonstrate the superior cere
bellar artery aneurysm and absence of the
right superior cerebellar artery. This young
patient presented with ischemic s ymptoms
from the occlusion of the superior cerebellar
artery and progressive mass effect.
3-60d View of the thrombos e d superior cerebel

lar artery and oculomotor nerve through an anterior
subtemporal a pproa ch.
3-60e Higher magnification of the superior cere

bellar artery with thrombus within it.
3-60f Exposure of the thrombos e d aneurysm

with a temporary clip on the posterior cerebral
artery.
3-60g Close-up view of the proximal neck of the

aneurysm with a temporary clip on the posterior
cerebral artery.
3-60h The aneurysm dome was resected and

multiple clips are applied to close the aneurysm
neck.
3-60i and j Postoperative

angiograms demons trate the
elimination of the aneurysm. The
patient made an excellent recovery
and returned to her acting career.
Case 3–61
Diagnosis: Peripheral superior cerebellar artery aneurysm
(rel. anatomy: p 56)
Approach: Infratentorial supracerebellar craniotomy with resection
(rel. approaches: pp 118-120)

vertebral artery angiograms reveal a distal
superior cerebellar artery aneurysm. The e ti
ology of this aneurysm is uncertain. The
patient presented with hemorrhage.
3-61c The aneurysm, which was exposed

through the cerebellum, involves the entire vessel
wa ll.
3-61d The aneurysm, with its parent vessel, is

resected.
Case 3–62
Diagnosis: Upper basilar trunk aneurysm projecting inferiorly and anteriorly
(rel. anatomy: pp 19, 37, 38, 45, 51, 58-60)
Approach: Right subtemporal with clipping (rel. approach: p 93)
3-62a A lateral subtraction vertebral 3-62b The tentorium has been opened to 3-62 c Having exposed the upper third of
angiogram demonstrates a multilobulated allow exposure of the upper third of the basi the basilar artery, the aneurysm neck is
basilar aneurysm projecting inferiorly and lar artery. The retractor holds the oculomotor clippe d. Notice the aneurysm dome as it
anteriorly from the basilar artery. nerve exposing the posterior cerebral artery points towa rd the clivus.
as it curves around the midbrain. A large por
tion of the brainstem is e xpos e d. Here the
approach varies in tha t the exposure is
directed below the oculomotor nerve.
3-62d Postoperative subtraction angiogra

phy demonstrates the obliteration of the
aneurysm.
Case 3–63
Diagnosis: Large BA trunk aneurysm arising from below the
superior cerebellar artery (rel. anatomy: pp 19, 37-39,
41, 43, 51, 58-60)
Approach: Right orbitozygomatic transapical with clipping
(rel. approaches: pp 88-91, 93)
3-63a CT scan demonstrates s uba rach

noid hemorrhage from the ruptured basilar
artery aneurysm.
3-63b Lateral basilar artery angiogram

demonstrates the aneurysm arising from the
basilar artery below the superior cerebellar
artery but above the anterior inferior cerebel
lar artery.
3-63c The orbital roof and zygomatic process

are removed.
3-63d The frontal and tempora l dura and the

orbit are now visible.
3-63e After the Sylvian fissure has been opene d

widely, the optic nerve, internal carotid artery, and
tip of the basilar artery are visible.
3-63f The posterior clinoid is removed with a

diamond drill.
3-63g The neck of the aneurysm is visible as it

arises from the trunk of the basilar artery.
3-63h A clip is applied parallel to the basilar

artery.
3-63i The orbitozygomatic process is shown

before re-implantation.
3-63j Oblique vertebral artery angiographic injec

tion demonstrates obliteration of the aneurysm.
Case 3–64
Diagnosis: Upper basilar trunk aneurysm (rel. anatomy: pp 19, 37-39, 41,
43, 51, 58-60)
Approach: Left orbitozygomatic with clipping under hypothermic cardiac
arrest (rel. approaches: pp 88-91)
3-64a Angiograms demonstrate a large 3-64b An orbitozygomatic approach is

aneurysm tha t hemorrhaged in a 26-year-old performed with special care taken to sepa
female in her 10th week of pregnancy. The rate the fascia on the temporalis muscle on
patient presented with subarachnoid hemor the fat pad to protect the frontalis branch of
rhage as well as right hemiparesis, pre s um the facial nerve.
ably from compression and small vessel
occlusion.
3-64c Overview demonstrates the entire course

of the zygomatic process, which is being separated
from the soft t is s ue .
3-64d The zygomatic process is being de ta che d

from its tempora l insertion with an oscillating saw.
3-64e A miniplate is attached to the zygo

matic process. An appropriate hole is drilled
on the other side of the saw cut so that nor
mal anatomical alignment can be achieved
during re construction.
3-64f The temporalis muscle is retracted interior

ly to allow a pterional craniotomy to be performe d.
A cuff is left a tta ched to the bone of the temporal
muscle to permit its reattachment at the end of the
case.
3-64g The orbital roof is cut with the oscillating

saw.
3-64h After the orbital cut has been pe rforme d,

a miniplate is attached to the rim of the orbit
across the cut, and a drill hole is made on the
other side to allow anatomical realignment.
3-64i A cut is now made through the zygomatic

bone anterior to the lateral portion of the orbit.
3-64j To protect the orbital contents, the saw

plate is inserted at the level of the inferior orbital
fissure in the orbit so that the cut can proceed
laterally.
3-64k Another miniplate is attached across the

saw cut before the orbitozygomatic process is
removed.
3-64l The cut is made along the superior orbital

fissure.
3-64m The resected bone is removed.
3-64n The floor of the anterior tempora l fossa is

flattened with a drill.
3-64o The superior orbital fissure is e xpos e d.

3-64p The dura is opened and used to retract

the orbital conte nts .
3-64q After the Sylvian fissure has been ope ne d,

the internal carotid artery and its bifurcation are
e xpos e d.
3-64r By focusing between the internal carotid

artery and the optic nerve at an angle, the surgeon
can visualize the hypophyseal stalk.
3-64s The top of the basilar artery is visible along

with the proximal neck of the aneurysm
.
3-64t After further disse ction, the superior cere

bellar artery and its relationship to the basilar artery
and aneurysm are apparent.
3-64u The contralateral oculomotor nerve is visi

ble between the contralateral posterior cerebellar
artery and superior cerebellar artery.
3-64v While the patient is under hypothermic cir

culatory arrest, the aneurysm is clippe d.
3-64w Retracting the dome of the aneurysm lat

erally allows visualization of the distal basilar artery
with the clip sparing the perforator.
3-64x The orbital roof and zygomatic process

have been replaced and fastened with the mini-
plates.
3-64y After the temporalis muscle has been

retracted anteriorly, the craniotomy is closed with
miniplates. The temporalis muscle is reattached to
its residual cuff on the craniotomy site, and the
scalp is reapproximated.
3-64z Postoperative angiogram de mon

strates obliteration of the aneurysm with
good patency of the basilar artery. The
patient recovered completely and delivered a
healthy infant.
Case 3–65
Diagnosis: Basilar trunk aneurysm (rel. anatomy: pp 58-61)

vertebral artery angiograms demonstrate the
aneurysm in the upper third of the basilar
trunk at a point of fenestration. This patient
presented with a cute subarachnoid hemor
rhage.
3-65c and d Immediate postoperative

angiograms demonstrate good coil place
ment in the dome of the aneurysm with
preservation of the parent vessel.
3-65e and f Six-month follow-up

tion of the aneurysm.
Aneurysms –P oste rior Circula tion 301
Case 3–66
Diagnosis: Angiographic occult aneurysm arising from a perforator
of the upper third of the B A (rel. anatomy: pp 19, 37-39,
41, 43, 58-61)
Approach: Right orbitozygomatic with clipping (rel. approaches:
pp 88-91)
3-66a CT scans shows subarachnoid

hemorrhage in the prepontine cistern. Several
weeks earlier the patient had experienced a
similar hemorrhage.
3-66b Anteroposterior angiogram fails to

demonstrate an aneurysm on the trunk of the
basilar artery. There is a hint of an aneurysm
arising from the posterior cerebral-posterior
communicating artery junction (a rrow).
3-66c and d Lateral and oblique

angiograms of the internal carotid artery give
further hints of an aneurysm (arrow) on the
posterior cerebral-posterior communicating
artery junction.
3-66e Through a right orbitozygomatic

a pproa ch, the entire posterior communicating
artery was exposed but no aneurysm was ide nti
fie d. However, 1 cm below the superior cerebellar
artery, a perforator from the basilar artery had an
associated thrombos e d aneurysm (a rrow).
3-66f A clip applied to the aneurysm preserves

he perforator.
3-66g Rostral to the aneurysm, the origins of the

superior cerebellar arteries and posterior cerebral
arteries can be seen. This case emphasizes the
need to maintain a high degree of suspicion for an
aneurysm when repeated hemorrhages are loca l
ized in the same region but angiography is nega
tive.
Case 3–67
Diagnosis: AICA aneurysm (rel. anatomy: pp 53, 57-62, 64)
Approach: Right combined retrolabyrinthine with clipping

vertebral artery angiograms demonstrate
aneurysm off the anterior inferior cerebellar
artery.
3-67c The combined approach with clips

on the sigmoid and superior petrosal sinuses.
Ne uros urge ry.
3-67e Postoperative angiogram de mon

strates elimination of the aneurysm.
3-67d The aneurysm is visible below the trige mi

nal, facial, and vestibulocochlear nerves. The a bdu
cent nerve drapes over the dome of the aneurysm.
The aneurysm was clippe d uneventfully. Re printe d
with pe rmis s ion from J ourna l of Ne uros urge ry.
3-67f CT scan demonstrates the bony

removal achieved with the combine d retro-
labyrinthine a pproach.
Aneurysms–Posterior Circula tion 305
Case 3–68
Approach: Right petrosal transcochlear with clipping
3-68a Lateral vertebral artery angiogram 3-68b Transpetrosal drilling exposes the
demonstrates a complex aneurysm of the sigmoid sinus and the dura of the middle
anterior inferior cerebellar artery. This patient and posterior fossae and outlines the bony
had a subarachnoid hemorrhage 2 days earli canal of the facial nerve.
er at another institution.
3-68c After the transpetrosal drilling has been completed

for a transcochlear approach, the facial nerve is visible, freed
from its bony canal. The bony protuberance over the jugular
bulb is visible, and the dura has been opened exposing the
subarachnoid hemorrhage overlying the aneurysm.
3-68d Under high-power magnification, the basi

lar artery, origin of the aneurysm, anterior inferior
cerebellar artery and abducent nerve are visible.
3-68e Medial to the origin of the anterior inferior

cerebellar artery, a small additional aneurysm is vis i
ble.
3-68g A clip is applied across the neck of the

aneurysm eliminating any flow through it.
3-68h An additional clip is placed across the

s e cond small aneurysm.
3.68i Lateral vertebral artery angiogram

demonstrates obliteration of the two aneurysms
of the anterior inferior cerebellar artery.
Case 3–69
Approach: Left petrosal translabyrinthine with clipping

large aneurysm of the anterior inferior cere
bellar artery.
3-69 c , d, e , and f Atte mpts a t coiling the

aneurysm resulted in loss of the anterior infe
rior cerebellar artery and an increase in neu
rological s ymptoms .
3-69 g, h, and i MR images demonstrate a

large thrombos e d aneurysm with brainstem
infarction (a rrows ) of the anterior inferior cere
bellar artery territory. The patient had a mild-
to-mode ra te neurological deficit.
3-69 j Through a modified left translabyrinthine

a pproa ch, the sigmoid sinus and the facial nerve
still within its canal are e xpos e d.
3-69k The facial nerve can be visualized within its

canal. This approach is a compromise between the
true transcochlear and the translabyrinthine
approaches. In this case, the sigmoid sinus was
preserved.
3-69l The aneurysm, the trigeminal nerve, and

the facial and vestibulocochlear nerves are visible.
The calcific nature of the aneurysm can be a ppre ci
a te d.
3-69m The proximal basilar artery and its pe rfo

rators are visible with the aneurysm retracted
upwa rd.
CN V
3-69n The distal basilar artery, dome of the

aneurysm, and the exit of anterior inferior cerebellar
artery are visible. Note the high-riding origin of the
anterior inferior cerebellar artery on the neck of the
aneurysm. ,
3-69o Postoperative lateral

angiogram demonstrates obliteration
of the aneurysm with two right-angle
clips placed parallel to the basilar
artery.
3-69p Anteroposterior vertebral

artery angiographic injection de mon
strates the preservation of the left
anterior inferior cerebellar artery. This
case emphasizes the danger of coil
ing wide -ba se d aneurysms because
perforating vessels te nd to originate
high on the neck of the aneurysm.
Case 3–70
Diagnosis: Lower trunk BA aneurysm (rel. anatomy: pp 58-64, 66)
Approach: Right far lateral with clipping under hypothermic circulatory
arrest (rel. approach: pp 109-113)
3-70a MR image demonstrates a large

basilar artery aneurysm compressing the
brainstem. The patient presented with pro
gressive compromise of the brainstem.
3-70b and c Oblique and lateral

angiograms demonstrate the aneurysm on
the lower third of the basilar artery.
3-70d Through a right far-lateral a pproa ch, the

vertebral arteries and basilar bifurcation are
e xpos e d.
3-70e With the patient under hypothermic circu

latory arrest, the aneurysm is collapsed exposing
the distal basilar artery.
3-70f Fenestrated clips allow closure of the distal

portion of the aneurysm. The clip blades are visible
at the junction of the aneurysm neck and proximal
basilar artery.
3-70g The remainder of the aneurysm neck is

occlude d with additional clips.
3-70h Schematic overview clarifies

placement of clips.
3-70i and j Anteroposterior and lateral

postoperative angiograms demonstrate good
obliteration of the aneurysm with preservation
of all the normal branches. The patient recov
ered completely.
Case 3–71
Diagnosis: Giant serpentine aneurysm of the BA (rel. anatomy:
pp 18, 51, 53, 57-62)
Approach: Right subtemporal for STA-to-superior cerebellar
artery bypass, endovascular, petrosal retrolabyrinthine
aneurysmorrhaphy (rel. approaches: pp 92-100)
3-71a and b MR images demonstrate a

giant basilar artery aneurysm with flow voids.
This patient presented with rapidly progres
sive brainstem compre s s ion.
3-71c and d Anteroposterior and lateral

angiograms demonstrate the serpentine
nature of the basilar artery aneurysm.
3-71e A superficial tempora l artery-to-superior

cerebellar artery anastomosis is performed.
3-71f Close-up view of the superficial te m

poral a rtery-to-superior cerebellar artery
ana stomosis .
3-71g Postoperative angio

gram demonstrates patency of
the superficial temporal arte ry-to-
superior cerebellar artery ana sto
mosis.
3-71h After the bypass, the

vertebral artery injection filled only
the inferior portion of the serpen
tine aneurysm. The upper bra in
stem is no longer perfused
through the vertebral artery. At
this point, an endovascular
approach was used to obliterate
the remainder of the aneurysm.
3-71i and j Two weeks later, the aneurysm was

opened and debulked through a petrosal retro
labyrinthine approa ch.
3-71k Dome of the emptied aneurysm.
3-71l Portions of the removed thrombus .
3-71m Final postoperative vertebral artery

angiogram demonstrates comple te absence of the
aneurysm. The patient's deterioration ceased and
he gradually improved.
Case 3–72
Diagnosis: Lower trunk BA aneurysm (rel. anatomy: pp 58-64, 67-69)
Approach: Right far lateral with clipping under hypothermic circulatory
arrest (rel. approach: pp 109-113)
3-72 a, b, c, d, and e Various angiographic

projections of the vertebral arteries de mon
strate a giant aneurysm of the lower third of
the basilar artery.
3-72f Through a far-lateral approach on the right

side with the patient in a modified pa rk-be nch pos i
tion, the right vertebral artery is identified.
3-72g Under higher magnification the vertebral

artery and the surrounding cranial nerves are
exposed through the far-lateral a pproa ch.
3-72h With the patient under hypothermic 3-72i With a long 45°-a ngle d fenestrated 3-72j A different orientation looking at the
circulatory arrest, the two vertebral arteries clip, the distal portion of the neck of the lateral aspect of the aneurysm neck nicely
can be seen to form the basilar artery. The aneurysm is occlude d parallel to the basilar shows the proximal and distal Pasilar artery.
neck of the aneurysm and distal basilar artery artery. The residual portion of the neck at the
are visible. fenestration is obliterated with additional
aneurysm clips.
3-72l and m Postoperative angiograms

demonstrate the occlusion of the aneurysm.
The patient made an excellent recovery.
3-72 k Low-powe r view of the far-lateral

a pproa ch.
Case 3–73
Diagnosis: BA aneurysm at junction of right VA (rel. anatomy:
pp 58, 60-64, 66)
Approach: Right retrosigmoid with clipping (rel. approaches:
pp 108, 109)
3-73a and b Angiography

demonstrates a basilar artery—
vertebral artery junction aneurysm
with the dome of the aneurysm
pointing towa rd the clivus.
3-73c The lower cranial nerves are visualized

through a right retrosigmoid a pproa ch. The glosso
pharyngeal nerve is most superior, followe d by the
vagal group and most interiorly by the accessory
nerve. The posterior inferior cerebellar artery loop is
visualized below, and coursing through, the cranial
nerves.
3-73d The microscope is angled so that the

aneurysm is exposed between the vestibulo
cochlear and glossopharyngeal nerves. The ve ntro
lateral abducent nerve is visible.
3-73e The aneurysm neck has been obliterated

with a clip and the protruding portion of the clip
has been cushioned against the cranial nerves with
a small piece of Gelfoam.
Case 3–74
Diagnosis: Giant vertebrobasilar artery aneurysm (rel. anatomy:
pp 60-69)
Approach: Left far lateral with hypothermic circulatory arrest,
aneurysmorrhaphy, and clip reconstruction
3-74a MR image demonstrates large

thrombos e d aneurysm with marked dis tortion
of the brainstem. The patient presented with
progressive right hemiparesis.

fusiform aneurysm involving both vertebral
arteries and the basilar artery.
3-74d A modified park-be nch position is used to 3-74 e, f, and g Various views show the position
allow the far-lateral approach as well as to access of the patient.
the groin vessels for hypothermic circulatory arrest.
3-74h Through the far-lateral a pproa ch, C 1 , C2,

the occiput, and the extradural vertebral artery are
e xpos e d.
3-74i The use of the fish hooks maximizes e xpo

sure and minimizes the distance between the
edges of the wound and the aneurysm. A cra nioto
my of the posterior fos sa has been performed, and
C1 has been removed.
3-74 j After the dura is ope ne d, the lateral edge

of the brainstem, vertebral artery, cerebellar tonsil,
and dome of the aneurysm are visualized.
3-74k With slight retraction of the tons il, the ver

tebral artery can be seen as it enters the large
aneurysm. The posterior inferior cerebellar artery
arises proximally.
3-74 l Hypothermic circulatory arrest is initiated.
3-74 m Brainstem evoked potentials gradually

disappear as the patient becomes more hypother
mic until comple te cessation is achieved with circu
latory arrest.
3-74 n Under hypothermic circulatory arrest, the

dome of the aneurysm is opened and de bulke d.
3-74 o The ultrasonic aspirator is used to remove

the thrombus .
3-74 p Under hypothermic circulatory arrest, the

entire vertebrobasilar system is open with a view
into the orifice of the contralateral vertebral and
basilar arteries. At this point, the left vertebral artery
wa s sacrificed as it entered the aneurysm distal to
the origin of the left posterior inferior cerebellar
artery. The dome of the aneurysm was folded to
form a conduit reconstructing the right vertebral and
basilar arteries.
3-74 q The brainstem and basilar artery

aneurysm are shown before resection of the
aneurysm. Note the distortion of the brainstem.
3-74 r The brainstem is shown after the

aneurysm has been resected. Note the relaxation
of the brainstem. Although the patient's postopera
tive course was stormy for 3 days, he eventually
made an excellent recovery with full return of neu
rological function.
Case 3–75
Diagnosis: Left giant VA aneurysm (rel. anatomy: pp 61-69)
Approach: Left far lateral with trapping and PICA-to-PICA bypass
and endovascular (rel. approaches: pp 109-113)

large aneurysm in a 5-year-old boy who pre
sented with subarachnoid hemorrhage.

aneurysm involving the left vertebral artery
and posterior inferior cerebellar artery.
Ne uros urge ry.
3-75e Position of the patient on the operating-

room table for the far-lateral approach. Re printe d
with pe rmis s ion from J ourna l of Ne uros urge ry.
3-75 g A side-to-side anastomosis of the poste ri

or inferior cerebellar artery loops is performed.
Re printe d with pe rmis s ion from J ourna l of Ne uro-
s urge ry.
^ k ^
3-75 h A ligature is placed on the proximal ve rte

bral artery.
3-75i Postoperative angiogram reveals

good filling of both posterior inferior cerebellar
arteries as well as retrograde filling of a small
portion of the aneurysm through the left ver
tebral artery and left posterior inferior cerebel
lar artery. Re printe d with pe rmis s ion from
3-75j The distal posterior inferior cerebellar

artery, as it emerges from the dome of the
aneurysm, is clipped. Re printe d with pe rmis -
s ion from J ourna l of Ne uros urge ry.
3-75k Selective angiography demonstrates

residual retrograde filling of the aneurysm
through the contralateral vertebral artery.
Ne uros urge ry.
3-75l and m With a catheter inserted into

the right vertebral artery, coils placed in the
distal left vertebral artery tra pped the
aneurysm entirely. One-year follow-up
angiograms and CT scan (not s hown) reveal
no recurrence of the aneurysm and dramatic
shrinkage of the aneurysm mass. Re printe d
with pe rmis s ion from J ourna l of Ne uro-
s urge ry.
3-75n Schematic overview of the treatment

of this aneurysm. Re printe d with pe rmis s ion
from J ourna l of Ne uros urge ry.
Case 3–76
Diagnosis: Left PICA aneurysm (rel. anatomy: pp 61-69)
Approach: Left far lateral with clipping (rel. approaches: pp 109-113)
3-76a and b Anteroposterior and lateral 3-76c Outline of the incision from the tip of
vertebral artery angiograms demonstra te a the mastoid to the midline of C2-C3.
complex posterior inferior cerebellar artery
aneurysm.
3-76d The muscle flap is elevated from the 3-76e After the dura has been opened and 3-76f The glossopharyngeal, vagus, and
occipital bone, leaving a generous cuff along the left cerebellar tonsil retracted gently, the accessory cranial nerve complex and the
its nuchal attachment for reapproximation at left posterior inferior cerebellar artery is visi hypoglossal nerve can be seen exiting from
the end of surgery. The occiput, C1, C2, and ble. their respective foramina.
the vertebral artery are exposed.
3-76g The thin-dome d aneurysm is 3-76h The aneurysm, now fully e xpos e d, 3-76i With the use of two clips, the bilobu-
e yn n s e H. has two lobes. lated aneurysm is eliminated and the pos teri
or inferior cerebellar artery is preserved.
3-76 j and k Postoperative anteroposterior

and lateral vertebral artery angiograms
demonstrate clipping of the aneurysm and
preservation of the posterior inferior cerebella
artery.
Case 3–77
Diagnosis: Left VA aneurysm at the junction of the PICA
Approach: Midline suboccipital with clipping (rel. approaches:
pp 102-105)
3-77a A left vertebral subtraction

angiogram reveals a multilobulated aneurysm
of the vertebral artery at the junction of the
posterior inferior cerebellar artery.
3-77b The dura has been ope ne d, e xpos 3-77c With minimal elevation of the left
ing the most lateral aspect of the cervical cerebellar tonsil, the vertebral artery is
spinal canal including a portion of the me dul exposed as it courses below the brainstem.
la, tonsil and cerebellum. Notice the wide
resection of the foramen magnum and the
cervical nerve root just below the arachnoid
covering the vertebral artery. Also observe
where the vertebral artery enters from the
extradural to the intradural s pa ce .
3-77d Higher magnification of the vertebral 3-77e A clip has been placed across the
artery reveals the base of the aneurysm, the neck of the aneurysm. The posterior inferior
posterior inferior cerebellar artery origin and cerebellar artery was mobilized and displaced
its loop ba ckwa rd and in front of the laterally to be certain that it would not be
aneurysm. The hypoglossal nerve sits at the compromised by the jaws of the aneurysm
apex of the dome of the aneurysm. clip. No retraction was required except for
the minimal elevation of the cerebellar tons il.
Case 3–78
Diagnosis: VA aneurysm at junction of left PICA (rel. anatomy:
pp 61, 65, 66)
Approach: Midline suboccipital spinal with clipping (rel. approaches:
pp 102, 103, 106)
3-78a The left cerebellar tonsil has been

e xpos e d. The first cervical nerve root can be seen
as it crosses the accessory nerve. The vertebral
artery is visualized in the lateral s pace.
3-78b The junction of the vertebral and posterior

inferior cerebellar artery with slight elevation of the
left tonsil is visualized. The aneurysm can be seen
as it points into the brainstem.
3-78c Higher magnification demonstrates the

neck of the aneurysm outlined by the two surgical
instruments.
3-78d A clip has been placed on the neck of the

aneurysm, cushioned against the brainstem with a
small piece of Gelfoam.
Case 3–79
Diagnosis: Right PICA aneurysm (rel. anatomy: pp 61, 65, 66)

vertebral artery angiograms demonstrate right
posterior inferior cerebellar artery aneurysm.
3-79c Superselective angiography at the

base of the posterior inferior cerebellar artery
aneurysm demonstrates the aneurysm before
placement of the GDC coils.
3-79d The aneurysm is coiled while the

posterior inferior cerebellar artery is pre
served.
3-79 e a nd f Anteroposterior a nd lateral

angiograms after obliteration of the posterior
inferior cerebellar artery aneurysm by GDC
coils .
3-79 g and h Anteroposterior and lateral

vertebral artery angiograms performed 6
months after treatment show continued oblit
eration of the posterior inferior cerebellar
artery aneurysm.
3-79 i Twelve-month postoperative vertebral

artery angiogram shows continued oblitera
tion of the posterior inferior cerebellar artery
aneurysm.
Case 3–80
Diagnosis: Right PICA aneurysm (rel. anatomy: pp 61, 65, 66)
3-80a MR image demonstrates the va s cu

lar lesion located ventrolaterally to the spinal
cord at the level of C 1 .

posterior inferior cerebellar artery aneurysm,
which originates at the intradural entrance of
the vertebral artery.
3-80d Superselective catheterization

shows partial obliteration of the posterior
inferior cerebellar artery aneurysm with a fur
ther coil to be pla ce d. Note the relationship
of the neck of the aneurysm to the posterior
inferior cerebellar artery—the goal of treat
ment is to preserve the origin of this vessel.
3-80e Lateral radiograph demonstrates the

placement of the GDC coils.
3-80f Final angiogram demonstrates oblit

eration of the aneurysm with preservation of
the posterior inferior cerebellar artery.
3-80g Twelve-month follow-up angiogram

reveals continued obliteration of the posterior
inferior cerebellar artery aneurysm.
345
346 Arte riove nous Ma lforma tions of the Brain
Arte rio ve n o u s Ma lfo rm a tio n s
Introd uctio n located in or adjacent to eloquent tissue (e.g.,

The arteriovenous malformations (AVMs) are speech centers). Such lesions carry a significant
presented in three sections: supratentorial, risk of morbidity and mortality, including normal
infratentorial, and dural. Within the first two sec perfusion pressure breakthrough.
tions, the AVMs are presented according to their The technical ability to expose and resect AVMs
Spetzler-Martin grade (Fig. 4.0, Table 4.0). has advanced rapidly. In conjunction with super-
Within each grade, the malformations again are selective embolization, large arteriovenous
presented anteriorly to posteriorly. shunts can be reduced in stages. Staged surgical
To determine the grade of an AVM, the size, procedures allow the resection of AVMs that
venous drainage, and eloquence of the adjacent have previously been considered inoperable (i.e.,
brain must be determined from angiography, by combining a subtemporal with a suboccipital
computerized tomography (CT), or magnetic res approach). AVMs along the midbrain are now
onance (MR) imaging. A numerical value is being resected with safety.
assigned for each of the categories, and the grade In the small percentage of patients with giant
of the lesion is derived by summing the points AVMs who present with fluctuating ischemic
assigned for each category (Table 4.0). symptoms, the reduction of high flow in a step
wise fashion has allowed the ischemic surround
Table 4.0 ing hemisphere to recapture normal autoregula-
Determination of arteriovenous malformation (AVM) tory capacity. This staged throttling of giant
grade* AVMs has made the excision of these lesions pos
sible with good results, avoiding the devastating
Graded feature Points as s igned
results from the normal perfusion pressure
Size of AVM breakthrough phenomenon when these formida
small (< 3 cm) 1 ble lesions are resected in one stage. It is not
medium (3-6 cm) 2 within the scope of any book to describe all pos
large (> 6 cm) 3 sible technical problems associated with these
Eloquence of adjacent brain formidable lesions. They require a great deal of
noneloquent 0 planning, patience, and circumspection. As with
eloquent 1 all neurosurgical procedures, but particularly
Pattern of venous drainage with AVMs, the ability to anticipate complica
superficial only 0 tions is most important during resection of these
deep 1 lesions. The senior author believes that grade IV
* Grade = [size] + [eloquence] + [venous drainage]; that is and V AVMs are often best left alone unless
(1, 2, or 3) + (0 or 1) + (0 or 1). Re printe d with pe rmis s ion of
J ourna l of Ne uros urge ry. repeated hemorrhage or progressive neurologi
cal deficits demand intervention.
The lowest possible grade is grade I, which would As in the section on aneurysms, cases treated
be a small (1 point) lesion with only superficial with endovascular techniques are also represent
drainage and located in a noneloquent area such ed here because they either serve as adjuncts to
as the frontal lobe. A grade I lesion would be rel open neurosurgical treatment or are the defini
atively easy to remove from a technical perspec tive treatment. Stereotactic radiosurgery can also
tive and would be associated with a low risk of be used to treat appropriate cases and is shown
morbidity or mortality. where used for deep inaccessible lesions or to
In contrast, a grade V AVM would be larger than assist with more complex large lesions.
6 cm (3 points), have a portion of its drainage into
the deep venous system (1 point), and would be
Arte riove nous Ma lforma tions 347
GRADE I GRADE III GRADE IV
GRADE II
GRADE V
4-0 S pe tzle r-Ma rtin grading system for combination each for Grades I and V, three
AVMs. Diagrammatic representation of the combinations for Grades II and IV, and four
combination of grade d variables (size, elo possible combina tions for Grade III. Re printe d
quence , and venous drainage) tha t are poss i with pe rmis s ion of J ourna l of Ne uros urge ry.
ble for each grade of AVM. There is one
348 Arte riove nous Ma lforma tions of the Bra in Gra de 1
S u p ra te n to ria l Arte rio ve n o u s

Ma lfo rm a tio n s E
V
= 0
= 0
Case 4 1
S = 1
Diagnosis: Right frontal AVM
Approach: Right frontal with resection Grade = 1
4-1a Lateral internal ca rotid artery

angiogram s hows a small frontal AVM.
4-1 b After the cortex overlying the AVM is

e xpos e d, the draining vein of the AVM is vis i
ble.
4-1c The draining vein is followe d down to the AVM.

Gra de 1 S upra te ntoria i Arte riove nous Ma lforma tions 349
4-1d The AVM is circums cribe d.

4-1e Bed of the resected AVM. Notice the
intact pial vasculature.
4-1f The venous anatomy after resection
of the AVM. Notice tha t the draining vein is
now dark and there is no longer any mixed
arteriovenous blood.
4-1g and h Postoperative anteroposterior
and lateral angiograms demonstrate absence
of the AVM.
350 Arte riove nous Ma lforma tions of the Brain Gra de 1
Case 4–2
E =0
Diagnosis: Left frontal AVM
V =0
Approach: Left frontal with resection
S = 1
Grade = 1
4-2a MR image demonstrates a cystic por

tion of the frontal lobe from old hemorrhage
with evidence of an AVM.
4-2b and c Anteroposterior

and lateral internal carotid artery
angiograms demonstrate the AVM.
4-2d The cortex overlying the AVM is e xpos e d.

Gra de 1 S upra te ntoria l Arte riove nous Ma lforma tions 351
4-2e The AVM is circumscribe d and ready for

removal.
4-2f After the AVM is removed, the normal va s

culature beneath it is e xpos e d.
4-2g Pathological specimen.

4-2h and i Postoperative anteroposterior

and lateral angiograms demonstrate resec
tion of the AVM.
Case 4–3
E = 1
Diagnosis: Left temporal AVM with hemorrhage
V = 0
Approach: Left temporal with resection
S = 1
Grade = 2
4-3a and b MR images

demonstrate a hematoma
in the left temporal lobe.
The patient experienced
several episodes of he m
orrhage and aphasia
but repeated angiography
was negative.
4-3c Exposure of the left temporal lobe next to a

draining vein reveals an arteriovenous shunt from
the small AVM.
4-3d After the AVM has been removed, the

shunt has disappeared. The cavity from which the
AVM was resected is adjacent to the cavity of the
hematoma.
4 -3 e and f Anteroposterior and lateral

angiograms demonstrate normal vascular
circulation.
Case 4–4
E = 1
Diagnosis: Left frontoparietal AVM
V =0
Approach: Left frontoparietal with resection
S = 1
Grade = 2
4-4a MR image reveals the location of the 4-4b Lateral internal carotid artery
AVM. angiogram demonstrates the small AVM adja
cent to the speech area. The patient present
ed with intermittent anomia.
4-4c After the dura has been ope ne d, the AVM

is visible through the arachnoid layer.
4-4d The AVM is visible through a protective

Gelfoam covering.
4 -4e Four retractors are placed to surround the

AVM.
4-4f A vessel en pa s s a ge is seen as it enters and

exits the AVM. These vessels are often seen in
AVMs. It is important to explore the proximal and
distal portions of the AVM to identify the exiting
arteries, which then can be followe d from the front
and the back in order to preserve the m.
4-4g The AVM, which has been surrounded and

freed on all sides, remains a tta ched only to its
draining vein.
4-4h After the AVM has been removed from its

venous pedicle, the bed of the AVM is visualized
and the vessel en pa s s a ge is seen coursing
through it.
4-4i Pathological specimen reveals the AVM and

nonfunctional brain substance within it.
Case 4–5
E = 1
V = 0
Approach: Stereotactic radiosurgery, left frontoparietal
S = 1
with resection (rel. approach: p 72)
Grade = 2
4-5a CT scan reveals the AVM, which was

first tre a te d with stereotactic radiosurgery
after the patient refused surgery.
4-5b CT scan 2 years later reveals acute
intracerebral hemorrhage. The patient presented
with a cute aphasia a nd right hemiparesis.
4 -5 c Lateral internal ca rotid artery
angiogram demonstrates the AVM. Although
the flow through the AVM has decreased as
compared to before radiation, the size of the
lesion remains approximately the same.
4-5d Intraoperative view during resection
of the AVM.
4 -5e Postoperative angiogram demonstrates
absence of the AVM. Although the patient recov
ered from her hemiparesis, her aphasia did not
improve.
Case 4–6
E = 0
Diagnosis: Left thalamic AVM (rel. anatomy: pp 25, 26)
V =1
Approach: Anterior transcallosal with resection
S = 1
(rel. approaches: pp 72, 78)
Grade= 2
4-6a Lateral posterior fossa angiogram reveals

the thalamic AVM fed by the posterior choroidal
vessels. The AVM was treated after this pregnant
adolescent had a normal delivery.
4-6b Through the transcallosal a pproa ch, the

AVM was identified on the surface and within the
left thalamus.
4-6c The AVM is mobilized.

4-6d The AVM has been resected, except for a

small cauterized pedicle.
4-6 e After the AVM has been resected, its bed in

the left thalamus is visible.
4-6 f Postoperative angiogram reveals absence

of the AVM.
Case 4–7
Septal
Diagnosis: Two AVMs;
septal, grade 2 E = 0
and occipital, grade 2 V = 1
(rel. anatomy: p 50) S = 1
Grade = 2
4-7a CT scan shows hemorrhage from a septal

AVM.
4-7b Angiogram shows the septal AVM.
4 -7 c With the frameless stereotactic guidance

s ys te m, the approach to the septal AVM is per
forme d.
First approach: Anterior transcallosal contralateral

for septal AVM with resection
(rel. approaches: pp 72, 75, 78)
4-7d Through an opening in the corpus callo

s um, the AVM is visible.
4-7 e The AVM is exposed within the s e ptum.
4-7f The septal AVM is resected completely.

Gra de 2 S upra te ntoria i Arte riove nous Ma lforma tions 363
Second approach: Posterior interhemispheric

with resection Occipital
E = 1
V = 0
S = 1
Grade= 2
4-7g and h Anteroposterior and lateral

angiograms of a vertebral artery injection show
a small grade 2 occipita l AVM.
4-7i Through a posterior interhemispheric

a pproa ch, the mixture of the arteriovenous
and regular venous blood is seen.
364 Arte rio ve n o u s Ma lfo rm a tio n s o f th e Bra in Gr a d e 2
4-7 j The vein is followe d to the s ulcus .
4-7 k The AVM is re s e cte d.
4–7 l The pre vious ly a rte ria lize d ve nous dra ina ge
ha s now turne d da rk.
4-7 m , n, o, and p Postoperative

angiograms show comple te obliteration of
the two AVMs. The patient had no neurologi
cal sequelae.
Case 4–8
E = 1
Diagnosis: Left temporal AVM (rel. anatomy: pp 35, 36)
V = 0
Approach: Left parietotemporal with resection
S = 1
Grade = 2
4-8a MR image reveals location of a left

te mpora l AVM.
4-8b and c Early and late phase lateral

angiograms reveal the AVM. Note the large
associated venous aneurysm.
4-8d and e Early and late phase antero
posterior angiograms show the AVM in rela
tion to the remainder of the middle cerebral
artery vessels of the Sylvian fissure.
4-8f The scalp incision

is outlined.
4-8g Frontal view of the
patient's position on the
ope ra ting-room ta ble .
The patient's head is fixed
in a three-point radiolucent
head holder to allow
intraoperative angiography.
4-8h After the scalp and dura are ope ne d, the

draining vein and some of the feeding arteries are
visible. The slight yellow discoloration is evidence of
old hemorrhage.
4 -8i The AVM is carefully separated from the sur

rounding brain.
4-8j The AVM is mobilized but still attached to its

venous pedicle.
4-8k The AVM is resected and lifted above the

large venous aneurysm and the draining vein.
4-8l Pathological specimen after resection.

4-8 m The bed of the AVM with the en pa s s a ge

vessels intact.
4-8n and o Postoperative angiograms

reveal the absence of the AVM. This patient,
who presented with intermittent aphasia, had
completely normal speech after surgery.
Case 4–9
E = 1
Diagnosis: Left Sylvian fissure AVM
V = 0
(rel. anatomy: pp 35, 36)
S = 1
Approach: Endovascular, left frontoparietal with
resection (rel. approach: p 72)
Grade = 2

angiograms of the left internal carotid artery
demonstrate an AVM with rapid shunting.
4 -9 c and d Selective catheterization

allows the placement of coils, which dramat
ically decreases the shunt of the AVM.
4 -9 e and f After the endovascular proce

dure, the flow through the AVM is reduced
markedly.
4-9g The patient's head is fixed in the 4-9h Overview of the operative site
thre e-point radiolucent head holder. demonstrates the use of fishhooks a ttached
to the Leyla bar to avoid the use of self-
retaining retractors. Note tha t the catheter is
inserted retrogradely through the superficial
temporal artery for intraoperative angiography.
4-9i The craniotomy flap has been comple te d.

4-9j The large shunt vessels are visible.
4-9k The Budde halo self-retaining retractor

system is placed with the AVM in the middle.
4-9l The Sylvian fissure is split, exposing the

AVM.
4 -9m The AVM is expose d. The coils are visible

proximally.
4-9n High-power view allows visualization of

the coils through the vessel wall.
4-9o After the AVM is resected, the distal dra in

ing vessel is clippe d.
4-9p Overview of the be d after resection of the

AVM.
4-9q Pathological specimen shows s ome of the

coils.
4-9r and s Left anteroposterior and lateral inter

nal ca rotid artery angiograms reveal absence of the
arteriovenous s hunt.
Case 4–10
E = 1
Diagnosis: Right parietal AVM with giant venous aneurysm
V = 0
S = 1
Grade = 2
c
4-10a MR image reveals a large vascular
abnormality in the right parietal region of a
16-year-old patient who presented with
seizures.
right internal carotid artery angiograms show
a high-flow fistula into a gaint venous sac.
Preferential flow through the fistula results in
only minimal filling of the normal vasculature.
4-10d Superselective catheterization of the

feeding vessel before balloon inflation.
4-10e Skull radiograph s hows the inflated
balloon.
4-10 f and g Anteroposterior and lateral

internal carotid artery angiograms of pos t-
balloon occlusion of the main fistula de mon
strate the patent fistula filling from another
source. Note the dramatically increased per
fusion in the remainder of the hemisphere.
4-10h and i Angiograms performed 6

months later reveal further reduction in flow
through the fistula despite lack of further
tre a tme nt.
4-10j and k One year after the last

angiogram, anteroposterior and lateral inter
nal carotid artery angiographic projections
reveal complete occlusion of the arterio
venous fistula/AVM. The balloon can be seen
in the s ubtra cte d view (a rrow).
4-10l Late MR image reveals complete

thrombosis of the large venous sac. The
patient remained neurologically intact and has
had no further seizures.
Gra de 2 S uprate ntoria l Arte riove nous Malformations 377
Case 4–11
E =0
Diagnosis: Callosal AVM (rel. anatomy: pp 31, 32, 50)
V = 1
Approach: Endovascular, anterior transcallosal with
S = 1
Grade = 2
4-11a and b MR images reveal location of

the AVM as well as the site of a large previous
hemorrhage.
angiograms demonstrate a pericallosal AVM.
4-11e Superselective angiography shows
the nidus and its relationship to the motor
branch of the pericallosal artery.
4-11f After the catheter position has been
advanced, only the posterior part of the nidus
is visualized with filling of the normal branch.
4-11g Visualization of the cast (glue) in the
nidus shown in Figure 4-11 f.
4-11h Lateral carotid angiogram shows the
remaining (anterior) part of the AVM fed by en
pa s s a ge vessels from the interhemispheric
motor branches.
4-11i Patient's position

on the operating room
ta ble .
4-11j The Midas Rex®
drill (Midas Rex P neu
matic Tools, Inc., Forth
Worth, TX) is used to
perform the craniotomy.
Sagittal and coronal
sutures are visible.
4-11k After the bone is removed, the superior

sagittal sinus is clearly visible.
4-11l The dura is opened and the falx is retract

ed with stay sutures. The dependent right hemi
sphere is separated gently using gravity to assist
in the retraction.
4-11m The callosomarginal artery is seen in the

interhemispheric fissure.
4-11n After the fissure has been split completely,

the AVM is visible lying over and within the corpus
callosum.
4-11o Where it opens into the lateral ventricle,

the AVM has been mobilized revealing the choroid
plexus in the de pth of the exposure.
4-11p The AVM has been mobilized but a portion is

still atta ched to the choroid plexus.
4-11q The AVM has been removed completely.

Note that the pericallosal artery, which had many
feeders to the AVM, is intact. The choroid plexus is
visible and a hole is present in the septum pellu-
cidum.
4-11r Lateral angiogram reveals successful

resection of the AVM.
Gra de 2 Supra te ntoria l Arte riove nous Ma lforma tions 381
Case 4–12
E =0
Diagnosis: Right temporal AVM
V =0
Approach: Endovascular, right temporal with resection
S =2
Grade =2
4-12a , b, c, and d MR images de mon

strate right temporal AVM with a large adja
cent hematoma.
angiograms demonstrate right temporal AVM.

angiograms after glue embolization.
4-12i and j Anteroposterior and lateral ver

tebral artery angiographic injections de mon
strate filling of the AVM through the posterior
circula tion.
4-12k and I Superselective catheterization

of the nidus of the AVM with glue emboliza
tion.
4-12m Vertebral artery injection after

embolization reveals no residual feeder
to the AVM.
Gra de 2 Supra te ntoria l Arte riove nous Ma lforma tions 383
4-12n Through a temporal craniotomy the 4-12o The largely embolized AVM is being 4-12p The dissection of the AVM contin
floor of the middle fossa is exposed, revealing mobilized. ues, revealing a portion of the still patent
the inferolateral aspect of the AVM. AVM.
4-12q The temporal lobe after resection

of the AVM.
4-12r and s Lateral internal carotid artery

and lateral vertebral artery angiographic injec
tions demonstrate comple te excision of the
AVM.
Gra de 3 S upra te ntorial Arte riove nous Malforma tions 385
Case 4–13
E = 0
Diagnosis: Corpus callosum AVM (rel. anatomy: p 32)
V = 1
Approach: Endovascular obliteration
S = 2
Grade = 3

angiograms show a 4-cm corpus callosum
AVM.
4-13 c and d Superselective angiograms

show one compartment of this two-compa rt
ment AVM before glue embolization.
4-13e and f The second compartment of

the AVM has been catheterized and is visible
just before embolization.

skull radiographs show glue deposition within
the nidus of the AVM.
4-13 i, j, k, and I Bilateral anteroposterior

and lateral internal ca rotid artery angiograms
demonstrate no residual filling of the AVM.
Flow through the anterior cerebral artery,
which had previously fe d the AVM, is s lug
gish.
4-13 m , n, o, and p Late phase follow-up

angiograms 3 years later verify continued
obliteration of the AVM. This AVM was partic
ularly suitable for endovascular obliteration
because the two separate compa rtme nts
could be catheterized selectively and there
were no vessels en pa s s a ge . This configura
tion made solid casting of the nidus feasible.
Case 4–14
E = 0
Diagnosis: Splenial AVM (rel. anatomy: pp 24, 25, 47-50)
V = 1
Approach: Endovascular posterior interhemispheric with
S = 2
Grade = 3
4-14a Internal carotid artery angiogram 4-14b Through selective catheterization,

reveals the anterior portion of a splenial AVM. the feeding vessel has been entered and is
being prepared for glue embolization.
4-14c After glue embolization, only a small 4-14d After embolization of the posterior
stain remains from the anterior injection. feeding vessels, a small residual stain shows
the remaining portion of the AVM. When the
anterior and posterior injections were com
bined for evaluation, the size of the AVM
was 4 cm.
Gra de 3 Supra te ntoria l Arte riove nous Ma lformations 389
4-14 e Through the posterior interhemi

spheric approach, the right occipital lobe is
retracted interiorly exposing the falx and te n
torium.
4-14f The wand of the frameless stereo
tactic guidance system is placed at the pos
terior margin of the AVM.
4-14g MR localization of the wand corre

sponding to Figure 4-14f reveals the sur
geon's exposure in relation to the remainder
of the hidden AVM. The use of the wand is
particularly promising in the treatment of
AVMs because the risk of residual AVM
can be minimized.
4-14h Dissection of the AVM proceeds. 4-14i The AVM is mobilized, exposing its 4-14j The AVM is mobilized to its
anterior pedicle. anterolateral pedicle.
Gra de 3 S upra tentoria l Arte riove nous Malforma tions 391
4-14k The AVM remains attached interiorly. 4-14l After the AVM is removed, its bed is
visualized.
4-14m The choroid plexus in the atrium is

visible after resection of the AVM.
4-14n and o Vertebral artery and internal

carotid artery angiograms reveal normal circu
lation with no evidence of residual AVM.
Case 4–15
E = 1
Diagnosis: Right medial temporal lobe AVM
V = 0
(rel. anatomy: pp 25, 26, 34-36)
S = 2
Approach: Right temporal with resection
Grade = 3

reveal evidence of the AVM
and a significant hemosiderin
stain from an old hemorrhage.
4-15c and d Right anteroposterior and lat

eral angiograms demonstrate the AVM.
4-15e Approa ch through the right middle te mpo

ral gyrus. The AVM, which was embolized pre
operatively, is e xpose d.
4-15f The AVM is resected and remains attached

to its pedicle on the choroid plexus. The ventricular
surface is visible.
4-15g and h Post

operative angiograms
reveal that the normal
circulation has been
preserved and that the
AVM has been eliminated.
Case 4–16
E = 1
Diagnosis: Left postcentral AVM
V =0
Approach: Endovascular, left parietal with resection
S = 2
Grade = 3
4-16a and b Coronal and sagittal MR

images show a postcentral AVM in a female
who became s ymptoma tic with seizures.
4-16c and d Left internal carotid artery

angiograms demonstrate the AVM and its
drainage into the superior sagittal sinus.

angiograms after two endovascular emboliza
tions with glue reveal a small residual nidus
with slow flow.
4-16g Intraoperative angiogram.
4-16h Microsurgical perspective after par 4-16i The AVM is mobilized completely and 4-16j After resection and hemostasis, all
tial mobilization of the AVM. Note the vein a tta ched only to its draining vein. The cortical the veins have turne d blue.
draining towa rd the sinus and the cortex. vein is kept patent and has turne d blue.
4-16k Postoperative injection reveals no 4-16l One-year follow-up MR tomogra phy

evidence of remaining nidus. demonstrates complete removal of the AVM.
Case 4–17
E = 0
Diagnosis: Callosal and intraventricular AVM
V = 1
(rel. anatomy: pp 31, 32, 50)
S =2
Approach: Anterior and posterior interhemispheric
with resection (rel. approach: p 75) Grade = 3
4-17a MR image reveals the location of an 4-17 b, c, and d Angiograms show the
AVM within the corpus callosum and the lat AVM located within the substance of the cor
eral ventricle. Evidence of a previous hemor pus callosum as well as within the lateral ve n
rhage is apparent. tricle.
4-17e Through an interhemispheric a pproa ch,

the AVM is visible below the edge of the falx.
4-17f After the anterior portion of the corpus ca l

losum with the AVM has been resected, both a nte
rior cerebral arteries are visible.
4-17g Transcallosal resection reveals the lateral

ventricle, the choroid plexus, and the foramen of
Monro.
4-17h Overview of the operative site from the

first stage reveals resection of the anterior portion
of the AVM with a view of the lateral ventricle,
choroid plexus, and foramen of Monro.
4-17i and j Right and left lateral internal ca rotid

artery angiograms demonstra te removal of the ca l
losal AVM fe d by these vessels.
4-17k Vertebral artery injection reveals residual
AVM posteriorly in the ventricle and corpus callo
s um.
4-17l Through a posterior interhemispheric

a pproa ch, the splenium at midcorpus callosum
is e xpos e d. The residual portion of the AVM
is removed.
4-17m Posterior vertebral artery injection

reveals tha t the residual portion of the AVM
has been removed.
Gra de 3 Supra tentoria l Arte riove nous Malforma tions 401
Case 4–18 E = 1
Diagnosis: Left thalamic AVM V = 1
Approach: Stereotactic radiosurgery S = 1
Grade = 3

internal carotid artery angiograms show the
small thalamic AVM that presented with a
small hemorrhage.
4-18c Magnified view shows the feeding
vessels off the middle cerebral artery.
4-18d and e The AVM is targeted for

stereotactic radiosurgery.
4-18f and g Two-year follow-up anteropos

terior and lateral angiograms show complete
obliteration of the AVM.
Case 4–19
E = 1
Diagnosis: Left parieto-occipital AVM
V = 0
S = 2
Approach: Right subtemporal and occipitoparietal
Grade = 3
with resection (rel. approaches: pp 72, 93)
4-19a and b MR angiograms demonstrate

large venous channels in an 18-month-old
infant.
4-19c and d MR images reveal the arterio

venous malformation with a large associated
venous aneurysm.
4-19e and f Contralateral right internal

carotid artery angiograms reveal a left shunt
with a large venous aneurysm.
4-19g Through a subtemporal a pproa ch, the

feeding vessel is identified and clippe d.
4-19h The clips are visible on the two feeding

vessels.
4-19i and j
Postoperative
angiograms after
the first stage
de mons tra te
much better
perfusion of the
hemisphere and
better visibility of
the AVM and
draining vein.
The patient's
high cardiac
output failure
was reversed.
4-19k Two weeks later the AVM was

a pproa che d. The large venous aneurysm is visible
as it drains into the transverse sinus.
4-19l The feeding vessels to the AVM are dis

se cte d free just before resection.
4-19m and n Lateral internal

ca rotid artery angiograms
demonstrate obliteration
of the AVM. Neurologically, the
patient developed normally.
Gra de 3 S uprate ntoria l Arte riove nous Ma lformations 405
Case 4–20
E = 1
Diagnosis: Left parietal AVM
V = 0
Approach: Left parietal with resection
S = 2
Grade = 3
4-20a and b MR images reveal an AVM of

the speech and motor areas in the parietal
region.
4-20 c, d, and e Different phases of internal

carotid artery angiograms show the AVM.
4-20f Through a parietal craniotomy, the surface

of the brain is visible with multiple feeding and
draining vessels.
4-20g The AVM is separated carefully from the

surrounding eloquent corte x.
4-20h The AVM has been mobilized completely

and is ready for removal.
4-20 i, j, k, and I Postoperative a nteropos

terior and lateral angiograms reveal oblitera
tion of the AVM. After some initial difficulty
with s pe e ch, the patient made an excellent
recovery.
Case 4-21
E = 1
Diagnosis: Right frontoparietal AVM
V =0
Approach: Endovascular, right frontoparietal
S =2
Grade = 3
4-21a MR image reveals an AVM.

4-21 b, c, and d Internal ca rotid artery
angiograms reveal the right parietal AVM.
4-21e and f Pre- and postembolization

anteroposterior angiograms reveal decreased
flow through AVM.
4-21g The AVM is exposed. 4-21h Dissection has begun. The venous
pedicle will be resected last.
4-21i The AVM is mobilized superficially.
4-21j The deep portion of the AVM is being

resected.
4-21k The AVM is freed circumferentially.

4-21l The AVM, which is resected from its

be d, is a tta ched only to its draining vein.
4-21m Extensive abnormal vessels surround

the bed of the AVM.
4-21n Pathological spe cime n.

4-21o and p Postoperative anteroposterior

and lateral angiograms demonstra te the
absence of the AVM,
Case 4–22
Diagnosis: Right choroid plexus and thalamic AVM E = 0
(rel. anatomy: p 50) V = 1
Approach: Endovascular, anterior transcallosal with S =2
resection, and stereotactic radiosurgery Grade = 3
4-22a CT scan reveals blood in the ve ntri

cle from a hemorrhage of the right thalamic
AVM.
4-22b and c Right anteroposterior internal

ca rotid artery and lateral vertebral artery
angiograms reveal the right thalamic AVM.
4-22d a nd e Pre- and postembolization

angiograms s how decreased flow through
the AVM but also occlusion of the distal por
tion of the posterior cerebral artery. The
patient, however, did not experience a per
manent visual field deficit from the emboliza
tion.
4-22f Through a right interhemispheric tra ns

callosal a pproa ch, the right lateral ventricle is
e xpos e d.
4-22g With the corpus callosum partially

ope ne d, the choroid plexus is visible.
4-22h Further opening of the corpus callosum

reveals the AVM with the old hemorrhage.
Gra de 3 Supra te ntoria l Arte riove nous Ma lformations 415
4-22i The AVM is exposed along with an 4-22j The AVM is being dissected free.
aneurysm that presumably was the source of the
initial hemorrhage.
4-22k The AVM is being removed along with the

aneurysm.
4-22l and m Postoperative angiograms
reveal a small residual portion of the AVM.
The patient underwent stereotactic radio
surgery. A 2-year follow-up angiogram (not
s hown) revealed complete obliteration of the
AVM.
Case 4–23
E = 1
Diagnosis: Left postcentral medial AVM
V = 0
Approach: Endovascular, left parietal and anterior
S = 2
interhemispheric with resection
(rel. approaches: pp 72, 75) Grade = 3
4-23a CT scan shows acute hemorrhage

into the left hemisphere tha t caused signifi
cant right hemiparesis.

internal carotid artery angiograms show left
postcentral parietal AVM.
4-23d Selective catheterization of the fe e d

ing vessel to the AVM.
4-23e Through a parietal craniotomy the dura

has been reflected to the midline, exposing the
embolized AVM.
4-23f Dissection of the AVM has begun along its

anterior border.
4-23g The medial border of the AVM is separat

ed from the falx. Small vascular channels to the
AVM can be appre ciated.
4-23h The AVM is dis s e cte d along the de pth

of the falx.
4-23i Further diss ection of the AVM.
4-23k Postoperative lateral angiogram de monstra te s

comple te removal of the AVM.
4-23j The AVM has been resected completely

a nd is ready to be re moved.
Case 4–24
E =0
Diagnosis: Right temporal lobe AVM
V =1
S =2
Grade = 3
4-24a MR image reveals an AVM involving

the entire right temporal lobe.
4-24 b, c, d, and e Angiographic injections

of the internal carotid artery, external carotid
artery, and vertebral arteries reveal recanaliza-
tion of previously embolized AVM. This young
man was initially trea te d with extensive
embolization followed by radiosurgery. Two
years later a small hemorrhage precipitated
repeat angiography that revealed recanaliza-
tion of the AVM except for a hole in the AVM
where the patient was radiated with the
gamma knife.
4-24f The dura overlying the right tempora l lobe,

from the transverse sinus to the tip of the temporal
lobe, is exposed entirely.
4-24g The AVM is resected superiorly but left

atta ched to its venous pedicle.
4-24h The Sylvian draining vein can be seen

anteriorly.
4-24i The poste rior draining vein into the tra ns

verse sinus is apparent.
4-24j After the AVM has been resected entirely,

the be d of the right middle fossa is visible.
4-24k Pathological s pe cime n.

4-24l Postoperative CT scan demonstrates

empty right middle temporal fossa.
4-24m Postoperative angiogram reveals

absence of the AVM. The patient had no
neurological deficits.
Case 4-25
E = 1
Diagnosis: Left caudate nucleus AVM
V = 1
Approach: Transventricular with resection
S = 1
Grade= 3
4-25a and b MR images show an area of

hemorrhage, some cerebral malacia, and a
caudate nucleus AVM.

internal carotid artery angiograms show fe e d
ing vessels and deep drainage of the caudate
AVM.

angiographic injections of superselective
catheterization that a tte mpte d to embolize
this AVM. Because the last curve of the fe e d
ing vessel that gives off a normal branch
(a rrow) could not be circumve nte d, emboliza
tion was too risky. Embolization was therefore
halted, and surgical excision without preoper
ative embolization was se lected.
4-25g Through a transventricular a pproa ch, the

AVM is e xpos e d. Considerable hemosiderin
remains from the previous hemorrhage.
4-25h With further exposure, a thrombos e d vein

is visible.
4-25i The AVM, which has been largely mobi

lized, remains attached to a small pedicle. The
viable portion of the AVM can be a ppre cia te d.
The deep feeding vessel is e xpos e d.
4-25j and k Postoperative angiograms

de monstrate obliteration of the AVM.
After recovering from his hemorrhage, the
patient's neurological examination was normal.
Case 4-26
E = 1
Diagnosis: Quadrigeminal plate AVM (rel. anatomy: pp 49, 52)
V = 1
S = 1
Grade = 3
4-26a a nd b Anteroposterior and lateral

vertebral artery angiograms s how a
quadrigeminal AVM.
4-26c and d Ante ropos te rior and lateral

superselective angiograms show the nidus
jus t before glue e mboliza tion.
4-26e and f Immediate postopera tive

angiograms show comple te obliteration
of the AVM.
Gra de 3 S upra te ntoria l Arte riove nous Ma lformations 427
4-26 g, h, i, and j Early and late phase ver

tebral artery angiograms at a 1 -year follow-up
examination demonstrate continued oblitera
tion of the AVM. Note that in the last
angiogram, the posterior cerebral artery,
which was not visible initially because of the
flow to the AVM, is now apparent.
Case 4–27
E = 1
Diagnosis: Quadrigeminal plate AVM
V = 1
(rel. anatomy: pp 42, 43, 48, 49, 52)
S =2
Approach: Infratentorial supracerebellar with resection
Grade = 4
4-27a and b CT scans demonstrate sever

al episodes of hemorrhage from the AVM.
4-27c and d Angiograms performed

8 years apart after proton-be a m radiation.
This is the only case in the senior author's
experience where proton-be a m radiation
visibly reduced the size of an AVM. In this
case, the size of the AVM was reduced
from an inoperable to an operable lesion.
Gra de 4 Supra tentorial Arte riove nous Ma lformations 429
4-27e The craniotomy, which has been 4-27f Operative field from the surgeon's 4-27g The dura has been opened and the
elevated, traverses both transverse sinuses perspective. transverse sinus elevated with dural ta ck-up
and the superior sagittal sinus. When the sutures.
bone flap is carried sufficiently high, the te n-
orium can be elevated with sutures.
4-27h The AVM is being removed.
4-27i Pathological s pe cime n.
4-27j View into the third ventricle through the

bed of the removed AVM, exposing the anterior
commissure and two fornice s .
4-27k The bone has been re a tta che d. The

occipita l musculature will be reattached to the cuff,
which is visible on the replaced bone .
4-27l and m Anteroposterior and lateral vertebral

artery angiographic injections reveal comple te
4-27 n and o Anteroposterior and lateral internal
ca rotid artery angiograms reveal oblite ration of the
AVM. The patient had no neurological de ficits .
Ca s e 4–28
E = 1
Diagnosis: Right thalamic AVM
V = 1
S = 2
Grade = 4
4-28a CT scan demonstrates hemorrhage

from the deep thalamic AVM.
4-28 b, c, and d MR images reveal edema,
hemorrhage, and the location of the AVM.
4-28e and f Internal ca rotid artery angio

graphic injections reveal the AVM, which is
responsible for the hemorrhage.
4-28g The anterior tempora l lobe is e xpos e d.

Note the swollen flattened gyri from the large hem
orrhage.
4-28h The surface of the te mporal lobe is pro

te cte d, exposing the anterior middle te mporal
gyrus through which the incision will be made.
4-28i The hematoma is localized ultrasono-

graphically.
4-28j The tra ct of the hematoma, which is cov

ered by thin membranes, is visible.
4-28k The hematoma is exposed and being

removed.
4-28l The bed of the AVM is visible.

4-28m Postoperative lateral internal carotid

artery angiogram demonstrates complete resection
of the AVM.
4-28n Postoperative CT scan demonstrates the

hematoma cavity. The patient made a good recov
ery from a near moribund state and was left with
residual left-sided weakness.
Case 4–29
E = 1
Diagnosis: Right frontal AVM (rel. anatomy: p 50)
V = 0
Approach: Right frontoparietal with resection
S = 3
Grade = 4
4-29a MR image reveals the location of 4-29b Lateral angiogram demonstrates

an AVM. On angiographic follow-up, there the AVM.
was a suggestion that the size of the AVM
had increased in this 15-year-old male, who
had undergone proton-be am radiation
8 years earlier.
4-29 c The AVM is exposed and circum

scribed leaving the venous pedicle attached
to the midline.
4-29e The medial portion of the AVM

resection is verified with the frameless s te re o
ta ctic guidance s ys te m.
4-29d The AVM is evaluated with the wa nd

of the frameless s te re ota ctic guidance system
to assure comple te resection.
4-29f Except for its medial pedicle, the AVM

is re se cted.
4-29g The deep portion of the AVM is re tra cte d,

e xposing the right lateral ventricle.
4-29h The wa nd is placed intraventricularly.
4-29i MR verification of the intraventricular wa nd.

4-29 j The wa nd is pla ced on the thalamostriate

vein.
4-29k The wa nd localization corre s ponding to

Figure 4-29 j pinpoints the thalamostriate vein.
4-29l The AVM is removed.

4-29m Pathological s pe cime n.
4-29n and o Postoperative anteroposterior

and lateral angiograms de mons tra te resec
tion of the AVM.
Case 4–30
E = 1
Diagnosis: Right parietal AVM (rel. anatomy: p 50)
V = 1
Approach: Right parietal with resection
S = 2
Grade = 4
4-30a and b CT scans reveal a recent

large hemorrhage and its resolution. Before
this most recent hemorrhage, this young
woman had undergone extensive treatment
with craniotomy and clipping of feeders, pro
ton-be a m therapy, radiation therapy, and
repeated embolization. From the multiple
transfemoral approaches, she had required
bilateral femoropopliteal bypasses.
4-30c CT angiogram demonstrates the AVM with

its deep venous drainage.
4-30d Lateral internal carotid angiogram de mon
strates a portion of the AVM.
4-30e Through a parietal a pproa ch, the AVM

is e xpos e d.
4-30f The medial portion of the AVM is e xpos ed

with a large venous aneurysm protruding into the
ventricle.
4-30g Pathological s pe cime n.

4-30h Postoperative CT s ca n.
4-30i Postoperative angiogram de mon

strates removal of the AVM. This patient had
no new neurological deficits and made an
excellent recovery from the severe recent
hemorrhage. She can ambulate inde pe nde nt
ly but has right-s ide d weakness .
4–31
E = 1
Diagnosis: Left parieto-occipital AVM
V =0
S = 3
Approach: Left frontoparieto-occipital with resection
(rel. approach: p 72) Grade = 4
4-31a and b MR images reveal areas of

past hemorrhage from a diffuse cortical AVM.
This 10-year-old boy had no neurological
deficits and excelled academically.

angiograms reveal the AVM with a small
compone nt associated with an aneurysm
medially (a rrow).
4-31e Late venous phase angiogram

shows the unusual venous drainage.
4-31f External carotid artery angiographic injec

tion reveals the feeders to the AVM.
4-31g Through a high parietal exposure, the

AVM—with its arterial aneurysm—is e xpos e d.
4-31h The aneurysm is rese cte d.

4-31i and j Repeat angiograms after the

initial stage show elimination of the aneurysm
with the AVM being restricted to the inferior
parietal and occipital regions.
4-31k Through a frontopa rie to-occipita l crani

otomy, the cyst tha t defines part of the AVM
is e xpos e d.
4-31l The AVM is visible before resection.
4-31m After resection, a postoperative

angiogram demonstrates no residual AVM.
4-31n CT scan reveals removal of the AVM

with a large area of hygroma from the
de compre sse d cys t. The patient's recovery
was uneventful and he remained an excellent
student with no neurological deficits.
Case 4–32
E = 1
V = 0
(rel. anatomy: pp 28, 29, 31, 32)
S = 3
Grade = 4
4-32a and b Anteroposterior

and lateral angiograms in a young
woman with incapacitating
headaches and intermittent
episodes of aphasia. A previous
craniotomy had a tte mpte d to
reduce the size of the AVM and to
clip feeders from the contralateral
internal carotid artery. The patient
also had undergone proton-bea m
therapy and several trials
of embolization.
4-32c The AVM is exposed in the left anterior

fos sa .
4-32d The AVM is mobilized, exposing the left

internal ca rotid artery and optic nerve.
4-32e Postoperative angiogram after the first 4-32f Opening during the s e cond stage reveals
stage reveals residual AVM with much slower flow. the radiographic marker (a rrow) left during the first
A radiographic marker from a sponge wa s left at s ta ge . The large draining vein is visible superiorly.
the posterior edge of the AVM to verify its border
during angiography.
4-32g The posterior edge of the AVM is

separated from its vascular supply.
4-32i After the AVM has been re se cted,

the empty anterior fos s a is visualized. The
internal ca rotid artery, anterior cerebral
artery, and optic chiasm are visible. The pitu
itary stalk is visible below the optic chia s m.
4-32h The AVM is separated from all sides 4-32j and k Postoperative anteroposterior
but is still a tta che d to its venous pedicle and lateral angiograms reveal comple te oblit
(a rrow). eration of the AVM.
Case 4–33
E = 1
Diagnosis: Left insular AVM (rel. anatomy: p 34)
V = 1
S = 2
Grade = 4
4-33a and b Antero

posterior and lateral
angiograms of a left
insular AVM. The
patient had multiple
previous hemorrhages.
4-33c Through the Sylvian fissure, the normal

middle cerebral artery vessels as well as the large
draining venous varices are visible.
4-33d With further dissection, the major middle

cerebral artery trunk and normal branches are sepa
rated from the adjacent AVM.
4-33 e After the AVM has been removed, the insular

corte x, along with the overlying middle cerebral
artery trifurcation a nd insular bra nches, is visible.
4-33f Pathological s pe cime n.
4-33g and h Ante roposterior and lateral

angiograms demonstra te comple te oblite ration of
the AVM. The patient suffered no new neurological
deficits.
Case 4–34
E = 1
Diagnosis: Left parietal AVM with hematoma
V = 1
Approach: Left parietal with resection
S = 2
Grade = 4
4-34a Unenhanced and enhanced CT scans are

consistent with hematoma. The feeding vessels of
the AVM are also enhanced.
4-34b Selective left internal carotid artery 4-34c Anteroposterior angiogram de mon
angiogram demonstrates that part of the AVM strates a portion of the AVM and the outline
is being fe d by the anterior cerebral artery. of the hematoma.
4-34e The apex of the AVM is identified. Here

the disse ction will proce e d. The underlying
hematoma has the advantage of having already
dis s e cte d half of the AVM, making the excision
much easier.
4-34d The AVM is e xpos e d through a left

parietal cra niotomy extending across the
midline.
4-34f Dissection of the AVM is initia ted. Notice

tha t all the expose d brain a nd AVM outs ide the
actual area of surgical manipulation are covered
with moist Gelfoam.
4-34g A small portion of AVM remains

a tta che d medially and interiorly along the
corpus ca llos um. Notice the pale color of a
portion of the AVM secondary to previous
embolization.
4-34h Following removal of the AVM and

the hematoma, the hemosiderin-stained
cavity is visualized. Notice the sharp rim
between normal brain a nd the cavity.
4-34i A lateral angiogram demons trate s
comple te removal of the AVM.
4-34j An anteroposterior angiogram

de mons tra te s removal of the AVM and
outlines the extent of the craniotomy.
Case 4–35
E = 1
Diagnosis: Left parietal AVM
V = 1
Approach: Endovascular, left parietal with resection
S = 2
Grade = 4
4-35 a, b, and c MR images reveal a left

parietal AVM in a patient who presented with
a hemorrhage.
4-35d and e Anteroposterior and lateral
angiograms show a left parietal AVM, which
extends from the cortica l surface to the ve n
tricular surface.
4-35f and g After glue embolization, the

size of the AVM is reduced significantly; how
ever, the deep feeding vessels could not be
embolized successfully.
4-35h The AVM is e xpos e d, a nd a cortica l dis

section is initiated along its anterior border.
4-35i The thrombos e d vein can be followe d into

the de pth of the AVM.
4-35j The thrombos e d AVM is clippe d and divide d.

4-35k A large feeding vessel full of glue is cut.
4-35l The AVM, which is completely separated

from the surrounding corte x, is ready to be lifted
from its be d.
4-35m Postoperative angiogram reveals

comple te removal of the AVM. The patient's
preoperative aphasia and right hemiparesis
were uncha nge d.
Case 4–36
E = 1
Diagnosis: Left thalamic AVM
V = 1
Approach: Left temporoparietal with resection
S = 3
Grade = 5
4-36a MR image of acute hemor

rhage from a thalamic AVM. The
patient presented in a moribund
condition.
4-36b Left internal ca rotid artery
angiographic injection reveals a
deep thalamic AVM. The flow
through the remainder of the te rritory
of the internal ca rotid artery is poor.
4-36c An emergency craniotomy

exposes a large hematoma overlying
the AVM.
4-36d Through the a pproa ch pro
vided by the hematoma cavity, the
AVM is dis s e cte d and removed.
4-36e and f Postoperative angio

grams reveal comple te oblitera tion
of the AVM. The patient made an
unexpectedly good recovery with
return of function, including s low-
halting spe ech and sufficient mobili
ty of the right side to allow inde pe n
dent a mbula tion. She continues to
have weakness of the right upper
extremity.
Case 4–37
E = 1
Diagnosis: Right frontal AVM with previous ventricular
V = 1
hemorrhage. Flow-related aneurysms of the
S = 3
right PCA and right MCA (rel. anatomy:
pp 22, 31, 36, 50) Grade = 5
4-37a and b Contrast-enhanced CT scan

and MR image demonstrate a right frontal
AVM and its deep drainage. Note the venous
congestion of the brain parenchyma.
4-37 c, d, e, and f Anteroposterior and lat

eral angiographic injections of the right and
left internal carotid arteries opacify the huge
AVM and a flow-related aneurysm on the
right middle cerebral artery (a rrow).
Approach: Endovascular, anterior interhemispheric, stereotactic

radiosurgery, and GDC embolization of the PComA aneurysm.
Right pterional with clipping of the MCA aneurysm
(rel. approaches: pp 75, 80, 82-85)
4-37g and h Left antero

posterior and lateral vertebral
artery angiographic injections
visualize a small nidus located
in the roof of the third ventricle
(a rrow).
4-37 i, j, and k After several endovascular

sessions, the size of the AVM is reduced
markedly.
Gra de 5 S upra te ntoria l Arte riove nous Ma lformations 461
4-37l After an interhemispheric exposure 4-37m Further dissection reveals the 4-37n After the AVM is resected, the bed
and reflection of the dura, the cortex is embolized part as well as the patent nidus. is covered with Surgicel and fibrin glue. The
exposed. Note the glue in some of the corti tip of the ventricular catheter is located in the
cal feeders. third ventricle. The left anterior cerebral artery
is now separated from the AVM.
4-37 o, p, and q Immediate postoperative

angiographic injections of both common
carotid arteries and the left vertebral artery
show minimal filling of pathological vascular
structures in the posterior part of the corpus
callosum.
4-37r and s Anteroposterior vertebral
artery angiograms before and after GDC
treatment of the flow-related posterior com
municating artery aneurysm. A perforating
branch (a rrow) arises from the aneurysm
neck.
4-37 t Six months later, angiography of the

right internal carotid artery before radio
surgery shows a small central nidus as well
as residual AVM structures in the splenium
(a rrows ). The size and shape of the middle
cerebral artery aneurysm are unchanged.
4-37u and v Microsurgical perspective of

the right middle cerebral artery after the Syl
vian fissure is ope ne d. The neck of the
aneurysm is diss e cte d and occlude d with
two straight clips .
4-37w and x Angiograms after clipping of

the right middle cerebral artery aneurysm
s how the occlus ion of the aneurysm as well
as the disappearance of the small residual
AVM.
4-37y a nd z Ante roposterior a nd lateral

vertebral artery angiograms 1 year after tre a t
ment s how tha t the posterior communica ting
artery has remained occlude d. The small per
forating branch is visible (a rrow).
Case 4–38
E = 1
Diagnosis: Left thalamic AVM (rel. anatomy: pp 29, 32)
V = 1
Approach: Endovascular, left pterional with embolization,
S = 3
and stereotactic radiosurgery (rel. approaches:
Grade = 5
pp 80, 82-85)
4-38a CT scan reveals a hemorrhage in a patient

who experienced repeated hemorrhages that
caused slow progressive neurological de teriora tion.
He had profound weakness of the right side and
significantly impaired s pe e ch.
4-38b and c Angiographic views of the AVM

after surgical removal of the hematoma and tra ns-
femoral embolization.
4-38d Exposure of feeding vessels from the

anterior and middle cerebral arteries.
4-38e Proximal vessel occlusion with a clip

allows extensive injection of glue into a feeding ves
sel tha t arises from the anterior cerebral artery.
4-38f The glue within the s e cond embolized ve s

sel is visible.
4-38g A third vessel is injected with glue. Intra

operative injection allows very small vessels to be
cannulated and injecte d, providing excellent high-
pressure casting of the nidus of the AVM.
4-38h and i Anteroposterior and lateral skull

radiographs demonstrate glue in the perforators.
A solid cast of the deep portion of the AVM was
thus a ccomplis he d.
4-38j CT scan demonstrates glue in the AVM.
4-38k and I Postoperative angiograms reveal

dramatic diminution of flow through the AVM. The
patient improved significantly as he recovered from
his previous hemorrhages. To date, he has had no
recurrent hemorrhages. Stereotactic radiotherapy
was directed towa rd the largest residual compo
nent of the AVM.
Case 4–39
E = 1
Diagnosis: Giant AVM, right frontoparietal
V = 1
Approach: Endovascular, right frontoparietal with
S =3
Grade = 5
4-39a A CT scan demonstrates the extent

of a large right frontoparietal AVM. Progres
sive neurological deterioration, involving
hemiparesis and multiple hemorrhages, led
to the surgical management of this lesion.
4-39b A lateral angiogram following several

embolizations of the right internal carotid
artery. The AVM, although unchanged in size,
has changed in flow so that now hemispheric
vessels appear angiographically for the first
time. The venous drainage, although impres
sive, has no bearing on the resectability of an
AVM.
4-39c Anteroposterior angiogram of the

AVM after initial embolization. Prior to internal
carotid artery embolization, the anterior
cerebral artery filled only from the contralateral
side. The appearance of flow into this vessel
is an indication of decreased flow through the
AVM along with the appearance of the normal
hemispheric vessels.
4-39d An external carotid artery injection

on the right demonstrates significant filling of
the intracranial AVM. Typical of these giant
AVMs, in which stepwise obliteration is
mandatory, feeding of the AVM through
extracranial vessels is the rule. All the external
feeders were embolized until they were com
pletely oblite rated. This maneuver is not only
efficient in decreasing the flow through the
AVM but makes operative exposure much
easier, since the channels from the scalp to
the dura are no longer viable. It is essential
tha t embolization results in occlusion of the
central portion of the AVM. Occlusion of
feeding vessels remote from the AVM is not
only ineffective but makes later correct
embolization much more difficult.
4-39 e Exposure of the hemisphere adjacent to

the AVM reveals thrombos e d nonviable feeding
vessels secondary to previous embolization.
4-39f A feeding middle cerebral artery vessel has

been cut and cannulated prior to intraoperative
embolization.
4-39g Notice the vascular pa ttern and color prior

to embolization.
4-39h A significant portion of feeding vessels

and underlying AVM has blanched from the
intraoperative embolization. During this s tage , the
middle cerebral artery contributors were cut and
embolized. One week later, the same technique
was utilized for the anterior cerebral artery with
exposure, ligation, and embolization.
4-39i The final appearance of the AVM is shown

prior to resection. Notice tha t a large portion of
the lesion has now thrombos e d, although viable
vessels are still present. Also notice the normal
appearance of the surrounding hemisphere.
4-39j The AVM has been dissected to its most

medial extent. At this stage, it is virtually devas cu-
larized. Nevertheless, the small deep perforating
AVM vessels require particular a tte ntion. They are
often difficult to coagulate since they have a
propensity to retract into the white matter and
thus make subsequent obliteration and occlusion
particularly difficult.
4-39k Lateral and anteroposterior angiograms

show the stepwise obliteration of this large AVM.
The first two lateral views demonstrate the AVM
following several embolizations through the internal
ca rotid artery and external carotid artery. The next
two views demonstrate the AVM following the first
intraoperative embolization of the middle cerebral
artery feeding vessels. The next two lateral
angiograms demonstrate the residual AVM follow
ing anterior cerebral artery embolization and liga
tion. The final two angiograms demonstra te the
removal and obliteration of the AVM in its entirety.
4-39 l An anteroposterior angiogram of the
right internal carotid artery demonstrates (on
the initial frame) the large middle cerebral
artery feeding vessels.
The s e cond frame is after middle cerebral artery
embolization a nd ligation. The AVM is being fe d
almost completely from the anterior cerebral
artery. The left lower frame demonstrates residual
AVM following obliteration and embolization of the
anterior cerebral artery feeder. Notice the improved
circulation of the remaining portion of the hemi
sphere with each subsequent sta ge . A final
angiogram reveals comple te obliteration
of the AVM.
Case 4–40
E = 1
Diagnosis: Right medial parietal splenial thalamic AVM
V = 1
S = 3
Approach: Endovascular, posterior interhemispheric, and
stereotactic radiosurgery (rel. approach: p 75) Grade = 5
4-40a and b MR images reveal an exten

sive AVM tha t involves the right medial pa ri
e tooccipita l lobe and the corpus callosum,
extending intraventricularly into the thalamus.

angiograms show the portion of the AVM
that fills from this injection.

angiograms after extensive glue embolization
in two stages. Note tha t the AVM is obliterat
ed except for a number of small deep perfo
rating branches (a rrow).
4-40g and h Through vertebral

artery angiographic injections,
the remaining portion of the AVM
is visualized.
4-40i and j With the two-s ta ge

embolization, the size of the AVM is
markedly diminished.
4-40k Intraoperative angiogram performed

before resection shows significant recanaliza-
tion of the AVM via the vertebral artery. Com
pare this to Figure 4-40i, the immediate
postembolization angiogram.
4-40 l Through a posterior interhemispheric

a pproa ch, the falx is cut a nd the AVM is
a pproa che d from the contralaferal side.
4-40m The thrombos e d a nd viable vessels are

coa gula te d and cut.
4-40n The viable portion of the AVM is visible

adjacent to a solid glue ca s t.
4-40o The resection reaches the AVM portion

extending into the roof of the third ventricle. Note
tha t the vein tha t had originally been red has now
turned blue.
4-40p Immediate postoperative angiogram

reveals a small portion of residual AVM in the
roof of the third ventricle. The aneurysm clip,
which was placed for localization during
surgery, was removed after the comple tion
of angiography.
4 -4 0q , r, s , and t Six months after the

completion of surgery, angiograms reveal the
residual nidus of the AVM, which was treated
with stereotactic radiation.
4-40 u, v, w, and x Posterior vertebral

artery and common carotid artery injections
performed 1 year after stereotactic radio
surgery demonstrate very slow flow through
a small residual portion (a rrows ) of the AVM.
In fra te n to ria l Arte rio ve n o u s Ma lfo rm a tio n s

Case 4–41 E =0
Diagnosis: Vermian AVM (rel. anatomy: pp 49, 52, 56) V =0
Approach: Endovascular S = 1
Grade = 1
4-41a MR image reveals a 1.5-cm AVM

at the tip of the vermis.
angiograms reveal a small AVM fe d by a
branch from the left superior cerebellar artery.
4-41d Superselective angiography reveals
a vermian branch (a rrow) and feeder to the
nidus.
4-41e The catheter has been advanced
past the vermian branch.
4-41f Lateral superselective injection

shows the AVM with its draining vein.
4-41g The cast as seen from its antero
posterior projection.
Gra de 1 Infra te ntoria l Arte riove nous Ma lforma tions 479
4-41h and i Postembolization angiograms

demonstrate the disappearance of the AVM.
4-41j Nine-month follow-up MR image

shows obliteration of the AVM.
4-41k and I Three-year follow-up MR

angiogram and MR image show continued
obliteration of the AVM.
Case 4–42
E =0
Diagnosis: Cerebellar AVM with associated aneurysm on
V =0
a feeding artery (rel. anatomy: pp 65, 67, 68)
S =2
Approach: Endovascular, paramedian suboccipital with
Grade = 2
4-42a Anteroposterior angiogram reveals

a cerebellar AVM with an aneurysm (a rrow) on
a feeding pedicle and a small aneurysm at
the origin of the posterior inferior cerebellar
artery (double a rrow).
4-42b Lateral angiographic view shows
a coil (a rrow) within the aneurysm before
embolization of the AVM.
4-42c After embolization, flow through the

AVM is reduced markedly. The stagnated
flow through the posterior inferior cerebellar
artery is visible. Note the coil (a rrow) occlud
ing the aneurysm.
4-42d Before surgery 2 weeks later, the
AVM has partially recanalized. The aneurysm
remains occlude d by the coil (a rrow). A small
posterior inferior cerebellar artery aneurysm,
presumed to be flow related, is visible
(double a rrow).
4-42e Through a paramedian suboccipital

craniotomy, the cerebellar AVM is e xpose d. The
partially embolized AVM is dissected from the sur
rounding cortex.
4-42f The e xpos e d draining vein is thrombos e d.
4-42g The AVM is mobilized completely and left

a tta che d to its venous pe dicle.
4-42h and i Postoperative anteroposterior

and lateral vertebral artery angiograms
de mons tra te resection of the AVM. The
coiled aneurysm remained occlude d (a rrow);
the small flow-re la te d posterior inferior ce re
bellar artery aneurysm is still visible (double
a rrow).
Case 4–43
E = 1
Diagnosis: Left brainstem AVM
V = 0
(rel. anatomy: pp 53, 57, 58, 60, 61, 64-66)
S = 1
Approach: Left petrosal retrolabyrinthine with resection
Grade = 2
4-43a CT scan demonstrates s uba rach

noid hemorrhage. The te mpora l horns of
the lateral ventricles are dila te d.
4-43b Anteroposterior vertebral artery

angiographic projection shows small AVM
draining into the superior petrosal sinus.
4-43c On top of the junction of the trigeminal

nerve and the brainstem, an AVM is present.
Engorged veins drain directly into the superior pe
trosal sinus.
4-43d The AVM was mobilized and rese cte d.
4-43e A lower view along the brainstem visual

izes the lower cranial nerves as they exit their
respective foramina.
4-43f Postoperative angiogram reveals

obliteration of the AVM. The patient e xperi
enced no new neurological deficits.
Ca0se 4–44
E = 1
Diagnosis: Left cerebellar hemispheric AVM
V = 0
S = 1
Approach: Endovascular, left retrosigmoid with
Grade = 2
resection (rel. approaches: pp 108, 109)
4-44a and b Early and late

phase anteroposterior
angiograms demonstra te
left cerebellar AVM.
4-44c AVM, which has been resected adjacent

to the brainstem, remains a tta ched to its venous
pedicle.
4-44d Postoperative angiogram reveals

Grade 3 Infra te ntoria l Arte riove nous Ma lforma tions 485
Case 4–45
E = 0
Diagnosis: Right cerebellar AVM (rel. anatomy: p 56)
V = 1
Approach: Infratentorial supracerebellar with resection
S = 2
Grade = 3
4-45a and b Anteroposterior

and lateral angiograms of a
patient with a cerebellar AVM
that hemorrhaged, precipitating
a 1 -month coma . An a tte mpt a t
embolization was unsuccessful.
4-45c Through a posterior fossa craniotomy, the

cerebellum is exposed along the transverse sinus.
4-45 d The cerebellum is de pre ss ed.

4-45e The AVM is identified below the falx and

the te ntorium.
4-45f The AVM is mobilized completely.
4-45g Postoperative angiogram reveals comple te

oblite ra tion of the AVM. This patient had no new
neurological deficits and made a slow steady
recovery from his initial hemorrhage.
Case 4–46
Diagnosis: Right lateral brainstem AVM E = 1
(rel. anatomy: pp 45, 49, 51, 52) V =0
Approach: Right retrosigmoid infratentorial S =2
supracerebellar with resection Grade = 3
(rel. approaches: pp 108,109)
4-46a A submental vertex view of left ver 4-46b Lateral arterial phase angiogram
te bra l artery angiogram demons trate s the de mons tra tes the extent of the AVM and the
fe eding vessels to the right pontine -midbra in early draining veins.
AVM. Important in this first a ngiogra m, is the
identification of the two feeders from the
superior cerebellar artery.
4-46c Late arterial phase angiogram 4-46d A lateral view localizes the AVM.
de montra te s the venous drainage of the AVM.
4-46e The right ambient cis tern is exposed 4-46f The right ambient ciste rn is ope ne d; 4-46g The abnormal vessels surrounding
through an infratentorial supracerebellar a nd for further exposure, the anterior edge of the AVM are visualized. The two fee ding
a pproa ch. the right cerebellar hemisphere is incise d. arteries from the superior cerebellar artery
are coa gula te d and cut.
4-46i A submental view of the left vertebral 4-46j A lateral angiogram demonstrate s
angiogram demonstra te s absence of feeding absence of the AVM.
vessels to the AVM.
4-46h View after extirpation of the AVM

from the midbra in.
Case 4–47
E = 1
Diagnosis: Cervicomedullary AVM (rel. anatomy: p 67)
V =1
Approach: Midline suboccipital spinal with resection
S = 2
(rel. approaches: pp 102, 103, 106)
Grade = 4
4-47a T2-we ighte d MR image de mon 4-47b and c Right and left anteroposterior
strates edema above and below a cervico vertebral artery angiograms show multiple
medullary lesion identified as an AVM. feeders to the cervicomedullary AVM. A large
Atte mpts at embolization failed after an venous aneurysm is apparent from the right
amytal challenge. vertebral artery injection.
4-47e After a midline suboccipita l spinal

approach was pe rformed, the cervico
medullary AVM with the venous drainage is
clearly visible.
4-47 d Lateral angiographic projection

shows venous drainage into the deep venous
system. This 16-month-old female presented
with the sudden onset of quadriparesis.
4-47f With further dis s e ction, the two vertebral

arteries are e xpos e d. Vessels leading directly to the
AVM were followe d carefully. When it could be
ascertained tha t the vessels went directly to the
AVM, they were s a crifice d.
4-47g The nidus of the AVM is mobilized carefully

and separated from the medulla.
4-47h With further dis s e ction, the AVM is cir

cums cribe d and left atta che d to its venous
aneurysm and pe dicle.
4-47i The AVM is removed, leaving behind a

collapsed segment of cervicomedullary junction.
Compare this view to Figure 4-47 e where the
medulla was expanded from the intramedullary
venous aneurysm.
4-47j and k Right and left anteroposterior improved on the day of surgery. She eventu
vertebral artery angiographic projections ally recovered completely and had no neuro
demonstrate comple te obliteration of the logical deficits. Questionable hyperreflexia
AVM with preservation of all the normal was present at her 5-year follow-up examina
branches. This patient's quadriparesis tion.
Case 4–48
Diagnosis: Left cerebellar AVM E = 1
(rel. anatomy: pp 45, 51-53, 56, 57, 65-67) V = 1
Approach: Endovascular, left subtemporal and S = 3
paramedian suboccipital with resection Grade = 5
(rel. approaches: pp 93,107)
4-48a CT scans demonstrate an AVM

replacing the entire left cerebellar hemisphere.
A shunt tube has been in place for the past
12 years for obstructive hydrocephalus.
Progressive difficulty with cerebellar function
and brainstem ischemia indicated surgical
evaluation of this AVM.
4-48b A selective vertebral artery injection

reveals an AVM fe d by all vessels originating
from the basilar artery. The large venous
drainage leads primarily into the internal
jugular vein.
4-48c Selective catheterization of the right

vertebral artery demonstrates filling only of
the AVM. Injection of the left vertebral artery
similarly fills the lesion exclusively. The
venous drainage as seen from the front,
although obviously going across the midline,
has no importance in deciding the resectabili-
ty of this lesion. Both selective internal ca rotid
artery catheterizations also de mons tra te d
excellent filling of the AVM. An important
observation is the outline of the AVM, in tha t
its shape implies a complete infratentorial
unilateral location.
4-48d Selective catheterization of various

external ca rotid artery branches show differ
ent additional portions of the AVM being fe d
by this route.
4-48e and f Injection of the contralateral

external ca rotid artery reveals a bra nch filling
a portion of the AVM. An additional anterior
view of an ipsilateral external ca rotid artery
bra nch also fills the AVM.
4-48g Each of the external carotid artery

contributors to the AVM is obliterated with
embolization. The postembolization film on
the right reveals filling of other external
ca rotid artery branches from the reflux of the
obliterated occipital artery.
4-48h Following multiple embolizations of 4-48i Following the clipping of this feeder, 4-48j Following the occlusion of the con
selectively catheterized contributing vessels, several other superior cerebellar artery con tributing superior cerebellar artery branches,
the first operative step is a subtemporal tributors are obliterate d. The use of the s urgi this operative stage is conclude d.
approach to the left ambient cis te rn. The te n cal mirror allows visualization of the undersur-
torium has been re tra cte d, and a very large face of the tentorium to allow further oblitera
superior cerebellar feeding vessel is identi tion of contributing vessels. The inspection of
fie d. the inferior surface of the te ntorium with the
surgical mirror allows separation of adherent
portions of the AVM prior to cutting the te n
torium.
4-48 k, I A selective internal

carotid artery injection. The
left view is prior to and the
right view is following the s ub
te mpora l a pproa ch.
4-48m One week after the subtemporal 4-48n A view of the upper portion of the The main body of the AVM was resected over
a pproa ch, the AVM is exposed through a cerebellar hemisphere reveals more 17 hours. One week later, the remaining por
paramedian suboccipita l craniotomy. The embolized vessels and AVM. tion of the AVM was removed. A reduction in
previous embolization of the external feeders 4-48o Following partial resection of the cerebellar dysfunction and the absence of fur
makes this a viable a pproa ch. Upon incising AVM, further previously embolized vessels ther brainstem ischemia allowed this patient to
the dura in the midline, the cerebellar AVM is are visible. In this unusual case, where the return to work.
e xpos e d. No cerebellar remnant is visible on feeding vessels could not be approached
the left. The right cerebellar hemisphere directly because of intervening AVM, the
seemed to be intact and normal. The non embolized arterial feeders were of significant
viable opaque white vessels are the result of help in separating the arterial from the venous
previous embolization. compone nt of the AVM.
4-48p A postopera tive arteriogram after

the main portion of the AVM has been
res e cted.
4-48q On the left, an intraoperative

angiogram demons trate s minimal residual
AVM. On the right, the final angiogram can
be seen with comple te absence of the AVM.
Dural Vascular Ma lforma tions 499
Dural Vas cular Ma lfo rm a tio n s

Cavernous Sinus Fis tulae
Case 4–49
Diagnosis: Bilateral traumatic carotid-cavernous sinus fistula
and aneurysm (rel. anatomy: pp 5-16, 20)
4-49a and b Right lateral internal carotid

artery angiograms demonstrate a cavernous-
sinus aneurysm with a small fistulous compo
nent. The aneurysm continued to grow
despite endovascular treatment.
4-49c and d Left internal carotid artery
angiograms demonstra te the cavernous-
sinus fistula with aneurysmal growth over
time despite endovascular packing.
4-49e and f Right and left anteroposterior
internal carotid artery injections show that
emPolization failed to obliterate the growing
aneurysm despite repeated a tte mpts .
4-49g and h Right and left internal ca rotid
artery injections demonstrate severe bilateral
carotid-artery stenosis resulting in ischemic
s ymptoms .
Case 4–49
Approach: Endovascular, subtemporal petrosal and pterional with
bilateral internal carotid artery-to-internal carotid artery
saphenous-vein bypass (rel. approaches: pp 80, 82-85, 92, 93)
4-49i The saphenous vein is prepared for a

petrous bone internal ca rotid a rte ry-to-s uba ra ch-
noid internal carotid artery bypass.
4-49j The petrous portion of the left internal

carotid artery is e xpos e d. A permanent clip is
placed as the internal carotid artery enters the
cavernous sinus.
4-49k The internal carotid artery and the petrous

bone have been cut in preparation for an e nd-to-
end anastomosis to the saphenous vein.
4-49l The saphenous vein is being anastomos ed

to the internal ca rotid artery in the petrous bone .
4-49m The other end of the saphenous-vein

graft is anas tomosed to the internal ca rotid artery
below the optic nerve.
4-49n Overview of the vein graft from the

petrous bone to the subarachnoid s pa ce .
4-49o Upon completion of the first 4-49p The patient underwent a right internal
bypass, good circulation is maintained carotid artery-to-internal carotid artery saphe-
in the internal carotid artery. Note the nous-vein bypass 1 week later. Postoperative
back flow to the ophthalmic artery angiogram demonstrates filling of the supra te n-
(a rrow). torial compa rtme nt through both internal ca rotid
artery saphenous-vein bypasses. The patient
had no further ischemic events.
Ca s e 4–50
Diagnosis: Left carotid-cavernous sinus fistula. Flow-related aneurysm
of the right PComA (rel. anatomy: pp 10, 13-16)
This patient's left carotid-cavernous fistula was 4-50a CT scan s hows the enlarged vein
treated more than 20 years ago by surgical draining from the left cavernous sinus towa rd
occlusion of the left internal carotid artery in the petrous sinus.
the neck and subsequent trapping at the level of
C2. Recently, the patient developed a left-sided
chemosis aproptosis and a retro-orbital bruit.
4-50b and c Right internal ca rotid artery

angiograms de mons tra te an aneurysm of the
posterior communica ting artery before and
after GDC occlus ion.
4-50d and e Left anteroposterior and later

al common ca rotid artery angiograms show
the internal ca rotid artery filling via the anas
tomos is from the external ca rotid artery. The
ca rotid-ca ve rnous sinus fistula drains via an
enlarged superior petrosal sinus as well as
via a small conne ction to the vein of Galen.
4-50f The endovascular venous a pproa ch 4-50g Superselective angiogram is per

is via the superior petrosal sinus and the cav forme d through the venous microcatheter
ernous sinus through the fistula into the distal after GDC occlus ion of the distal internal
internal ca rotid artery. ca rotid artery.
4-50 h Left common ca rotid artery injection

demonstrate s tota l occlusion of the fistula.
Case 4–51
Diagnosis: Traumatic cavernous-sinus fistula (rel. anatomy: pp 10, 13-16)

internal carotid artery angiograms de mon
strate a large cavernous-sinus fistula resulting
from tra uma 1 year earlier. Despite ophtha l
moplegia, the patient had sought no
treatment. During this pe riod, the fistula
developed and changed from a pure ca rotid-
to-cave rnous sinus fistula into a ca rotid-
cavernous and left external carotid artery-
cavernous fistula.
4-51c and d The fistula is

treated by sacrificing the left
internal carotid artery by
balloon occlusion.
4-51e Repeat external carotid artery

angiogram performed 6 months later
because of recurring s ymptoms reveals
revascularization of the fistula.
506 Arteriovenous Malformations of the Brain
4-51f The external compone nt of the fistula

is obliterated using particle embolization.
4-51g Left vertebral artery angiographic
injection reveals retrograde filling of the cav
ernous sinus through the posterior communi
cating and internal carotid arteries.
4-51h With superselective catheterization
through the vertebral to the posterior com
municating arteries and then retrograde
through the internal carotid artery, the fistula
is occlude d with coils.
4-51i Vertebral artery angiographic injection
demonstrates patency of the posterior com
municating artery without further filling of the
fistula.
4-51j One-year follow-up external ca rotid

artery angiogram demonstrates continued
obliteration of the cavernous-sinus fistula.
4-51k Vertebral artery angiographic injec
tion performed 1 year after embolization
demonstrates continue d patency of the pos
terior communicating artery without filling of
the cavernous-sinus fistula. The patient
recovered from his ophthalmoplegia and has
remained as ymptomatic.
Case 4–52
Diagnosis: Posttraumatic carotid-cavernous sinus fistula (rel. anatomy: pp 10, 13-16)
4-52a and b Right anteroposterior and lat

eral internal ca rotid artery angiograms de mon
s tra te pos ttra uma tic ca rotid-ca ve rnous fistula.
4-52c and d The fis tula is

obs tructe d (a rrow) with GDC
coils placed through the fis tula
into the cavernous sinus.
The caliber of the internal
ca rotid artery is preserved.
4-52e and f One-year follow-up

angiograms de mons tra te continue d occlusion
of the fistula by the coils. A small residual
aneurysm is visible (a rrow).
Case 4–53
Diagnosis: Posttraumatic carotid-cavernous sinus fistula (rel. anatomy: pp 10, 13-16)
4-53a Left lateral internal ca rotid artery 4-53b A balloon placed through the inter
angiogram s hows a high-flow ca rotid-ca v nal carotid artery into the cavernous sinus
ernous sinus fistula. obliterates the fistula. The balloon extends
slightly into the internal ca rotid artery (a rrow).
4-53c and d One-year follow-up

angiograms de mons tra te continue d oblite ra
tion of the ca rotid-ca ve rnous sinus with mini
mal obs truction of the internal ca rotid artery
by the balloon (a rrow).
Dural Vascula r Ma lforma tions 509
Vein o f Ga le n Ma lfo rm a tio n s

Case 4–54
Diagnosis: Vein of Galen malformation (rel. anatomy: pp 37, 41, 49, 50, 59)

vein of Galen malformation with contributions
through the thalamoperforators.
4-54c and d Superselective catheterization

identifies two pedicles leading to the vein of
Galen malformation. These pedicles were
obliterated with glue.
4-54e and f Immediate postoperative

anteroposterior and lateral vertebral artery
angiographic injections show markedly
decreased flow through the vein of Galen
aneurysm. A thalamoperforator vessel con
tinues to feed the malformation. No further
embolization was performed at this stage.
4-54 g , h , i, j, k, and I One-year follow-up

angiograms reveal complete obliteration of
the vein of Galen malformation.
4-54m Late phase venous angiogram

shows alternative drainage with absence of
the deep Galenic venous system. The patient
is neurologically intact.
Case 4–55
Diagnosis: Vein of Galen malformation (rel. anatomy: pp 49, 50)
4-55a and b MR images of a 2-we e k-old

infant who pre sente d with an enlarging heart
and cardiac failure.
4-55c and d Ante roposte rior and lateral 4-55e Through a transfemoral venous
angiograms show a vein of Galen malforma a pproa ch, coils are being place d in the
tion. venous sac.
4-55f and g Anteroposterior and lateral

venous angiographic projections just before
discontinuation of coil placement. Because
the last coils began to protrude into the
straight sinus, the embolization was dis con
tinue d. Continued partial drainage through
the venous sac is intentional to allow cardiac
a ccommoda tion.
4-55 h , i, j, and k Two-year follow-up

angiograms reveal obliteration of the vein of
Galen malformation with small residual
venous pouch (a rrow).
Case 4–56
Diagnosis: Vein of Galen malformation
(rel. anatomy: pp 39, 42, 48, 49, 50, 52)
Approach: Endovascular, posterior transcallosal with resection
4-56a MR image reveals a large circular

venous s tructure with significant thrombos is
4-56b and c After endovascular emboliza

tion of the rapid-flowing arterial pedicles to
the malformation, a residual arteriovenous
compone nt is visible (a rrow). This 6-year-old
patient presented with seizures and hydro
cepha lus.
4-56d The patient is prepared for a posterior

transcallosal a pproa ch. The dependent hemisphere
on the right will be retracted by gravity.
4-56e Exposure along the falx.
4-56f The corpus callosum is e xpose d with large

draining veins and a feeding artery.
4-56g After the splenium of the corpus callosum

has been ope ne d, the enlarged venous sac with
multiple feeding channels is revealed.
4-56h The arteriovenous compone nt can be

seen within the third ventricle , anterior to the
venous sac.
4-56i Close -up view of the arteriovenous con

ne ction anterior to the venous sa c.
4-56j Overview after the malformation has been

resected.
4-56k and I Postoperative anteroposterior

and lateral vertebral artery angiograms were
within normal limits. The child is normal ne u-
rologically.
Case 4–57
Diagnosis: Superior sagittal sinus dural AVM
Approach: Endovascular, anterior and posterior interhemispheric
4-57a External ca rotid artery angiogram

demonstrate s multiple feeders to a superior
sagittal sinus AVM.
4-57b Selective catheterization of the mid
dle meningeal branches before e mboliza tion.
4-57c After extensive embolization, the
AVM is almost obliterated but still continue s
to fee d through the falcine branch from the
ophthalmic artery and through small collateral
scalp and meningeal vessels. This 2-year-old
patient prese nted with a seizure a nd
papilledema.
4-57d Through a bilateral frontoparietal inter

hemispheric craniotomy, the superior sagittal sinus
is e xpos e d. The dura has been opene d bilaterally
along the superior sagittal sinus exposing the
enlarged aneurysmal dila ta tion.
4-57e Venous dilatation is visible.
4-57f Overview of exposure after skeletonization

of the superior sagittal sinus. The falx was cut in its
entirety up to the superior sagittal sinus anteriorly
and posteriorly.
4-57g Postoperative angiogram de mons tra tes

absence of the dural AVM.
Case 4–58
Diagnosis: Petrous dural AVM (rel. anatomy: pp 53, 57, 58, 64, 66)
Approach: Endovascular, right combined retrolabyrinthine with
resection (rel. approaches: pp 92, 94-100)
4-58a Lateral internal carotid artery angio 4-58c and d Anteroposterior and lateral
graphic injection demonstrates filling of the external carotid artery angiograms demonstrate
dural AVM through the meningeal branches filling of the AVM.
arising from the internal ca rotid artery. This 4-58e Vertebral artery angiographic injec
18-year-old male suffered a severe s uba ra ch tion reveals a component of the AVM fe d
noid hemorrhage while skiing. from the anterior inferior cerebellar artery and
4-58b Later phase angiogram demonstrates the superior cerebellar artery.
the venous drainage.
520 Arteriovenous Malformations of the Brain
4-58f Through a retrolabyrinthine a pproa ch,

the brainstem is e xpos e d.
4-58g The venous portion of the AVM is visible

after it has been dis conne cte d from its dural arterial
supply.
4-58h The AVM is mobilized completely jus t

before its final excision.
4-58i After excision of the arteriovenous pedicle,

the lateral aspect of the brainstem is visible.
4-58j Postoperative CT scan de monstra te s

the retrolabyrinthine a pproa ch.
4-58k a nd I Vertebral artery a nd internal

ca rotid artery angiograms de mons trate tha t
the AVM has been oblitera te d completely.
The patient made a slow and progressive
recovery to independent ambulation but wa s
left with a spastic gait.
Ca s e 4–59
Diagnosis: Torcular dural arteriovenous fistula
Approach: Endovascular, posterior fossa supra-infratentorial with resection
(rel. approaches: pp 102-105, 114-120)
4-59a Anteroposterior internal

ca rotid artery angiogram
de mons tra te s filling of a torcular
arteriovenous fistula .
4-59b Left vertebral artery
injection shows the feeding
and draining vessels of the
torcular fistula.
4-59c and d Pre- and pos te m-

bolization angiograms of the
external feeder to the torcula
show good reduction of flow
through the fistula.
4-59e After the size of the fistula has been diminished

significantly through e mbolization, a direct a pproa ch with a
bone flap above and below the torcula exposes the fis tu
lous compone nt. Clips pla ced across the arteriovenous fis
tula oblite rate it entirely.
4-59f and g Postoperative angiograms

de mons tra te comple te oblite ration of the fis
tula .
525
526 Ca ve rnous Ma lforma tions of the Brain
Ca ve rn o u s Ma lfo rm a tio n s
Introduction superficial point (point 2) and out toward the

Because cerebral cavernous malformations do skull, subcutaneous tissues, and skin. This line dic
not readily lend themselves to a classification sys tates the approach to be used for resection of the
tem, cerebral lesions are presented first followed lesion.
by those harbored in deeper locations that neces Important factors to be considered are the elo
sitate transcallosal approaches. Cavernous mal quence of the floor of the fourth ventricle, which
formations of the brainstem are presented supe often dictates a lateral approach even though a
riorly to inferiorly. direct approach through the floor of the fourth
The therapeutic approach to cavernous malfor ventricle would be technically easier. Placing a
mations should be individualized. Patients with point in the center of the lesion and connecting it
small, deep lesions may often lead normal lives. to the appropriate entry point dictates an angle
Familial patients with multiple lesions usually that avoids a tangential approach to the lesion as
have the symptomatic cavernous malformation would be possible if one considered only where
treated. In patients with a single lesion, the risk of the lesion comes closest to the surface. This
access and removal plays a pivotal role in decid important concept decreases the risk of addition
ing whether to remove the cavernous malforma al damage from retraction while removing the
tion. lesion.
Cavernous malformations coexist with venous
malformations. Because the resection of venous
malformations has been associated with ca
tastrophic infarction, we cannot overemphasize
the importance of leaving the venous malforma
tion intact. Only the cavernous malformation
should be resected.
We use a two-point method to access cavernous
malformations from below the craniovertebral
junction to above the tentorial incisura. (The
method, however, is universally applicable for
surgical lesions of the brainstem.) The objective
of the two-point method is to select the approach
that leads to the pathology while avoiding inci
sion of brainstem tissue. Hence, most lesions that
are to be approached surgically are close to or
contact a pial or ependymal surface.
A magnetic resonance (MR) imaging study that
includes the lesion in the sagittal, coronal, and
axial planes is obtained. The images in which the 5-0 Diagrammatic representation of how the two-point
center of the lesion can be assigned as well as me thod plots a (A) suboccipital and a (B) far-lateral
those images in which the lesion abuts or comes a pproa ch. In these two examples, similarly located lesions
closest to the pial or ependymal surface or over suggest quite different surgical approaches, illustrating the
importance of where the lesion nears a pial or ependymal
lying tissue are selected. A line is then drawn (Fig. surface. Re printe d with pe rmis s ion of the Ba rrow Ne uro-
5-0) from the center point (point 1) through the logica l Ins titute ®.
Ca ve rnous Ma lforma tions 527
Ca s e 5-1
Diagnosis: Small intrachiasmatic cavernous malformation
Approach: Left subfrontal unilateral (rel. approaches: pp 80, 81)
5-1a Through a left subfrontal unilateral 5-1b Under greater magnification, the 5-1c Through an opening into the chia s m,
exposure, the left optic nerve, chiasm, and expanded optic chiasm and tra ct are obvi the hematoma was eva cuated, and a small
tra ct are identified. Sudden onset of blind ously secondary to an area of underlying tangle of vessels was rese cte d. This was ver
ness and a small dense lesion on CT scan hemorrhage. ified pathologically as a cavernous malforma
prompte d this exploration. tion. Significant vision recovered immediately
and returned to normal by 3 months.
528 Cavernous Malformations of the Brain
Case 5-2
Diagnosis: Left parietal cavernous malformation
Approach: Left parietal (rel. approaches: p 72)
5 -2 a Compute d tomo
graphic (CT) scan de mon
strates a hemorrhagic lesion
in the speech area. The
patient presented with a
fluctua ting speech deficit.
5 -2 b MR image shows
the cavernous malformation
adjacent to the gyrus that was
used to expose the cavernous
malformation.
5 -2 c The cavernous malformation is resected

and all the pial vessels, including the adjacent
veins, are left intact.
5 -2 d View of the bed of the cavernous malfor

mation.
5 -2 e Pathological specime n. 5 -2 f Postoperative MR image after resec

tion of the cavernous malformation.
Case 5-3
Diagnosis: Right occipitoparietal cavernous malformation
Approach: Right occipitoparietal (rel. approach: p 72)

demonstrate multiple cav
ernous malformations in a
patient with a history of
familial cavernous malfor
mations. The patient's
symptoms were caused by
the large cavernous malfor
mation in the right occipi
toparietal region.
5-3c The craniotomy is performed over the cav

ernous malformation.
5-3d The cavernous malformation is separated

from the arachnoid and an en pa s s a ge artery.
5-3e The cavernous malformation, which has 5-3f Pathological specimen.

been circums cribe d completely, is being lifted from
its be d.
5-3g An arterial vessel e n pa s s a ge 5-3h Low-powe r view demonstrates the be d of

courses over the bed of the resected the resected cavernous malformation with several
cavernous malformation. vessels en pa s s a ge tha t have been s pa re d.
Case 5-4
Diagnosis: Right parietal cavernous malformation
Approach: Interhemispheric contralateral (rel. approach: p 75)
5-4 a and b MR images de mon

strate a 2-cm cavernous malforma
tion close to the midline.
5-4c Through a contralateral midline a pproa ch,

the falx is exposed and cut. The wand of the
frameless stereotactic guidance system is placed
over the cortex suspected of harPoring the cav
5-4d The frameless stereotactic guidance sys

te m image demonstrates the location of the cav
5-4e After the cortex is ope ne d, the cavernous

malformation is identified.
5-4f The cavernous malformation is pulled

through the falx ope ning.
5-4g Pathological spe cime n.
5-4h View into the hemosiderin-stained bed of

the cavernous malformation.
Case 5-5
Diagnosis: Right parietal cavernous malformation
Approach: Right parietal (rel. approach: p 72)
5-5a MR image demonstrates a large cav

ernous malformation that grew over a num
ber of years, resulting in mass effect and pro
gressive hemiparesis. Re printe d with pe rmis -
s ion of Ba rrow Ne urologica l Ins titute ®.
5-5d Postoperative CT scan demonstrates

removal of the cavernous malformation. The
patient improved progressively compa red to
his preoperative condition.
5-5b Through a right parietal craniotomy, the

cavernous malformation is expose d. Re printe d with
pe rmis s ion of Ba rrow Ne urologica l Ins titute ®.
5-5c The cavernous malformation is resected.

Note the intact pial vessels in the surrounding brain.
Case 5-6
Diagnosis: Left thalamic cavernous malformation
Approach: Anterior transcallosal contralateral
5-6 a, b, and c MR images demonstrate a

cavernous malformation of the anterior thala
mus.
5-6d With the right hemisphere down, a cra nio

tomy is performed crossing the midline. The open
dura along with the sagittal sinus is retracted with
dural sutures.
5-6e The falx is retracted upward and the right

hemisphere is retracted by gravity.
5-6f The corpus callosum is exposed in the mid

line. The sucker is retracting the inferior sagittal
sinus.
5-6g The contralateral ventricle is entered,

exposing the choroid plexus.
5-6h Looking anteriorly, the cavernous malforma

tion is visible in the left anterior thalamus.
5-6i With the round knife, the rim of the hemo-

siderin-stained thalamus is separated from the cav
5-6j Intraoperative view with the frameless

stereotactic guidance system.
5-6k Except for a small atta chme nt, the cav

ernous malformation is separated from the thala
mus.
5-6l With the resection comple te d, the frameless

stereotactic guidance system is used to verify the
comple te removal of the cavernous malformation.
5-6m The thin margin of the thalamus is visible

where the cavernous malformation has been
resected.
5-6n When the medial edge of the cavity is

retracted with the sucker, the foramen of Monro,
the fornix, and the choroid plexus are visible.
5-6o Pathological specimen.
5-6p A catheter is left in the lateral ventricle 1 to

2 days to avoid the risk of ventricular obs truction.
5-6q Postoperative MR image de mon

strates resection of the cavernous malforma
tion. Note the small opening on the corpus
callosum.
Case 5-7
Diagnosis: Right thalamic cavernous malformation
(rel. anatomy: pp 31, 32, 43, 50)

cavernous malformation and recent hemor
rhage in the right posterior thalamus.
5-7 d With the patient's head in the lateral pos i

tion and inclined 45°, the two hemispheres are
separated in the midline exposing the two perical
losal arteries. The patient's hemisphere is down.
5-7e When carried further, the dissection ex

poses the corpus callosum, which is being split.
5-7f The corpus callosum is ope ne d, exposing

the right lateral ventricle. The choroid plexus is visi
ble anteriorly. The wa nd of the frameless stereotac
tic guidance system has been placed on the sur
face of the right thalamus. This approach from the
left side of the falx into the right ventricle allows a
greater angle laterally in the thalamus than an ips i
lateral approach would provide.
5-7g The frameless stereotactic guidance sys

te m provides precise intraoperative knowledge of
where the cavernous malformation comes closest
to the surface.
5-7h Yellow staining is visible on the sur 5-7i After resection, the bed of the cav
face of the thalamus under which the cav ernous malformation is visualized along with
ernous malformation is loca te d. a deep venous malformation.
5-7 j The frameless stereotactic guidance

system is used to verify that the entire lesion
has been resected.
5-7 k Postoperative CT scan demonstrates

absence of the cavernous malformation with
just a small residual amount of blood in its
be d.
Case 5-8
Diagnosis: Left thalamic cavernous malformation

left thalamic cavernous malformation.
5-8d The bone has been exposed for a tra ns ca l

losal a pproa ch. Two-thirds of the bony opening is
in front of the coronal suture. A small burr hole is
made before making the saw cut.
5-8e Overview of the operative site with a retrac

tor pulling up the falx. The operation was per
forme d in front of the bridging vein.
5-8f The corpus callosum is identified. The left

pericallosal artery is retracted laterally to assure an
opening through the corpus callosum into the
appropriate lateral ventricle.
5-8g View through the contralateral ventricle

demonstrates the hemosiderin-stained surface of
5-8h The dissection of the cavernous malforma

tion is begun.
5-8i The cavernous malformation is being

removed.
5-8j Pathological spe cime n.

Case 5-9
Diagnosis: Cavernous malformation of the midbrain
(rel. anatomy: pp 18-21, 37-39, 41, 42, 44)
Approach: Left orbitozygomatic (rel. approaches: pp 88-91)
5-9 a and b MR images

demonstrate a large cavernous
malformation in the midbrain.
The cavernous malformation
comes closest to the
surface anteriorly dicta ting
an anterior a pproa ch.
5-9c After the left Sylvian fissure is exposed

through an orbitozygomatic craniotomy, the fissure
is opened and the middle cerebral artery is
e xpose d. The tip of the left temporal lobe is
exposed completely with this a pproa ch, which
allows extensive lateral exposure along the edge of
the te ntorium.
5-9d With retractors in place, the field is ce n

tered on the oculomotor nerve with visualization of
all of the adjacent vasculature.
5-9e Higher magnification demonstrates the

superior cerebellar artery and posterior cerebral
artery located in front of and behind the oculomo
tor nerve, respectively.
5-9f Retraction of the oculomotor nerve laterally

exposes the surface of the cavernous malformation
between the oculomotor nerve, superior cerebellar,
and posterior cerebral arteries.
5-9g After partial dis s e ction, the relationship of

the cavernous malformation to the surrounding
neurovascular structures can be a ppre ciated.
5-9h The cavernous malformation is being

removed.
5-9i The cavernous malformation is pulled a nte

riorly to allow further dissection before its final
evacuation.
5-9j Deep into the bed of the cavernous malfor

mation, a large vein is visible. This is a venous mal
forma tion, which must be left intact.
550 Cavernous Malformations of the Brain
5-9k Final overview of the bed of the cavernous

malformation with the wand of the frameless
stereotactic guidance system in place.
5-9l Placement of the probe into the bed of the

cavernous malformation in the brainstem de mon
strates on the frameless stereotactic guidance sys
te m tha t the surgical resection extends to the edge
of the cavernous malformation, suggesting its com
plete removal.
5-9m Postoperative CT scan demonstrates

some blood in the bed of the cavernous malforma
tion.
Case 5-10
Diagnosis: Midbrain cavernous malformation
(rel. anatomy: pp 17-21, 37-39, 41, 42, 44, 45)
Approach: Right subtemporal (rel. approach: p 93)
5-10a and b CT scan

and MR image de mon
strate a cavernous malformation
in the midbrain that extends
to the surface laterally.
5-10c Through an anterior subtemporal

a pproa ch, the edge of the tentorium is exposed
demonstrating the oculomotor nerve and surround
ing vasculature.
5-10d High-power view of the cavity after resec

tion of the cavernous malformation demonstrates a
large venous malformation.
5-10e Low-power view demonstrates the bed of

the cavernous malformation and its relationship to
the oculomotor nerve, the posterior cerebral artery,
and the superior cerebral artery.
5-10f Postoperative CT scan demonstrates

resection of the cavernous malformation.
Case 5-11
Diagnosis: Cavernous malformation of the midbrain
(rel. anatomy: pp 37-39, 42, 45, 46, 51-54, 6
Approach: Right combined retrolabyrinthine
5-11a and b MR images demonstrate a large

cavernous malformation. Resection had been
a tte mpte d several times.
5-11c The lateral exposure shows the previous

subtemporal craniotomy, the zygomatic process,
and the mastoid bone. A combine d retro-
labyrinthine approach was performed.
5-11d After the tentorium has been partially sec

tione d, the lateral portion of the midbrain is
e xpos e d. Significant adhesions are visible from the
previous surgery and hemorrhages. The cavernous
malformation is circumscribe d and ready for
removal.
5-11e After the cavernous malformation has

been re sected, a hole is present that allows visual
ization of the fourth ventricle through the midbrain.
5-11f Postoperative CT s ca n.
Case 5-12
Diagnosis: Cavernous malformation of the pons and
cerebellar peduncle with a venous malformation
(rel. anatomy: pp 53, 57, 58, 61, 64, 66)
Approach: Left petrosal retrolabyrinthine
5-12a MR image demonstrates a cavernous

malformation in the cerebellar peduncle and
pons extending to the surface both in the
fourth ventricle and in the subarachnoid
space . However, a large venous malformation
drains the region of the fourth ventricle, mak
ing a midline fourth ventricular approach haz
ardous. Recognizing the association of venous
malformations and cavernous malformations
is paramount to their successful treatment.
Because of the location of this venous malfor
ma tion, a retrolabyrinthine approach was
used to expose the cavernous malformation
without disturbing the venous malformation.
5-12b Late phase angiogram demonstrates

the venous malformation.
5-12c Through a retrolabyrinthine approach

working adjacent to the facial and vestibulo
cochlear nerve comple x, the cavernous malforma
tion is e xpos e d.
5-12d After the cavernous malformation is

removed, the bed is visualized.
Case 5-13
Diagnosis: Midbrain thalamic cavernous malformation
(rel. anatomy: pp 45, 46, 52, 53)
Approach: Left combined retrolabyrinthine
5-13a and b MR images demonstrate

a recently hemorrhaged cavernous
malformation.
5-13c After the petrous bone has been drilled

out, the labyrinth is visualized.
5-13d By cutting the superior petrosal sinus and

te ntorium, the cerebellum and tempora l lobe are
visible.
5-13e The midbrain has been e xpos e d, and a

hemosiderin stain demonstrates the location of the
cavernous malformation.
5-13f The cavernous malformation is removed.

5-13g The bed of the cavernous malformation

with a venous structure is visible.
5-13h The frameless stereotactic guidance sys

te m image verifies that the cavernous malformation
was removed.
5-13i Postoperative CT scan demonstrates

removal of the cavernous malformation.
5-13j Bone window of CT scan demonstrates

retrolabyrinthine a pproa ch.
Case 5-14
Diagnosis: Cavernous malformation of the quadrigeminal plate
(rel. anatomy: pp 48, 49, 50)
Approach: Infratentorial supracerebellar
(rel. approaches:pp 118-120)
5-14a MR image demonstrates a cavernous

malformation in the region of the quadrigeminal
plate with evidence of recent hemorrhage.
5-14b The patient is placed in the prone position

with the head moderately fle xe d.
5-14c From the top of the head, a craniotomy is

performed tha t crosses the two transverse sinuses
and the superior sagittal sinus. As long as the foot
plate of the Midas Rex® drill (Midas Rex Pneumatic
Tools, Inc., Forth Worth, TX) is extradural at the
edge of the sinus, we have crossed the sinus
several hundred times without problems. The
exception to this rule, however, is the sigmoid
sinus, which should never be crossed because the
sharply angulated bone indents the internal surface
of the cranium.
5-14d The dura is opened and hinged along the

transverse sinus. Because the bone flap extends
significantly across the sinus, the dura can be
retracted pulling the torcula and transverse sinus
upwa rd. Note the excellent visualization along the
superior margins of the cerebellum without the use
of retractors.
5-14e After the vermis has been retracted, the

edge of the te ntorium, the precentral cerebellar
vein, and the typical thick arachnoid around the
vein of Galen are visualized. We make every
a tte mpt to preserve the precentral cerebellar vein
and to work on either side of it.
5-14f The cavernous malformation is visible as it

protrudes and discolors the surface of the bra in
s te m.
5-14g Overview of the operative field after resec

tion of the cavernous malformation.
Case 5-15
Diagnosis: Pontine cavernous malformation (rel. anatomy: pp 53, 61, 66)
Approach: Left far lateral (rel. approaches: pp 109-113)

demonstrate a pontine
cavernous malformation that
extends closest to the
surface at the inferolateral
aspect of the left pons.
5-15c Through a far-lateral a pproa ch, the

expanded pons is visualized. The wand from the
frameless stereotactic guidance system is placed
on the surface of the pons to confirm the location
of the cavernous malformation.
5-15d The frameless stereotactic guidance sys

tem confirms the appropriate entry point to reach
5-15e The cavernous malformation is exposed

through the surface of the pons .
5-15f The wa nd of the frameless stereotactic

guidance system is placed in the midportion of the
bed as the cavernous malformation is being resect
ed to determine the extent of additional resection
required.
5-15g The cavernous malformation is resected

completely, exposing the inferior wall of the be d.
5-15h The wa nd, placed against the edge of the

inferior be d, demonstrates complete resection of
5-15i Postoperative MR image demonstrates

comple te removal of the cavernous malformation.
The patient's preoperative neurological deficit
improved immediately after surgery.
Case 5-16
Diagnosis: Pontomedullary cavernous malformation
Approach: Midline suboccipital (rel. approaches: pp 102-105)
5-16a MR image demonstrates a cav

ernous malformation at the junction of the
pons and the medulla protruding into the
fourth ventricle.
5-16b With the patient in the prone position and

the surgeon working from the top of the head, the
floor of the fourth ventricle is e xpos e d. Working
between the two tonsils, the surgeon exposes the
cavernous malformation.
5-16c Further resection of the cavernous

malformation.
5-16d The cavernous malformation is separated

from the surrounding parenchyma.
5-16e The cavernous malformation is being lifted

from the brainstem.
5-16f The bed of the cavernous malformation

with a venous malformation in its floor is visualized.
5-16g Pathological s pecime n. 5-16h Postoperative MR image de mon

strates complete removal of the cavernous
malformation.
Case 5-17
Diagnosis: Cavernous malformation of the floor of the fourth ventricle
5-17a MR image demonstrates a cav 5-17c Under higher magnification, the cav 5-17d After the cavernous malformation
ernous malformation extending into the floor ernous malformation is visualized as it pro has been rese cte d, the bed and floor of the
of the fourth ventricle. trude s into the fourth ventricle. fourth ventricle are visible.
5-17b Through a midline a pproach in the

sitting pos ition, the tonsils are retracted later
ally, exposing the foramen of Magendie.
5-17e Postoperative MR image de mon

strates removal of the cavernous malforma
tion.
Case 5-18
Diagnosis: Medullary cavernous malformation
Approach: Left far lateral

demonstrate cavernous
malformation of the left
medulla.
5-18c Through a far-lateral approach working

medial to the vertebral artery between the lower
cranial nerves, the medulla is opened with localiza
tion provided by the frameless stereotactic guid
ance s ys tem. The cavernous malformation can be
seen through the ope ning.
5-18d After the cavernous malformation has

been circumscribe d with a small circular knife, the
cavernous malformation is lifted from its be d.
Case 5-19
Diagnosis: Cavernous malformation of the medulla
Approach: Midline suboccipital spinal (rel. approaches: pp 102-106)

cavernous malformation in the medullocervi-
cal junction.
5-19c In a view from the top of the head

while the patient is in the prone pos ition, the
tonsils and expanded medulla are visible.
5-19d After the arachnoid is ope ne d, the

cavernous malformation is identified and
rese cte d.
5-19e Overview of the operative site after

the arachnoid stay sutures have been
removed.
Case 5-20
Diagnosis: Cavernous malformation of the medullocervical junction
5-20a MR image demonstrates

a cavernous malformation pro
truding into the cisterna magnum.
5-20c Pathological specimen.
5-20b Through a midline posterior fossa

approach with the patient in the prone position and
the surgeon operating from the top of the head,
the cisterna magnum has been ope ne d, exposing
the cavernous malformation and foramen of
Maqendie.
5-20d Operative view of the bed of the cav

Case 5-21
Diagnosis: Venous malformation with a cavernous malformation
Approach: Midline suboccipital with resection of venous
malformation (oops!) (rel. approaches: pp 102-105)
5-21a and b CT scan and MR image of a

patient who presented with multiple hemor
rhages over several years. Because a venous
malformation was demonstra te d by angiogra
phy, the hemorrhages were mistakenly
a ttribute d to this venous anomaly. This was
our first and only case of operating on a
venous malformation. It is included to
emphasize the association between venous
and cavernous malformations and the impor
tance of leaving the venous malformation
intact.
5-21c Late phase angiogram demonstrates a

typical venous malformation.
5-21d Through a midline posterior fossa

a pproa ch, a cavernous malformation is visualized
(although not appreciated at the time of surgery).
5-21e The venous malformation is 5-21f The venous malformation is resected

exposed as it enters the te ntorium. and hemorrhagic swelling of the cerebellum is
note d. Fortunately, this hemorrhagic swollen
cerebellum was tolerated by the patient and
did not result in herniation. The cavernous
malformation was then resected incidentally.
In retrospect, it is obvious tha t the patient's
hemorrhages were from the cavernous ma l
formation and that the venous malformation
was the incidental finding.
5-21g and h This MR image and
angiogram are included to again demons trate
the association between venous and cav
ernous malformations and why it is so easy
to a ttribute the hemorrhage to the venous
malformation whe n, in fa ct, the cavernous
malformation has bled into itself. Aga in, the
importance of maintaining anomalous venous
drainage when a cavernous malformation is
removed cannot be overemphasized.
575
576 Vascular Compre s s ion
1 Va s c ula r Co m p re s s io n
6-0 A basal view of the brainstem and cra

nial nerves and overlying vessels. From the
top down, compression syndromes of the
optic nerve can occur from dolichoectatic
anterior cerebral arteries or internal carotid
arteries. Obviously, arteriovenous malforma
tions , aneurysms, or tumors may produce
similar compres sion. Oculomotor nerve com
pression can occur from the posterior ce re
bral or superior cerebellar artery, and trige mi
nal nerve compression can occur from the
anterior inferior cerebellar artery, or from a
loop of the posterior inferior cerebellar artery.
The same vessels may produce compression
syndromes of the facial or vestibulocochlear
nerves. The posterior inferior cerebellar artery
or vertebral artery may produce compression
of the glossopharyngeal a nd vagus nerves.
The cases of vascular compression are pre
sented superiorly to interiorly.
Case 6-1
Diagnosis: Vascular compression of right CN II (rel. anatomy: pp 27-30)
Approach: Unilateral subfrontal (rel. approaches: pp 80, 81)
6-1 An exposure of the right optic nerve fol

lowing mobilization of the anterior cerebral
artery. A groove remains from where the
anterior cerebral artery compres s ed the optic
nerve.
Va scular Compre s s ion 577
Case 6-2
(Courtesy of Dr. R. Apfelbaum, Salt Lake City, UT)
Diagnosis: Right CN V vascular compression (rel. anatomy:
pp 54, 55, 58)
Approach: Right retrosigmoid (rel. approaches: pp 108, 109)
6-2a The area of the trigeminal nerve has been

e xpos e d. An elongated loop of the superior cere
bellar artery can be seen coursing beneath the
trigeminal nerve just a fe w millimeters away from
the nerve root entry zone. The loop reemerges lat
erally.
6-2b The loop of the superior cerebellar artery

has been mobilized and is now lying on top of the
nerve. A branch right at the nerve root entry zone,
which is now on top of the nerve, is responsible for
the compre ssion. A piece of muscle or Teflon
sponge is used to fix the artery away from the
nerve root entry zone.
Case 6-3
Diagnosis: Left CN V vascular compression (rel. anatomy: pp 54, 55, 58)
Approach: Left retrosigmoid (rel. approaches: pp 108, 109)
6-3a The trigeminal nerve through an exposure

over the superior aspect of the cerebellum is visual
ized. An elongated loop of the superior cerebellar
artery is seen as it compresses and splays the
nerve root at the entry zone of the trigeminal nerve.
6-3b After the loop has been mobilized, it is lifted

above the nerve. Following this maneuver, a piece
of Teflon sponge or crushed muscle is inserted
between the artery and the nerve to prevent it from
recompressing the nerve root.
Va scular Compre s s ion 579
Case 6-4
Diagnosis: Vascular compression of the right CN V at its cranial
exit for atypical facial pain (rel. anatomy: pp 54, 55, 58)
6-4a In this patient with atypical facial pain, 6-4b The loop of the superior cerebellar
the trigeminal nerve is markedly compre ssed artery has been mobilized away from the
by a large loop of the superior cerebellar trigeminal nerve and fixed with Surgicel and
artery laterally. Exploration of the trigeminal fibrin glue.
nerve root entry zone revealed a smaller
branch of the superior cerebellar artery that
was not compre s s e d.
Case 6-5
Diagnosis: Left CN VII compression by AICA displaced by tumor
6-5 In this patient with a 2-year history of hemifacial

s pa s m, the exploration of the left cerebellopontine
angle revealed an e pidermoid tumor. The facial
nerve was compre s se d at the nerve root entry zone
by a loop of the anterior inferior cerebellar artery
displa ce d by the tumor. The lower cranial nerves
can be seen exiting into the jugular fora me n. The
loop of the artery is seen as it courses over the
facial and vestibulocochlear nerves and is held in
position by pieces of e pide rmoid tumor. Removal of
the tumor and relocation of the arterial loop result
ed in cessation of hemifacial s pa s m.
Vascular Compre s s ion 581
Case 6-6
Diagnosis: Left CN VII compression by PICA (rel. anatomy: pp 53, 64)
6-6a Visualization of the cerebellopontine angle

on the left reveals the trigeminal nerve most s uperi
orly with a loop of the superior cerebellar artery
below it. The large vertebral artery is visualized as it
emerges from below the facial and ves tibulo
cochlear nerves. Most medially, a vessel can be
seen as it traverses below the nerve root entry
zone of the facial and vestibulocochlear nerve.
This is the posterior inferior cerebellar artery.
6-6b By mobilizing the vertebral artery away from

the brainstem, the origin of the posterior inferior
cerebellar artery is identified. As the posterior inferi
or cerebellar artery is followe d along its course, it is
exposed where it was compressing the facial nerve
at the bra instem.
Case 6-7
Diagnosis: Right CN VIII compression by loop of AICA
6-7a Prior to opening the arachnoid me m 6-7b Following arachnoid dis se ction, a 6-7c The mobilization of the artery at the
branes, two vessels can be seen coursing loop of the anterior inferior cerebellar artery is vestibulocochlear nerve entry zone resulted
over the vestibulocochlear nerve. mobilized from the origin of the vestibulo in marked elongation and displacement of
cochlear nerve. the compressing vessels. The nerve root
entry zone was prote cte d from recompres
sion by crushed muscle and fibrin glue.
Case 6-8
Diagnosis: Left glossopharyngeal neuralgia (rel. anatomy:
pp 60, 61, 64, 66)
6-8a Through a far-lateral a pproa ch, the lower

cranial nerves are e xpos e d. Notice the posterior
inferior cerebellar artery as it lies below the glos so
pharyngeal and vagal nerve complex at the entry
zone of the nerve roots.
6-8b The posterior inferior cerebellar artery loop

is displaced laterally, decompressing the lower
cranial nerves.
6-8c A Teflon sponge inserted between the cra

nial nerves and the vessels decompresses the
entry zone of the nerve roots.
584 Va scular Compre s s ion
Case 6-9
Diagnosis: Right CN IX and X compression by loop of PICA
(rel. anatomy: pp 60, 61, 64, 66)
6-9a The right cerebellopontine angle is 6-9b Approaching the brainste m, a loop of
e xpos e d. The facial a nd vestibulocochlear the posterior inferior cerebellar artery is seen
nerves are visualized superiorly. The glosso medially as it has been mobilized from the
pharyngeal and vagus nerve complex is glossopharyngeal and vagus nerve comple x.
seen as it enters the jugular foramen. A piece of Gelfoam has been placed distal to
the nerve to elevate the loop. Fibrin glue was
utilized to prevent its migration.
Case 6-10
Diagnosis: Compression of the medulla by the VA
(rel. anatomy: pp 60, 61, 65, 66, 68)
6-10a and b Magnetic resonance images

reveal a dolichoectatic vertebral artery com
pressing the medulla. This patient became
symptomatic with progressive transient
ischemic atta cks of the brainstem as well as
with progressive hypertension.
6-10d Through a far-lateral a pproa ch, the

subarachnoid portion of the vertebral artery is
e xpos e d.
6-10c Vertebral artery angiogram demon

strates dolichoectatic loop.
6-10e The vertebral artery is mobilized. 6-10f A 4–0 suture is placed around the 6-10g Overview of the mobilized vertebral
vertebral artery and secured to the cut end o1 artery. The patient's symptoms progressively
a dentate ligament. cleared.
587
In d e x
Italicized numbers indicate related anatomy.

Boldface numbers indicate particularly detailed relevant anatomy or cases.
A 271–273, 274, 275, 286, 287–289, 290–299, coils, 147–148, 167, 197, 236–238, 245,
300, 301–302, 312–314, 315–318, 319–322, 271–273, 274, 276, 300, 308, 333, 341–342,
Abducent n., see Cranial nerves 323–324, 325–330 343, 459–463, 480–481, 503
Accessory n., see Cranial nerves tip, 248–252, 274, 275 debulking, 267–270, 315–318
Adenohyphophysis, see Pituitary trunk, 286, 287–289, 290–299, 300, endovascular, 147–148, 167, 168, 271–273,
Anastomosis, sec also Bypass 312–314, 315–318, 319–322 274, 275, 276–277, 278–279, 300, 315–318,
location internal carotid artery, 123, 124–126, 331–333, 341–342, 343, 503
anterior temporal artery-to-middle cerebral 127–130, 131–134, 149–152, 153–156, Hunterian ligature, 267–270
artery, 229–232 157–158, 159–163, 169, 170–172, 173–174, hypothermic circulatory arrest, 255–258,
callosomarginal artery reconstruction, 175–178, 179–181 259–260, 261–266, 267–270, 290–299,
202–203 bifurcation (ICA-MCA), 170–172, 312–314, 319–322, 325–330
middle cerebral artery reconstruction, 173–174, 175–178, 179–181, 207–208, resection & reanastomosis, 202-203,
22 –2 2 5, 226–228 209–211 222–225, 226–228, 285
pericallosal artery reconstruction, 204–206 intracavernous sinus, 124–126, 127–130, trapping, 143–144, 159–163, 179–181,
posterior inferior cerebellar-to-posterior 131–134, 499–502 204–206, 229–232, 239–244, 331–333
inferior cerebellar artery, 331–333 paraclinoid (cave), 149–152, 153–156, wrapping, 200–201
saphenous vein-to-internal carotid artery, 157–158, 159–163 type
128,500 middle cerebral artery, 175–178, 179–181, angiographic occult, 301–302
superficial temporal arlery-to-superior 207–208, 209–211, 212–214, 215–216, 217, cave (paraclinoid), 149–153
cerebellar artery,315–318 218–221, 222–225, 226–228, 229–232, complex, 159–163, 334–336
type 233–235, 236–238, 239–244, 245, 246–247, dissecting, 236–240
end-to-end, 129, 203, 225, 228, 500 459–463 ectatic, 200–201
end-to-side, 128,316 ophthalmic artery, 123, 135, 136–139, fusiform, 159–163, 175–178, 179–181,
side-to-side, 204-206,229–232, 332 140–142, 143–144, 145–146, 147–148, 222, 200–201, 204–206, 218–221, 226–228,
Aneurysms, 122-343 225 236–238, 325–330
associated with pericallosal artery, 198–199, 200–201, giant, 127–130, 136–139, 143–144, 157–158,
arteriovenous malformation, 253–254, 202–203 179–181,183–185, 189–191, 192–194,
259–260, 366–369, 375–376, 402–404, posterior cerebral artery, 259–260, 276–277, 204–206, 222–225, 226–228, 229–232,
413–415, 441–442, 443–446, 459–463, 278–279 233–235, 246–247, 255–258, 259–260,
480–481, 490–492, 499–502, 503–504, 507 posterior communicating artery, 164–166, 261–266, 267–270, 276–277, 282–284,
calcification, 124–126, 159–163, 189–191, 167, 168, 459–463 319–322, 325–330, 331–333
267–270, 310 posterior inferior cerebellar artery, giant serpentine, 239–244, 315–318
dural vascular malformation, 499–502 334–336, 341–342, 343, 480–481, 503–504 high riding, 255–258
hemorrhage, 159–163, 167, 179–181, superior cerebellar artery, 280–281, large, 124–126, 131–134, 140–142, 145–146,
186–187, 188, 202–203, 248–252, 259–260, 282–284, 285 153–156, 159–163, 175–178, 218–221,
274, 275, 278, 285, 287-289, 290–299, 300, vertebral artery, 323–324, 325–330, 331–333, 287–289, 308–311, 312–314
301–302, 305–307, 331 337–338, 339–340 tabulated, 124–126, 170–172, 278–279, 286,
ischemia, 143-144, 159-163, 204-206, 224, vertebrobasilar artery bifurcation, 323–324, 334–336, 337–338
229, 282-284 325–330 mycotic, 202–203, 217
mass effect, 236–238, 276–277, 282–284 treatment Approaches, surgical
pregnancy, 290–299 aneurysmorrhaphy, 233–235, 239–244, by region
regrowth after endovascular treatment, 267–270, 282–284, 315–318, 325–330 cortical and transcortical, 72–74
271–273 bypass, 127–130, 131–134, 143–144, 159–163, interhemispheric, 75–78, see also anterior
stenosis, 159–163, 179–181, 229 179–181, 229–232, 233–235, 236–238, and posterior interhemispheric
thrombus, 138, 191, 205, 223, 226–228, 234, 239–244, 246–247, 315–318, 331–333, approaches
239, 244, 247, 267–270, 282–284, 302, 309, 499–502 middle cranial fossa, 92, 93, see also sub
318, 325, 329 clips/clipping, 124–126, 135, 136–139, temporal approach
venous aneurysm, see Arteriovenous mal 140–142, 145–146, 149–152, 153–156, middle and posterior fossae, 92–100,
formations 157–158, 159–163, 164–166, 169, 170–172, 556–558, see also combined approaches
distribution, 122 173–174, 175–178, 179–181, 182–185, and subtemporal transapical approach
anterior circulation, 122–247 186–187, 188, 189–191, 192–194, 195–196, posterior fossa and craniocervical junction,
posterior circulation, 122, 123, 248–343 198–199, 200–201, 207–208, 209–211, 100–113, 485–486, see also far-lateral
location, 122, 123 212–214, 215–216, 218–221, 225, 239–244, approach, infratentorial supracerebellar
anterior cerebral artery, 123, 182, 183–185, 248–252, 253–254, 255–258, 259–260, approach, midline suboccipital approach,
204–206 261–266, 271–273, 280–281, 282–284, 286, paramedian suboccipital approach, pe
anterior communicating artery, 186-187, 287–289, 290–299, 301–302, 303–304, trosal approaches, posterior fossa
188, 189–191, 192–194, 195–196, 197 305–307, 308–311, 312–314, 319–322, supra-infratentorial approach, retrosig-
anterior inferior cerebellar artery, 303–304, 323–324, 333, 334–336, 337–338, 339–340, moidapproach, and supratentorial
305–307, 308-311 459–463 transtentorial approach
basilar artery, 123, 248–252, 253–254, clip reconstruction, 182–185, 218–221, pineal region, 114–120, see also infratento
255–258, 259–260, 261–266, 267–270, 282–284, 325–328 rial supracerebellar approach, posterior
588 Index
transcallosal approach, and supratentori petrosal translabyrinthine, 97, 98,101, 102,108 204–206, 243, 256, 272, 2 8 1 , 296, 386, 398,
al transtentorial approach anatomy related to, 53, 58, 61 449, 452, 461, 465, 466, 469, 471, 472, 501,
sellar and parasellar, 80, see also orbito case related to, 308–311 547, 576
pterional approach, orbitozygomatic- posterior fossa supra–infratentorial A1, 20, 21, 27–32, 37, 43, 44, 173, 174, 182,
approach, pterional approach, and sub case related to, 522–523 183–185, 191, 193–196, 576
temporal approach posterior interhemispheric, 75–78, 114, 115 A2, 28–32, 37, 42–44, 123, 187, 191, 193–196,
skull base, anterior, 79–91, see also anatomy related to, 47, 115 199,204–206
orbitopterional approach, cases related to, 361–365, 388–391, 416–418, aneurysm of, 123, 182, 183–185, 204–206
orbitozygomatic approach, pterional 473–477, 517–518, 532–534 branches, 4, 31
approach, and subfrontal approaches pterional, 79, 80, 82–85, 89, vascular compression of optic nerve,
anterior interhemispheric, 75, 76, 78 anatomy related to, 75, 17–20, 21, 22, 29, 576
anatomy related to, 31, 32 32–36 anterior communicating (ACoA), 4, 10, 18, 19,
cases related to, 198–199, 200–201, 202–203, cases related to, 124–126, 127–130, 131–134, 28–32, 38, 43, 44, 123, 186–187, 188, 189–191,
204–206, 397–400, 459–462, 517–518, 136–139, 140–142, 143–144, 145–146, 192, 194–197
532–534 149–152, 153–156, 157–158, 159–163, aneurysm of, 186–187, 188, 189–191,
combined-supratentorial/infratentorial, 92, 164–166, 169, 179–181, 182, 195–196, 192–194, 195–196, 197
94, 95, 97–100 207–208, 209–211, 212–214, 215–216, 217, anterior inferior cerebellar (AICA), 6, 7, 37,
anatomy related to, 45, 51, 52, 54, 55, 57, 64, 218–221, 222–225, 226–228, 229–232, 53, 54, 58, 60–64, 66, 68, 69, 123, 287,
66 233–235, 239–244, 280–281, 459–463, 303–304, 305–307, 308–311, 317, 482, 519,
combined-supratentorial/infratentorial retro 464–467, 499–502 520, 580, 582
labyrinthine, 92, 94, 95, 97, 99, 100 retrosigmoid, 101, 102, 108, 109 aneurysm of, 303–304, 305–307, 308–311
anatomy related to, 37, 51–54, 57, 58, 61, 64, anatomy related to, 52–58, 60, 61, 64, 66 vascular compression of
66 cases related to, 323–324, 484, 487–489, facial nerve, 576, 580
cases related to, 303–304, 519–521, 553–554, 577–582, 584 trigeminal nerve, 576
556–558 subfrontal, 79–81, 89 vestibulocochlear nerve, 576, 582
combined-supratentorial/infratentorial anatomy related to, 27, 28, 29–31 anterior spinal, 60–62, 68, 312
transcochlear, 92, 94–100 subfrontal-bilateral, 79–81 anterior temporal, 84, 123, 229–232, 235
anatomy related to, 6, 51, 58 anatomy related to, 27, 28, 29–31 basilar (BA), 8, 18–21, 30, 37–39, 41, 43, 44, 51,
combined-supratentorial/infratentorial case related to, 204–206 53, 57–64, 85, 88, 89, 122, 248–252, 253–254,
translabyrinthine, 92, 94, 95, 97, 98 subfrontal-unilateral (frontolateral), 79–81 255–258, 259–260, 261–266, 267–270,
anatomy related to, 51, 52, 58, 61 anatomy related to, 27, 28, 29–31, 33 271–273, 274, 275, 284, 286, 287–289,
cortical and transcortical, 72, 73 cases related to, 135, 173–174, 186–187, 188, 290–299, 300, 301–302, 304, 306, 307, 310,
cases related to, 236–238, 348–349, 350–352, 527, 576 311, 312–314, 315–318, 319–322, 323–324,
353–354, 355–357, 358, 366–369, 370–374, subtemporal, 92, 93 325–330, 493, 551
381–384, 392–393, 394–396, 402–404, anatomy related to, 13–16, 17, 18, 19, 21, aneurysm of, 248–252, 253–254, 255–258,
405–407, 408–412, 416–418, 419–422, 45, 46, 51 259–260, 261–266, 267–270, 271–273, 274,
423–425, 432–435, 436–440, 441–142, cases related to, 261–266, 267–270, 282–284, 275, 286, 287–289, 290–299, 300, 301–302,
443–446, 447–149, 450–451, 452–454, 286, 315–318, 402–404, 493–498, 551–552 312–314, 315–318, 319–322, 323–324,
455–57, 458, 468–472, 528–529, 530–531, subtemporal-petrosal, 92, 93 325–330
535 anatomy related to, 5–7, 17, 18, 45, 46, 51 bifurcation, 20, 30, 312, 323–324, 325–330
lar lateral, 94, 101–103, 109–113, 526 cases related to, 127–130, 131–134, 499–502 lateral pontine branch, 41, 55, 58, 60
anatomy related to 60–65, 66, 68, 69 subtemporal transapical, 92, 93 medial pontine ramus, 58
cases related to, 312–314, 319–322, 325–330, anatomy related to, 5–7, 17, 18, 45, 46 pontine branches, 53
331–333, 334–336, 562–564, 569, 583, supratentorial transtentorial, 114, 116, 117 tip, 43, 248–252, 274, 275, 288
585-586 anatomy related to, 42, 47–50 trunk, 286, 287–289, 290–299, 300, 312–314,
inlratentorial supracerebellar, 114, 118–120 transcallosal, 75–78 315–318, 319–322
anatomy related to, 42, 48–50, 56 anatomy related to, 31, 32, 42 calcarine, 47, 116
cases related to, 285, 428–431, 485–486, transcallosal anterior, 75, 76, 78 callosomarginal, 57, 32, 75, 198, 199, 200–201,
559–561 anatomy related to, 31, 32, 43, 50 202, 205, 379
midline suboccipital, 101–105, 526 cases related to, 359–360, 361–365, 377–380, carotid
anatomy related to, 67 397–400, 413–415, 536–540, 541–543, common (CCA), 462, 477, 503, 504
cases related to, 337–338, 565–567, 568, 572 544–546 external (ECA), 123, 244, 419, 444, 469, 472,
midline suboccipital-spinal, 101–103, 105, 106 transcallosal posterior, 75, 77, 78, 115 495, 496, 505–506, 517–518, 519
anatomy related to, 65, 67 anatomy related to, 48–50,115 internal (ICA), 4–22, 27–31, 33, 35, 39, 41,
cases related to, 339–340, 490–492, 570, 571 cases related to, 397–400, 513–516 42, 44–46, 51, 52, 54, 59, 60, 80, 85, 89, 92,
orbitopterional, 79, 80, 86, 87 transcortical, 72, 73, see also cortical 95, 122, 123, 127–129, 133, 135, 137,
anatomy related to, 20, 29, 30, 32, 33 transfrontal transventricular, 72, 74 140–142, 145, 147, 149–152, 154–159, 160,
cases related to, 170–172, 189–191, 192–194 case related to, 423–425 161, 163–165, 169, 170, 173, 174, 176–178,
orbitozygomatic, 79, 80, 88–91 transoccipital transventricular 179–181, 182, 183, 188, 189, 193–195, 197,
anatomy related to, 15, 18, 20, 21, 32, 33, 39, anatomy related to, 23–25, 47 198, 200, 202, 209, 218, 219, 221, 222, 232,
43, 44, 51 transpetrosal, see Petrosal 233, 235, 238, 239, 242–245, 250, 2 5 1 ,
cases related to, 175–178, 183–185, 248–252, Approaches, nonsurgical 253–254, 256, 260, 268, 2 7 1 , 272, 280, 2 8 1 ,
253–254, 255–258, 259–260, 267–270, endovascular, 147–148, 167, 168, 197, 236–238, 288, 296, 301, 302, 348, 350, 355, 358, 370,
271–273, 287–289, 290–299, 301–302, 245, 271–273, 274, 275, 276–277, 278–279, 374–376, 384, 386, 388, 3 9 1 , 394, 399, 4 0 1 ,
547–550 300, 315–318, 331–333, 341–342, 343, 346, 402, 404, 405, 408, 413, 416, 419, 423, 431,
orbitozygomatic transapical, 79, 80, 88, 89–91 370–374, 375–376, 377–380, 381–384, 385– 432, 435, 441, 447, 449, 452, 458, 459, 462,
anatomy related to, 6, 7 387, 388–391, 394–396, 408–412, 413–415, 465, 468, 469, 472, 494, 497, 499–508, 519,
case related to, 287–289 416–418, 426–427, 447, 455–457, 459–463, 521, 522, 527, 547, 576
paramedian-suboccipital, 101–103, 107 464–467, 468–472, 473–477, 478–479, aneurysm of, 123, 124–126, 127–130,
anatomy related to, 52, 56, 65–67 480–481, 484, 493–498, 499–502, 503–504, 131–134, 149–152, 153–156, 157–158,
cases related to, 480–481, 493–498 505–506, 507, 508, 509–510, 511–523 159–163, 169, 170–172, 173–174,
petrosal, 97–103 radiosurgery, 346, 358, 401, 413–415, 419, 175–178, 179–181
anatomy related to, 5, 6, 53, 58, 61 459–463, 464–467, 473–477 bifurcation, 27, 169, 170–172, 173–174,
petrosal retrolabyrinthine, 97, 99–103 Arteries 175–178, 179–181, 182, 183, 296
anatomy related to, 53, 58, 61 anteromedial frontal, 32 bypass, 499–502
cases related to, 315-318, 482–483, 555 anterior cerebral (ACA), 4, 7–10, 14, 18, 19, caroticocavernous branch, 15, 16
petrosal transcochlear, 98–103 21, 27–33, 35, 37, 39, 42–44, 46, 51, 59, 85, carotid siphon, 7, 12
anatomy related to, 5, 6, 51, 53, 58 122, 123, 142, 158, 160, 169, 170, 171, 173, dural rings, 14–16, 141, 150, 151
case related to, 305–307 174, 176, 177, 182, 183, 187, 188, 193–196, extracavernous portion, 4
Inde x 589
extracranial portion, 4, 7 posterior communicating (PCoA), 18–22, trauma, 499–502, 505–506, 507, 508
fistula in cavernous sinus, 499–508 28–30, 37–39, 41, 45, 46, 51, 58, 59, 85, 123, venous aneurysm, 366–369, 375–376,
intracavernous portion, 6–8, 10–16, 44, 129, 137, 152, 163, 164–166, 167–169, 173, 402–404, 442, 490–492
123, 124–126, 127–130, 131–134 174, 180, 243, 250, 252, 253, 264, 268, 297, location
occlusion of, 128, 133, 505–506, 508 301, 302, 503, 506, 549, 551 brainstem, 482–483, 487–489
petrosal portion, 4–7, 95, 127–130, 132, aneurysm of, 164–166, 167, 168, 459–463 carotid-cavernous sinus, 499–502, 503–504,
500, 501 posterior inferior cerebellar (PICA), 37, 53, 505–506, 507, 508 .
supraclinoid portion, 13, 15, 123, 501 58, 60–69, 123, 3 2 1 , 323, 324, 328, 329, caudate nucleus, 423–425
vascular compression of optic nerve, 576 331–333, 334–336, 337–338, 339–340, cerebellum, 478–479, 480–481, 484, 485–486,
choroidal 341–342, 343, 480, 483, 568, 5 7 1 , 5 8 1 , 583 493–498
anterior, 8, 17, 18, 20–23, 25, 26, 41, 46, 51, aneurysm of, 334–336, 341–342, 343, cervicomedullary junction, 490–492
52, 56, 85, 156, 160, 164–166, 169, 174, 180, 480–481, 503–504 corpus callosum, 377–380, 385–387,
181, 243, 257 vascular compression of 388–391, 397–400, 473–477
lateral, 26 facial nerve, 576, 581 frontal lobe, 348–349, 350–352, 436–440,
lateral posterior, 23, 46, 52, 119 glossopharyngeal nerve, 576, 583, 584 459–463
medial posterior, 22, 23, 39, 45, 51, 56, 119 trigeminal nerve, 576 frontoparietal lobes, 355–357, 358, 408–412,
posterior, 25, 26, 359 vagus nerve, 576, 584 447–449, 468–472
circle of Willis, 37, 41–43 vestibulocochlear nerve, 576 insula, 450–451
diencephalic branches, 18, 20, 21, 30, 44 posterior temporal, 36 lateral ventricle, 397–400, 413–415
frontopolar, 32, 187, 195, 196 quadrigeminal, 21, 45, 51, 52 occipital lobe, 361–365, 402–404
interpeduncular, 19, 37, 40, 43, 44, 58, 59 recurrent artery of Heubner, 18, 28, 29, 35, parietal lobe, 375–376, 394–396, 405–407,
labyrinthine, 66 123, 169, 173, 182, 187, 188, 193–196 416–418, 441–442, 452–454, 455–457,
lenticulostriate, 18, 29, 32, 171, 177, 243 subarcuate, 68 473–477
marginal tentorial, 53 superficial temporal, 83, 123, 143, 159, 162, parietal–occipital lobes, 402–404, 443–446,
meningeal 163, 179–181, 233–235, 236–238, 239–244, 473–477
middle, 6, 7, 55, 89, 128, 132, 517, 519 246–247, 315–318, 371 petrous dural, 519–521
posterior, 61 superior cerebellar, 6, 8, 15–19, 21, 30, 37, 39, postcentral gyrus, 394–396, 416–418
middle cerebral (MCA), 4, 8–10, 18, 20, 22, 41, 45, 46, 51–61, 64, 85, 119, 123, 251, 257, quadrigeminal plate, 426–427, 428–431
26–29, 31–37, 42, 46, 84, 85, 122, 123, 137, 260, 267, 268, 279, 280–281, 282–284, 285, sagittal sinus, 517–518
143, 144, 158–160, 162, 163, 169–171, 286, 287–289, 297, 298, 302, 315–318, 478, septum, 361–365
173–177, 179–183, 193, 207–208, 209–211, 487, 488, 496, 519, 521, 547–550, 552, 557, Sylvian fissure, 370–374
212–214, 215–216, 217, 218–221, 222–225, 558, 577, 581 temporal lobe, 353–354, 366–369, 381–384,
226–228, 229–232, 233–235, 236–238, aneurysm of, 280–281, 282–284, 285 392–393, 419–422
239–244, 245, 246–247, 256, 272, 2 8 1 , 296, lateral hemispheric branches, 56, 57 thalamus, 359–360, 401, 413–415, 432–435,
351, 366, 401, 447, 450, 451, 465, 466, superior hemispheric branches, 56 458, 464–467, 473–477
470–472, 5 0 1 , 547 vascular compression of vein of Galen, 509–516
aneurysm of, 175–178, 179–181, 207–208, oculomotor nerve, 576 vermis, 478–479
209–211, 212–214, 215–216, 217, 218–221, trigeminal nerve, 577–579 treatment
222–225, 226–228, 229–232, 233–235, vermian branches, 56,119 bypass of cavernous carotid, 499–502
236–238, 239–244, 245, 246–247, 459–463 superior hypophyseal, 19, 21, 151 clipping, 403, 4 4 1 , 465
fxontobasal, 30, 36 vertebral (VA), 37, 51, 53, 57, 58, 60–69, 112, endovascular, 346, 370–374, 375–376,
fronto-orbital branches, 28 113, 122, 123, 253, 259, 261, 266, 267, 269, 377–380, 381–384, 385–387, 388–391,
insular branches, 34, 213–216, 451 271, 274, 275, 278–279, 280, 285, 286, 289, 394–396, 408–412, 413–415, 416–418,
M 1 , 4, 20, 27, 29, 31, 32, 143, 173, 174, 207, 300, 303–304, 305, 307, 308, 3 1 1 , 312, 426–427, 447, 455–457, 459–463, 464–467,
208, 246–247 317–321, 323–324, 325–330, 331–333, 468–472, 473–477, 478–479, 480–481, 484,
M 2 , 4, 143, 207, 208 334–336, 337–338, 339–340, 341–342, 343, 493–498, 499–502, 503–504, 505–506, 507,
M 3 , 219–220 363, 382, 391, 399, 400, 413, 419, 426, 427, 508, 509–510, 511–523
temporopolar, 33 431, 459, 462, 463, 474, 477, 481, 482, 487, resection, 348–349, 350–352, 353–354,
occipital, 6, 123, 496 489, 490–494, 506, 509, 516, 519, 5 2 1 , 522, 355–357, 358, 359–360, 361–365, 366–369,
ophthalmic, 7, 17, 123, 134–136, 143, 145, 147, 569, 571, 581, 583–586 377–380, 381–384, 388–391, 392–393,
150, 161, 188, 222, 225, 501, 502, 517 aneurysm of, 323–324, 325–330, 331–333, 397–400, 402–404, 405–407, 408–412,
aneurysm of, 123, 135, 136–139, 140–142, 337–338, 339–340 413–415, 416–418, 419–422, 423–425,
143–144, 145–146, 147–148, 222, 225 vascular compression of 428–431, 432–435, 436–440, 441–442,
pericallosal, 4, 31, 32, 75, 122, 198–199, glossopharyngeal nerve, 576 443–446, 447–449, 450–451, 452–454,
200–201, 202–203, 204–206, 377, 379, 380, medulla, 585, 586 455–457, 458, 459–463, 468–472, 473–477,
537, 538, 541, 545 vagus nerve, 576 480–481, 482–483, 484, 485–486, 487–489,
aneurysm of, 198–199, 200–201, 202–203 vertebrobasilar junction, 60–64, 323–324, 490–492, 493–498, 513–516, 517–518,
pharyngeal, 4, 61 325–330 519–521, 522–523
pontine, 60 Arteriovenous malformations, 346–523 s t e r e o t a c t i c radiosurgery, 358, 4 0 1 , 413–115,
pontomesencephalic, 60 associated with 419, 459–463, 473–477
posterior cerebral (PCA), 8, 15–22, 26, 30, 37, arterial aneurysm, 253–254, 259–260, types
39, 41–48, 50–52, 54, 57–61, 85, 116, 123, 413–415, 443–446, 459–463, 480–481, dural vascular malformations, 499–523
159, 160, 163, 250, 2 5 1 , 2 5 3 , 257–260, 264, 499–502, 503–504, 507 cavernous sinus fistula, 499–508
265, 268, 275–277, 278–279, 2 8 1 , 283, 286, edema, 490–492 petrous dural AVM, 519–521
297, 301, 302, 403, 413, 427, 496, 547–552 hemorrhage, 350–352, 353–354, 358, superior sagittal sinus dural AVM,
aneurysm of, 259–260, 276–277, 278–279 361–365, 366–369, 377, 381–384, 392–393, 517–518
basal branch, 26 397–400, 401, 413–415, 416–418, 419, torcular dural arteriovenous fistula,
calcarine branch, 47, 116 423–425, 428–431, 432–435, 441–442, 522–523
corporalis callosi dorsalis ramus, 48 443–446, 450–451, 452–454, 455–457, 458, vein of Galen malformation, 509–516
fetal origin, 8, 17, 45,159,160 459–463, 464–467, 468–472, 482–483, infratentorial, 346, 478–498
hippocampal branches, 47 485–486, 519–521 Grade 1, 478–479
lateral occipital, 47 hydrocephalus, 493–498, 513–516 Grade 2, 480–484
medial occipital, 47, 48 infancy, 402–404, 511 Grade 3, 485–489
P 1 ,20, 30, 38, 39, 41, 44, 59, 251 ischemia, 493–498, 499–502 Grade 4, 490–492
P2 , 17, 20, 41, 276–277 multiple arteriovenous malformations, Grade 5, 493–498
P3, 278–279 361–365 supratentorial, 346–477
temporal inferior, 45 pregnancy, 359 Grade 1, 348–352
vascular compression of oculomotor nerve, stenosis, 499–502 Grade 2, 353–384
576 thrombus, 513–516 Grade 3, 385–427
590 Index
Grade 4, 428–457 cervical-to-supraclinoid carotid, 123 Cochlea, see Auditory System

Grade 5, 458–477 double-barrel, 239-244 Colliculi, see Nuclei
Atlanto-occipital joint, see Joint extracranial-intracranial, 246-247 Commissures
Atlas, see Bones occipital artery-to-posterior inferior cerebel anterior, 9, 19, 30, 39, 43, 44, 59, 430
Atrium, see Ventricle, trigone lar artery, 123 posterior, 39, 42, 48, 49
Auditory System petrous-to-supraclinoid carotid (C5-C3), 7, Condyles, see Bones
cochlea, 5, 89, 95–97, 100, 132 123, 127-130, 131-134, 499-502 Corpus callosum, see Tracts
external auditory meatus, 73, 94, 303 posterior inferior cerebellar artery-to-posteri Cranial nerves
incus, 556 or inferior cerebellar artery, 331-333 abducent (CN VI), 6, 11–16, 37, 53, 57, 58,
inner ear, 4, 94 saphenous-vein graft, 123, 127-130, 131-134, 60–64, 66, 304, 306, 310, 324
internal acoustic porus, 582 143-144, 159-163, 179-181, 499-502 accessory (CN XI), 37, 57, 60–69, 312, 320,
tragus, 96 superficial temporal artery-to-middle cerebral 323, 327, 328, 332, 335, 339, 483, 562, 569,
Axis, see Bones artery, 123, 143-144, 159-163, 179-181, 580, 583, 584, 586
233-235, 236-238, 239-244, 246-247 cranial roots, 57, 61–66, 68, 69
B superficial temporal artery-to-posterior cere ganglion, 65, 68
bral artery, 123 spinal root, 57, 67–69, 339
Balloon occlusion, 128, 133, 246–247, 278–279, superficial temporal artery-to-superior cere facial ( C N V I I ) , 6, 7, 11, 37, 53, 54, 57, 58,
375–376, 505–506, 508 bellar artery, 315-318 60–66, 69, 94–96, 99, 249, 255, 290, 304, 305,
of fistula, 375–376, 505–506, 508 310, 482, 520, 521, 555, 556, 580, 581, 584
of internal carotid artery, 128, 133, 505, 506, frontalis branch, 94, 96, 249, 255, 290
508
C
intermedius, 53, 64, 66
of middle cerebral artery, 246–247 Calcification, 124–126, 159–163, 189–191, superficial petrosal, greater, 89, 95, 132
of posterior cerebral artery, 278–279 267–270, 310 tympanic portion, 6
Basal ganglia, 538, see also Nuclei Caudate, see Nuclei vascular compression of, 580, 581
Bones Cavernous malformations, 72, 526–573 glossopharyngeal (CN IX), 57, 53, 57, 58,
atlas (C1), 67, 69, 105, 327, 335 associated with 60–62, 64–66, 68, 69, 304, 323, 324, 335, 483,
posterior arch, 67, 69 familial, 526, 530–531 520, 580, 583, 584
axis (C2), 68, 327, 334, 335 hemorrhage, 527, 528–529, 541–543, 554, neuralgia of, 583
C3, 334 556–558, 559–561, 572–573 vascular compression of, 583, 584
clinoid mass effect, 535 hypoglossal (CN XII), 37, 57, 60–69, 320, 335,
anterior, 8, 13, 14, 17, 20, 32, 33, 44, 83, 84, two-point method, 526 336, 338, 483
87, 135, 140, 141, 145, 146, 149, 150, 154, venous malformation, 526, 543, 549, 551, canal, 113
161 555, 558, 566, 572–573 trigonum, 67
posterior, 8, 11, 14–21, 27, 29, 32, 45, 46, 51, location oculomotor (CN III), 6–8, 10–13, 17–19, 21,
85, 87, 90, 169, 248, 250, 251, 255, 256, 288 cerebellar peduncle, 555 27, 30, 32, 37–42, 44–46, 51, 52, 54, 59–61, 85,
clivus, 4, 11, 12, 19, 37, 38, 51, 57–59, 62, 88–90, floor of fourth ventricle, 568 125, 127, 137, 169, 174, 257, 260, 263–265,
94, 98, 99, 112, 113, 286, 323 intrachiasmatic, 527 268, 269, 280, 281, 283, 284, 286, 288, 297,
condyles, 111, 113 medulla, 569, 570 547–552
dorsum sellae, 8, 11, 16, 19, 21, 30, 37, 38, 44, 59 medullocervical junction, 570, 571 olfactory (CN I), 186, see also Tracts
incus, 556 midbrain, 547–550, 551–552, 553–554, optic (CN II), 6, 7, 10–21, 27–33, 35, 37, 39, 41,
mandible, 9 556–558 42, 44, 46, 51, 59, 80,81,85,127,129,130,
mastoid, 87, 96, 108, 112, 305, 334, 553, 556 occipitoparietal, 530–531 135,137, 141, 142, 145, 146, 149–152,
occiput, 327, 335, 431 parietal, 528–529, 532–534, 535 154–158,160,161,169,170,176,180, 182,
orbital roof, 87, 89, 90, 249, 250, 287, 293, 298, pons, 555, 562–564 186–188, 193, 196, 219, 243, 253–254, 256,
447 pontomedullary, 565–567 271, 272, 280, 288, 296, 447, 465, 501, 527,
petrous, 5, 58, 79, 89, 92, 94–96, 98–100, 128, quadrigeminal plate, 559–561 547, 576, see also Tracts
132, 501, 556 thalamus, 536–540, 541–543, 544–546, canal, 14, 15, 17, 30
pterion.81, 83, 84, 90 556–558 vascular compression of, 576
sphenoid, 19, 80, 82–84, 127, 186 Cavernous sinus, see Sinuses optic chiasm, 10, 19, 21, 27–32, 37–39, 41, 43, 44,
anterior process, 82 Cerebellopontine angle, 53, 64, 66, 96, 103, 108, 59, 80, 81, 85, 135, 187, 188, 194, 449, 527
planum, 12, 17, 30, 33, 42, 186 580, 581, 584 cavernous malformation of, 527
suboccipital, 111, 112 Cerebellum, 6, 45, 49, 52–57, 64–68, 103, 105, 107, optic radiation, 25
tuberculum sellae, 11, 12, 17, 30, 42, 80 109, 110, 113, 115, 117, 119, 120, 285, 303, 320, optic recess, 19, 30, 37, 38, 42, 43, 59
zygomatic, 9, 81, 87, 89, 94, 96, 249, 256, 324, 327, 328, 332, 335, 337–339, 429, 488, 4 9 1 , optic tract, see Tracts
261–263, 287, 289, 291–295, 298, 420, 4 2 1 , 492, 520, 523, 557, 560, 562, 568–570, 572, 573, trigeminal (CN V), 5–7, 11–13, 15, 37, 46,
553 578, 584, 585 51–58, 61, 62, 64, 66, 68, 89, 99, 131, 132, 304,
Brainstem, 37, 57, 62, 109, 110, 113, 276, 286, 306, arteriovenous malformation of, 478–479, 310, 311, 482, 581
312, 315, 317, 325, 327, 330, 332, 337–340, 484, 480–481, 484, 485–486, 492–498 ganglion (Gasser's),5–7, 13, 37, 54
496, 520, 521, 550, 560, 566, 576, 581, 584, 585 anterior hemisphere, 113, 120, 560 mandibular (V 3 ), 7, 54, 131, 132
arteriovenous malformation of, 482–483, cavernous malformation of, 572–573 maxillary (V 2 ), 7, 54, 131
487–489 flocculus, 53, 64, 66, 324, 520, 584 Meckel's cave, 7
compression from aneurysm, 276,312–314, peduncles, cavernous malformation of, 555 motor portion, 6, 54, 55, 57, 579
315–318 tonsils, 65, 67, 68, 113, 327, 328, 332, 335, ophthalmic (Vj), 10, 54, 131
medulla oblongata, 37, 59, 63–66, 332, 337, 337–339, 4 9 1 , 565, 569, 570, 585 sensory portion, 6, 12, 54, 55, 57, 579
339, 490–92, 565–567, 569–571, 585, 586 vermis, 49, 56, 67,117,120, 285, 478–479, 485, vascular compression of, 55, 577–579
arteriovenous malformation of, 490–492 560, 568, 572, 573 trochlear (CN IV), 6–8, 12, 13, 21, 37, 45, 46,
cavernous malformation of, 565–567, 569, Cerebral aqueduct, 39, 42, 49 51–58, 68, 85, 89, 125, 263, 316, 496, 577, 578
570, 571 Cisterns vagus (CN X), 37, 53, 57, 58, 60–69, 304, 320,
vascular compression of, 585–586 ambient, 45, 51, 52, 57, 263, 488, 496 323, 324, 335, 483, 520, 580, 583, 584
pons, 6, 19, 20, 37, 39–41, 43, 51, 53, 58, 59, 61, cisterna magna, 571 trigonum, 67
64, 577, 578 parasellar, 55 vascular compression of, 584
cavernous malformation of, 555, 562–564, prepontfne, 301 vestibulocochlear (CN VIII), 6, 7, 11, 37, 53,
565–567 quadrigeminal, 42 54, 57, 58, 61–66, 68, 69, 304, 310, 317, 324,
Budde halo, 372 Sylvian, 33, 84, 217 482, 520, 5 2 1 , 555, 580–582, 584
Bypasses, see also Anastomosis Cholesteatoma, 580 vascular compression of, 582
A 2 -to-A 2 , 123 Choroid plexus, see Ventricles Craniocervical junction, 101–113
anterior temporal artery-to-middle cerebral Clinoid, see Bones Craniotomy, see Approaches
artery, 123, 229–232 Clipping, see Aneurysms, treatment Cribriform plate, see Fossae, olfactory
carotid-to-carotid artery, 127–130, 131–134, Clivus. sec Bones Cuneus, 47
499–502 Cyst, colloid, 39
Inde x 591
D Gasser's ganglion, 6, see also Trigeminal n. Gruber's, 11 , 15

GDC coils, 167, 197, 245, 274, 275–276, 341–342, intracavernous, 13, 14
Diaphragma sellae, 17, 19, 30, 39, see also 343, 459–463, 503–504, 507, see also nuchal, 104
Sinuses, cavernous Aneurysms Ligature, Hunterian, 267–270
Diencephalon, 56, see also Hypothalamus Glossopharyngeal n.,see Cranial nerves Lilliequist's membrane, 38, 280
Dorsum sellae, see Bones Grafts Lobes
Dural rings, see Arteries, carotid saphenous-vein, 123, 127–130, 131–134, frontal, 26, 27, 29, 31, 33–36, 44, 8 1 , 8 3 , 8 4 , 129,
143–144, 159–163, 179–181, 499–502 135, 137, 169, 173, 182, 186, 188, 207, 208,
E Gyri 217, 372, 576
ambient, 47 arteriovenous malformation of, 348–349,
Endovascular, see Approaches, nonsurgical angular, 74 350–352, 355–357, 358, 408–412, 436–440,
Epipharynx, 9 cingulate, 51, 47, 115 447–449, 459–463, 468–472
Eustachian lube, 132 dentate, 47 occipital, 50, 116, 117, 119, 389
fasciolar, 47 arteriovenous malformation o f , 361–365,
hippocampal, 32 402–404, 443–446, 473–477
F middle temporal, 393, 433 cavernous malformation of, 530–531
parahippocampal, 10, 26 parietal
Facial n., see Cranial nerves postcentral, 394, 416–418 arteriovenous malformation of, 355–357,
Falx rectus, 19, 28, 29, 31, 32, 35, 59, 135, 186, 187 3 5 8 , 375–376, 394–396, 402–404, 405–407,
cerebelli,486
408–412, 416–418, 441–442, 443–446,
cerebri, 43, 49, 50, 78,115,199,203,378,379,
447–449, 452–454, 455–457, 468–472,
389, 398, 417, 418, 444, 461, 475, 514, 515, H 473–477
518, 532, 533, 537, 542, 545
cavernous malformation of, 528–529,
Fibrocartilago basalis, 5 Hemisphere, cerebral, 24,389,416,514,536,537,
530–531, 532–534, 535
Fissures 541
temporal, 6, 9, 18, 20, 27, 28, 33, 35, 36, 51, 57,
calcarine, 47, 116 Hemorrhage, associated with
83, 84, 89, 95, 99, 137, 169, 173, 182, 207, 208,
choroidal, 73 aneurysm, 159–163, 167,179–181, 186–187,
217, 219, 286, 303, 372, 433, 488, 496, 501,
inferior orbital, 90, 294 188, 202–203, 248–252, 259–260, 274, 275,
547, 557
interhemispheric, 31, 76, 379 278, 285, 287–289, 290–299, 300, 301–302,
arteriovenous malformation o f , 353–354,
longitudinal, 186 305–307, 331
366–369, 381–384, 392–393, 419–422
superior orbital, 87, 294, 295 arteriovenous malformation, 350–352,
Sylvian, 29, 32, 34, 35, 82, 84, 137, 144, 157, 160, 353–354, 358, 361–365, 366–369, 377,
169, 170, 173, 176, 183, 193, 207, 209. 381–384, 392–393, 397–400, 401, 413–415, M
212-214, 215-217, 219, 223, 227, 230, 233, 416–418, 419, 4 2 3 – 4 2 5 , 4 2 8 – 4 3 1 , 432–435,
240, 250, 256, 288, 296, 366, 370-374, 441–442, 443–446, 450–451, 452–454, Mammillary body, see Nuclei
450-451, 463, 547 455–457, 458, 459–463, 464–467, 468–472, Mandible, see Bones
transverse cisternal, 50 482–483, 485–486, 519–521 Mass effect, 236–238, 276–277, 282–284, 535
Fistulae, 375-376, see also Arteriovenous mal cavernous malformation, 527, 528–529, Massa intermedia, 19, 30, 44
formations 541–543, 554, 556–558, 559–561, 572–573 Mastoid, see Bones
cavernous sinus, 499-508 Hippocampus, 25–26 Meckel's cave, see Cranial nerves, trigeminal
torcular dural arteriovenous, 522-523 Hypoglossal n., see Cranial nerves Medulla, see Brainstem
Flocculus, see Cerebellum Hypophyseal fossa, see Fossa, pituitary Mesencephalon, see Midbrain
Fold, petroclinoid Hypophysis, see Pituitary Midbrain, 17–19, 21, 22, 46, 49, 51–53, 56, 59, 85,
anterior, 6-8, 17, 18, 32, 42, 46, 85 Hypothalamus, 21, 59 89, 114, 118, 261, 286, 489, 557
posterior, 7, S, 17, 32, 46, 85 Hypothermic circulatory arrest, 255–258, cavernous malformation of, 547–550, 551–552,
Foramina 259–260, 261–266, 267–270, 290–299, 312–314, 553–554, 556–558
diaphragmatic, 17, 30 319–322, 325–330 microDoppler flow probe, 132, 156, 214
jugular, 11, 69, 580, 584 miniplates, 292–294, 298, 299
of Luschka, 65 Muscles
I lateral pterygoid, 9
magnum, 94, 105, 113, 337, 559
of Majendie, 65, 568, 571 occipital, 431
Incus, see Bones
of Monro, 19, 30, 39, 50, 72, 73, 78, 362, 398, paraspinous, 112
Infundibulum, see Pituitary temporal, 9, 33, 94, 160, 193, 248, 249, 255, 256,
399, 540 Inner ear, see Auditory System
optic, 87, 146 2 5 8 , 262, 2 8 7 , 290–292, 294, 2 9 5 , 2 9 9 , 372,
Insula, 25, 212, 213, 447, 450–451 530
ovale, 128, 132, see also Bones, sphenoid Internal capsule, see Tracts
spinosum, 7, 132 tensor tympani, 7
Ischemia, associated with
Fornix, 9, 19, 26, 30, 39, 43, 48, 50, 73,359,362, aneurysm, 143–144, 159–163, 204–206, 224,
430, 540
Fossae
229, 282–284 N
arteriovenous malformation, 493–498,
anterior (frontal), 33, 81, 84, 256, 287, 447-449 499–502 Nerves, see also Cranial nerves
interpeduncular, 19, 37 , 38, 40, 43, 44, 49, 58, vascular compression, 576, 579, 585 spinal roots
59, 61 ISG wand, see Frameless stereotactic guidance Ch60, 63, 67, 68, 332, 339
middle (temporal), 5, 6, 11, 92–100, 127, 132, system C 2 , 60, 63, 65, 67–69, 491
136–139, 256, 262, 263, 287, 295, 305, 383, C3, 68, 69
419–422, 556 suboccipital, 68
olfactory, 12 J
superficial petrosal, lesser, 132
pituitary, 16 Joint sympathetic (root from carotid plexus), 15
posterior, 92-113,116, 327, 346, 359, 429, 571, atlanto-occipital, 61, 69 Neurohypophysis, see Pituitary
572 Normal perfusion pressure breakthrough, 346
rhomboid, 67 L Nuclei
Frameless stereotactic guidance system, 361, caudate, 50, 423–425
389, 437–439, 532–534, 538, 539, 542, 543, 550, Labyrinth, 556,557 inferior colliculus, 488
558, 562–564, 565, 569 Lamina mammillary body, 19–21, 30, 35, 37–44, 59, 60
Frontal cortex, see Lobes tecti, 49 olives, 61
terminalis, 9, 19, 27–32, 37–39, 42, 44, 59,158, pulvinar, 46, 52, 56
193 substantia nigra, 42, 44, 53
G Leyla bar, 94,112,371 superior colliculus, 52, 120
Gamma knife, 419 Ligament, see also Fold thalamus, 23, 24, 26, 43, 50, 119, 362, 398, 400,
Ganglia, see Nerves dentate, 65–68, 586 401, 415
592 Index
arteriovenous malformation of, 359–360, inferior petrosal, 11, 89 V

4 0 1 , 413–415, 432–435, 458, 464–467, inferior sagittal, 537
473–477 intercavernous Vascular compression, 576–586
cavernous malformation of, 536–540, anterior, 10, 19 of facial nerve, 580,581
541–543, 544–546, 556–558 posterior, 19, 39, 59 of glossopharyngeal nerve, 583, 584
sigmoid, 94–96, 99, 108, 110, 303–304, 305, 310, of medulla, 585–586
O 556, 559 of optic nerve, 576
sphenoid, 1, 9, 10, 19, 37, 38, 43, 44, 51, 59 of trigeminal nerve, 577–579
Occiput, see Bones straight (rectus), 50, 102, 512 of vagus nerve, 584
Occipital lobe, see Lobes superior petrosal, 46, 56, 89, 94–96, 99, of vestibulocochlear nerve, 582
Occlusion, see Balloon occlusion 303–304, 482, 5 0 3 , 557 Vagus n., see Cranial nerves
Oculomotor n., see Cranial nerves superior sagittal, 75, 77, 78, 114, 116, 378, 394, Veins
Olfactory cortex, see Uncus 395, 429, 436, 475, 514, 517–518, 536, 544, basal vein of Rosenthal, 46, 49, 50, 52,56,115,
Olfactory n., see Cranial nerves, Tracts 559 117,119,120,488,560
Olives, see Nuclei dural arteriovenous malformation of, basilar venous plexus, 38, 51, 59
Optic n.,see Cranial nerves, Tracts, Visual sys 517–518 carotid venous plexus, 4
tem torcula Herophili (confluens sinuum), 116, cerebellar, 285
Orbit, 248–252,256,287,291,293,294,298, see 522–523, 560 cerebral, middle superficial, 33
Bones, Visual system transverse, 94–96, 99, 110, 116, 118, 404, 420, choroid, 56, 359
421, 429, 485, 486, 559, 560 condylar emissary, 69
Spetzler–Martin Grading System, 346, 347
P of Galen, 49, 50, 52, 56, 115, 117–119, 503, 560
Sphenoid bone, see Bones approaches to, 114–120
Parasellar region, see Pituitary Sphenoid planum, see Bones malformation of, 509–516
Parietal lobe, see Lobes Spinal cord, 65, 327, 343, 490, 562, 570, 571, 585 internal cerebral, 49, 50, 56, 115, 117, 119, 120,
Parkinson's triangle, 8 Stenosis, 159–163, 179–181, 229, 499–502 515
Peduncle, cerebellar, 61, 65 Stereotaxy, 72, 361. 389 internal occipital, 56, 116, 117, 119, 120
cavernous malformation of, 555 Striae medullares, 568 interpeduncular, 40, 59
cerebral, 18, 42, 44–46, 51–53, 58, 161, 286 Striatum, 179
j u g u l a r , 4, 5, 11, 95, 305, 493
Perforated substance, 20, 28 Substantia nigra, see Nuclei of Labbe, 94–96, 99
Petroclinoid, see Fold Sulcus lateral atrial, 24, 25
Petrous, see Bones cingulate, 31 lateral mesencephalic, 18, 45, 46, 52, 53, 57
Pharynx, 4, 9 medianus (of fourth ventricle), 568 medial occipital, 115, 117
Pineal body, 42, 47–49, 56, 114–120 parietooccipital, 47 petrosal, 46, 52, 53, 61, 64, 66, 482, 557, 558
Pituitary, 8, 9, 11, 12, 15, 16, 18, 19, 21, 27, 28,30, pontomedullary, 60 pharyngeal plexus, 4
32, 35, 37–39, 41, 43, 44, 51, 59, 82 precentral,56 pineal, 49,120
adenohypophysis, 19, 37, 39, 44, 51, 59 pontine, 60
hypophyseal fossa, see Fossa, pituitary posterior spinal, 67
infundibular recess, 19, 30, 42–44, 59 T posterior superior thalamic, 56
neurohypophysis, 19, 37, 39, 44, 51, 59 precentral cerebellar, 49, 117, 119, 120, 560
parasellar region, 80–82, 87 Tegmentum, 19, 37, 59
Tela choroidea, see Ventricles rete venosum pontis, 53, 58
sellar region, 80, 87 septum pellucidum, 43
Temporal Lobe, see Lobes
stalk, 8, 9, 11, 12, 18, 19, 27, 28, 32, 35, 37, 38, superior cerebellar, 56
41, 43, 44, 59, 254, 296 Tentorium, 17, 18, 45, 46, 50–53, 57, 58, 61, 62, 85,
89, 94, 95, 99, 115, 117, 118, 120, 263, 264, 269, superior vermian,56
Pons, see Brainstem Sylvian vein, 420
Premammillary recess, 42 270, 283, 286, 316, 389, 403, 429, 486, 488, 496,
547, 551, 554, 557, 560, 573, 577, 578 thalamostriate, 73, 439
Proton-beam radiation therapy, 428–433, Venous malformations, 526, 543, 549, 551, 555,
436–440, 441–442, 447–449 tentorial edge, 45, 51, 58, 85
tentorial notch, 17, 18, 51 558, 566, 572–573
Plerion, see Bones Ventricles, 72, 75–78, 82, 114. 116
Pulvinar, see Nuclei Thalamus, see Nuclei
Torcula Herophili, see Sinus choroid plexus, 19, 22–26, 39, 46–50, 52, 53, 56,
Pyramids, see Tracts 61, 64–67, 73, 362, 379, 380, 391, 393, 398,
Tracts
corpus callosum, 30-32, 43, 44, 47–49, 75-78, 399, 413–415, 439, 537, 539, 540, 542, 543,
Q 114, 115, 117, 120, 202-203, 362, 379, 414, 571
454, 462, 514, 515, 537-540, 542, 545 fourth ventricle, 53, 61, 64–67, 526, 554–565,
Quadrigeminal plate, 39, 42, 46, 48, 49, 52, 56, 568, 571
aneurysm of, 202-203
117,119,120 cavernous malformation of, 568
arteriovenous malformation of, 377–380,
arterial network of lamina tecti, 49 obex, 67
385–387, 388–391, 397–400, 473–477
arteriovenous malformation of, 426–427, rhomboid fossa, see Fossae
genu, 31, 32, 43, 44
428–431 lateral ventricle, 9, 22–26, 46, 48–50, 52, 56,
splenium, 47–49, 77, 114, 115, 117, 120,
cavernous malformation of, 559–561 72–75, 78, 379, 393, 397–400, 414, 415, 424,
388–391, 400, 462, 473–477, 514
fasciculus, median longitudinal, 39 438, 442, 455, 459–463, 473, 482, 537, 540,
R internal capsule, 22, 46, 179 542, 545
mammillothalamic, 43 anterior horn, 50
Radiosurgery, see Approaches, nonsurgical arteriovenous malformation in, 397–400,
Retractor, see Budde Halo olfactory, 27–29, 31, 35, 42, 186, 187
optic, 9, 17, 18, 20, 22, 27–31, 35, 37, 42, 85, 527 413–415
Revascularization strategies for aneurysms, 123 atrium (trigone), 25, 24, 47, 50, 74, 391, 415
cavernous malformation of, 527
pyramids, 61, 64 posterior horn, 25, 50
S Trigeminal n., see Cranial nerves temporal horn, 22, 23, 25, 26, 47, 482
Trigone, see Ventricles third ventricle, 9, 19, 30, 37–39, 42, 43, 49,56,
Sellar region, see Pituitary 73, 75, 78, 114, 430, 460, 461, 476, 515
Semicircular canals, 556, 557 Trochlear n., see Cranial nerves
Tuberculum jugulare, 57 optic recess, 19, 30, 37, 38, 42, 43
Septal cavum,50 tela choroidea, 56
Septum pellucidum, 32, 43, 50, 380 Tuberculum sellae, see Bones
Two-point method, 526, see also Cavernous mal trigonal recess, 9
Sinuses Vermis, see Cerebellum
formation
cavernous, 4–11, 13–16, 44, 124–126, 127–130, Vestibulocochlear n., see Cranial nerves
131–134, 149, 499–508 Visual system, see Cranial nerves, Optic n.
aneurysm of, 124–126, 127–130, 131–134,
U
499–502 Z
fistula of, 499–502, 503–504, 505–507, 508 Ultrasonography, 433
transverse plate, 13, 14, 16 Uncus, 20, 27, 32, 41, 47 Zygomatic process, see Bones

Язык

Добро пожаловать в Scribd!

(SPETZLER) Color Atlas of Microneurosurgery vol2.pdf

Загружено:

Сведения о документе

Дата загрузки

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Описание:

Авторское право:

Доступные форматы

(SPETZLER) Color Atlas of Microneurosurgery vol2.pdf

Загружено:

Описание:

Авторское право:

Доступные форматы

Похожие издания

s

of Micron eu r osu rger y

Volume 2: Cerebrovascular Lesions

Robert F. Spetzler, M.D. Wolfgang T. Koos, M.D.

Bernd Richling, M.D. Johannes Lang, M.D.

2537 illustrations, most in color

Robert F. Spetzler, M. D. Library of Congress Cataloging-in-Publication Data

Aneurysms — Anterior Circulation 122

5 Ca ver nous Malfor mations

6 Vascular C om p r ession 575

Gener al Anatomy Terms Vessels

a., aa. artery, arteries A1, A2 Segments of the ACA

Org a n iza tio n of Volume Two

Introduction brobasilar artery junction. Clearly, there is con

1-1 Corrosion cast of the internal carotid arteries as they enter

1-2 A slice through the internal ca rotid artery as it

1-3 Anatomical exposure of the petrous and intracavernous por

1-5 The intrapetrous portion of the

1-6 A frontobasal view of the internal carotid artery as it courses

1-7 Oblique view of the cavernous sinus de mon

1-8 Microanatomy of the cavernous sinus (viewed

1-9 Higher magnification demonstrates the rela

1-10 The posterior cavernous sinus is opened

1-11 Further exposure of the intracavernous

1-12 The cavernous sinus has been dissected fur

1-13 The cavernous sinus has been disse cted still

1-14 In this view of the cavernous sinus, the inter

1-15 By opening the lateral wall of the pituitary

1-17 A fetal posterior cerebral artery

1-18 The entire course of the posterior communi

1-19 Midsagittal section through the pituitary and third ventricle

1-20 A paramedian section shows posterior communicating

1-21 Inferior view of the posterior communica ting artery. Also

1-22 The posterior communica ting artery is visualized in relation

1-23 Lateral view of the course of the anterior choroidal artery

1-24 Inferior diencephalic branches

1-25 The anterior choroidal artery is exposed completely from the

1-26 Through a section of the trigone, the anterior

1-27 Trigone of the right lateral ventricle.

1-28 The choroid plexus is elevated exposing the

1-29 Choroid plexus of tempora l horn of the lateral

1-30 Cortical branch of anterior choroidal artery from below.

1-31 In a view obtained through a bilateral s ub-

1-32 With further retraction, the entire course of

1-33 The anterior communicating artery complex is exposed from

1-35 Superior view of the anterior communica ting artery complex.

1-36 A midsagittal section through the

1-37 In an exposure obtained with a bilat

1-38 Branches of the anterior cerebral arteries within the inter-

1-39 The anterior cerebral artery as it courses around the genu of

1-40 The middle cerebral artery, as it lies in the Sylvian fissure, is

1-41 Frontolateral exposure of the parasellar and

1-42 The distal middle cerebral artery branches are

1-43 Inferior view of the middle cerebral artery

1-44 Overview of the entire course of the middle

1-46 A midsagittal section through the third ventricle and basilar

1-47 A good demonstration of the medial aspect of Lilliequist's

1-48 Close-up paramedian section through the