New Trends in Management of Cerebro-Vascular Malformations: Proceedings of the International Conference Verona, Italy, June 8–12, 1992

569 Pages·1994·22.084 MB·English

by  Bengt Ljunggren M.D., S. Sharma, H. Fodstad (auth.), Alberto Pasqualin M.D., Renato Da Pian M.D. (eds.)

New Trends in Management
of Cerebro-Uscular
Malformations
of
Proceedings the International Conference
VeronaJ ItaIYJ June 8-12J 1992
Edited by
A. Pasqualin and R. Da Pian
In collaboration with
R. Scienza
Springer-Verlag Wien New York
Alberto Pasqualin, M.D.
Renato Da Pian, M.D.
Department of Neurosurgery, Verona City Hospital, Verona, Italy
This publication was supported by an educational grant from The Upjohn Company and Bayropharm
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Library of Congress Cataloging-in-Publication Data.
New trends in management of cerebro-vascular malformations : proceedings of the international conference, Verona, Italy, June 8-12, 1992 / edited by
A. Pasqualin and R. Da Pian : in collaboration with R, Scienza,
p, em.
"International Conference "New Trends in Management of Cerebra-vascular Malformations" - Pref. ISBN-13: 978-3-7091-9332-7
ISBN-13: 978-3-7091-9332-7 I. Intracranial aneurysms-Congresses. 2, Subarachnoid hemorrhage-Congresses.
I. Pasqualin, A. (Alberto), 1951- . II, Da Pian, R. (Renato), 1928- , III, Scienza, R,
IV. International Conference "New Trends in Management of Cerebra-vascular Malformations" (1992 : Verona, Italy).
[DNLM: 1. Cerebral Arteriovenous Malformations-therapy--<:ongresses, 2. Cerebral Aneurysm-therapy--<:ongresses, WL 355 1994]
RD594,2,N494 1992. 616,8'I-dc20. DNLMIDLC 94-7680
ISBN-13: 978-3-7091-9332-7 e-ISBN-13: 978-3-7091-9330-3
DOl: 10.1007/978-3-7091-9330-3
Foreword
Every so often a gathering of minds and experience occurs that results in an all encompassing overview in depth
of such a vast subject as Cerebro-Vascular Malformations, as occurred in Verona in June 1992 and which warrants
publication. Professors Da Pian and Pasqualin deserve high compliment and it is a measure of the respect in which
they are held that virtually all those most knowledgeable around the world attended, presented their work and
thoughts and contributed to intense discussion.
Ljunggren's opening historical survey set the stage and must be the most comprehensive yet published.
Subarachnoid hemorrhage from aneurysm rupture still constitutes, I dare say, the most difficult problem for
neurosurgeons, in relief of the brain injury and arterial reaction and the technical perfection of aneurysm
obliteration, even for small, as well as large and giant sacs. Very large high flow A VMs can be as demanding too.
The bulk of the conference was devoted to subarachnoid hemorrhage, aneurysms and A VMs which were discussed
under about 14 headings each. But vein of Galen malformations, dural A VMs, cavernous angiomas and venous
angiomas (renamed developmental venous anomalies) came under scrutiny, not always with consensus.
Trends are perceptible such as fibrinolysis of subarachnoid clot, non surgery for Galenic and dural malforma
tions, the benignity of venous angioma, but there is still much variation in approach, pharmacologically,
technically and with such as the evolving endovascular and radiosurgical stories, used alone or in conjunction.
Ofthe more than 200 presentations, just about 100 have been selected for publication but these best survey the
gamut of the conference
March 1994 Charles G. Drake,OC. M.D. FRCS (C)
Preface
The management of cerebral aneurysms and arteriovenous malformations (A VMs) still poses considerable
problems and is still the subject of controversy. In spite of dramatic advances in surgical techniques, endovascular
therapy and anesthesia, the largest lesions - as well as those located in deep areas of the brain - remain a challenge
for the neurosurgeon. When dealing with aneurysms, the initial subarachnoid hemorrhage can be devastating -
creating difficulties in management - and cerebral vasopasm has still to be solved. The hemodynamic conse
quences of the occlusion of large A VMs are difficult to predict and combined or alternative treatments may be
preferable to surgical removal of these lesions. For less common malformations - such as dural fistulas,
cavernomas and venous angiomas - the indications for treatment have still to be established.
In order to discuss these problems, the International Conference "New Trends in Management of Cerebro
Vascular Malformations" was held in Verona, Italy, from June 8 to 12, 1992; Prof. Renato Da Pian was the
President of the meeting, and Prof. Charles C. Drake was the Honored Guest. During the Conference, the major
international experts discussed in depth the various aspects of this pathology, including diagnosis, patho
physiology, pharmacology, surgery, embolization and endovascular occlusion, radiosurgery, anesthesia and
perioperative care.
This book contains the proceedings of that Conference, which - as a whole - represent an update of the
achievements made in the management of cerebro-vascular malformations, with particular attention paid to the
hemodynamics of subarachnoid hemorrhage and intracranial A VMs, and to the new possibilities of interventional
neuroradiology.
Our gratitude goes to the many contributors to this book and to all those who participated in the Conference.
We are indebted to The Upjohn Company and Bayropharm for support in the publication of this book. We also
want to express our gratitude to Mrs. Giuliana Rossi Pasqualin for her skilfull assistance.
March 1994 The Editors
Contents
Introduction
Ljunggren, B., Sharma, S., Fodstad, H.: History and Epidemiology of SAH and Cerebrovascular
Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
McKenzie, R., Awad, I., Magdinec, M., Masaryk, T.: Clinical Usefulness of Magnetic Resonance
Angiography in Neurosurgical Practice ..................................................... 16
Intracranial Aneurysms and Subarachnoid Hemorrhage
Research in Cerebral Vasospasm
Macdonald, R. L., Weir, B. K. A.: New Evidence Pointing to Oxyhemoglobin as the Cause of Vasospasm 27
Sasaki, T., Itoh, S., Nishikibe, M.: Recent Advances in Research of Cerebral Vasospasm - Possible
Participation of Endothelin in the Genesis of Vasospasm ....................................... 32
Taylor, W. A. S., Sydserff, S. G. C., Bell, B. A.: Cerebral Blood Flow in Middle Cerebral Ischaemia is
Increased by Calcitonin Gene-Related Peptide ............................................... 38
Kanamura, K., Waga, S., Tanaka, K., Sakakura, M., Morikawa, A.: Anticoagulation Factors, Protein C,
Protein S, and Antithrombin III in Subarachnoid Haemorrhage Patients ........................... 41
Gaetani, P., Grignani, G., Spanu, G., Rodriguez y Baena, R.: A Study on Cisternal CSF Levels of
Endothelin-l After Subarachnoid Haemorrhage .............................................. 43
d'AveUa, D., Germano', A., Tomasello, F.: Early Blood-Brain Barrier Changes After Experimental
Subarachnoid Haemorrhage: a Quantitative and Electron Microscopy Study ....................... 48
Sasaki, T., Takakura, K., Wakamatsu, T., Tsuboi, T.: Prevention of Experimental Vasospasm with Inter-
mittent Intracisternal rtPA ............................................................... 52
Cerebral Hemodynamics After SAH
Yonas, H.: Cerebral Blood Flow Assessment Following Subarachnoid Hemorrhage ................. 59
Pickard, J. D., Czosnyka, M., Nelson, R., Stanley, J., Reid, D., Coull, R., Lovick, A. H. J., Campbell, M.:
Haemodynamic Evaluation of Cerebral Perfusion After Subarachnoid Haemorrhage - a Review ....... 67
Romner, B.: Transcranial Doppler Evaluation of Cerebral Perfusion After SAH .................... 71
Pasqualin, A., Talacchi, A., Chioffi, F., Pavesi, G., Da Pian, R.: Combined Transcranial Doppler Sono-
graphy and rCBF Measurements in the Early Stage of Subarachnoid Hemorrhage ................... 76
Pharmacological Treatment of Vasospasm
Haley, E. C.: Principles of Pharmaceutical Therapy for Vasospasm Following Subarachnoid Hemorrhage 85
Brandt, L., Saveland, H.: A Calcium Antagonist in Aneurysmal SAH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
x
Contents
Dorsch, N. W. c.: Nimodipine and Cerebral Vasospasm: Review of Effects and Mechanisms 95
Kassell, N. F., Haley, E. C., Alves, W.: Tirilazad and Aneurysmal Subarachnoid Hemorrhage 99
European CGRP in Subarachnoid Haemorrhage Study Group: Effect of Calcitonin Gene-Related Peptide on
Outcome of Ischaemic Deficits After Subarachnoid Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 102
Pasqualin, A., Barone, G., Scienza, R., Mortini, P., Cappelletto, B., Licata, C., Da Pian, R.: Clinical Effects
of Nimodipine in Prevention of Vasospasm After Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . . .. 107
Kodama, N., Sasaki, T., Yamanobe, K., Sato, M., Kawakami, M.: Prevention of Cerebral Vasospasm-
Cisternal Irrigation Therapy with Urokinase and Ascorbic Acid ................................. 113
Findlay, J. M., Weir, B. K. A., Grace, M. G. A.: Intracisternal Recombinant Tissue Plasminogen Activator
After Aneurysmal Subarachnoid Hemorrhage: Results of a Preliminary Study ...................... 121
Zabramski, J. M., Spetzler, R. F., Papadopoulos, S. M., Bovill, T.: Intracisternal Therapy with Tissue
Plasminogen Activator for the Prevention of Vasospasm in Patients with Aneursymal Subarachnoid
Hemorrhage. A Review ................................................................. 125
Levy, M. L., Rabb, C. H., Zelman, V., Gianotta, S. L.: The Use of Dobutamine to Enhance Cardiac
Performance and Improve Outcome in Patients Refractory to Hypervolemic Therapy for Cerebral
Vasospasm: a Preliminary Study .......................................................... 132
Kanamuru, K., Waga, S., Niwa, S., Sakakura, M., Sakaida, H., Morikawa, A., Murao, K., Yamamoto, Y.,
Morooka, Y., Sakakura, T., Okada, M., Furuno, M.: Single Intracisternal Injection of Recombinant Tissue
Type Plasminogen Activator for Prevention of Cerebral Vasospasm .............................. 136
Endovascular Approaches to Vasospasm
Dowd, C. F., Higashida, R. T., Halbach, V. V., Fraser, K. W., Smith, T. P., Hieshima, G. B.: Angioplasty of
Cerebral Vasospasm .................................................................... 141
Eskridge, J. M., Winn, H. R., Newell, D. W., Alotis, M. A.: Balloon Angioplasty for the Treatment of
Symptomatic Vasospasm ................................................................ 146
Helm, G. A., Kassell, N. F., Simmons, N., Phillips, C. D., Cail, W. S.: Intra-Arterial Papaverine for the
Treatment of Cerebral Vasospasm ......................................................... 151
Anesthesia and Temporary Clipping in Aneurysm Surgery
Stone, D. J.: Anesthesia in Aneurysm Surgery ............................................... 159
Young, W. L., Stone, J. G.: Special Anesthetic Considerations for Management of Cerebral Aneurysm
Clipping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 164
de Tribolet, N., Ravussin, P.: Total Intravenous Anesthesia Using Propofol for Burst Suppression in
Cerebral Aneurysm Surgery: Preliminary Report of 44 Cases .............................. ,.... 174
Symon, L.: Temporary Clipping in Aneurysm Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 176
Batjer, H. H., Samson, D. S.: Limits of Temporary Arterial Occlusion ............................ 180
Solomon, R. A., Smith, C. R., Young, W. L., Stone, J. G.: Deep Hypothermic Circulatory Arrest as an
Adjunct to Complex Intracranial Aneurysm Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185
Surgery of Giant Aneurysms
Sugita, K., Shibuya, M., Negoro, M., Suzuki, Y.: Clipping Techniques for Partially Thrombosed Giant
Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 195
Gianotta, S. L.: Complication Avoidance for Large and Giant Carotid Ophthalmic Aneurysms. . . . . . . .. 198
Contents XI
Galzio, R. J., Tassi, G. P., Lucantoni, D., Ricci, A.: Direct Microsurgical Approach to Giant Intracranial
Aneurysms. Considerations, Technical Notes and Results in a Series of 47 Cases ................... 203
Tamaki, N., Ehara, K., Asada, M., Nagashima, T., Fujita, K., Taomoto, K.: Surgical Treatment of Large and
Giant Carotid-Ophthalmic Artery Aneurysms ................................................ 212
Surgery of Posterior Circulation Aneurysms
Flamm, E. S., O'Rourke, D.: Vertebrobasilar Artery Aneurysms: Current Management Techniques 219
Samson, D., Batjer, H.: The Transsylvian Approach to Basilar Aneurysms ........................ , 228
Dolenc, V. V., Prestor, B. P., Sustersic, J., Pregelj, R.: Transclinoid-Transsellar-Transcavemous
Approach to Basilar Tip Aneurysms ....................................................... 231
Da Pian, R., Pasqualin, A., Scienza, R., Pavesi, G., Licata, c.: Combined Pterional-Subtemporal Approach
to Upper Basilar Artery Aneurysms ........................................................ 238
Moriyama, T., Kurosaki, M., Shiwaku, T.: Early Surgery for Ruptured Aneurysms of the Posterior
Circulation - 60 Consecutive Cases ........................................................ 244
Gianotta, S. L.: Retrolabyrinthine Trans-Sigmoid (RLT S) Approach to Aneurysms of the Basilar Trunk and
Vertebrobasilar Junction: an Update ....................................................... 250
Taylor, W. A. S., Uttley, D., Archer, D. J.: An Anterior Approach to Aneurysms of the Vertebro-Basilar
Junction .............................................................................. 253
Kawase, T., Toya, S.: Anterior Transpetrosal Approach for Basilar Trunk Aneurysms - Further
Experience .......................................................................... " 255
Endovascular Treatment of Aneurysms
Dowd, C. F., Higashida, R. T., Halbach, V. V., Smith, T. P., Fraser, K. W., Hieshima, G. B.: Standard and
Giant Aneurysms: The Role of Endovascular Therapy ......................................... 263
Guglielmi, G., Vinuela, F.: Endovascular Treatment of Intracranial Saccular Aneurysms with GDC
Platinum Detachable Coils: Small-Necked Aneurysms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 269
Witt, J.-P., Yonas, H., Johnson, D. W.: Internal Carotid Artery Balloon Test Occlusion Does Require
Quantitative Assessment of CBF .......................................................... 272
Perini, S., Pasqualin, A., Zampieri, P., Pecoraro, M. G., Talacchi, A., Maschio, A., Rosta, L., Benati, A.:
Endovascular Treatment of Giant Intracranial Aneurysms by Balloon Occlusion of the Parent Vessel:
Clinical and Diagnostic Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 275
Severe Subarachnoid Hemorrhage, Un ruptured and Intracavernous Aneurysms, Aneurysm Rests
Zabramski, J. M., Spetzler, R. F.: Acute Medical and Surgical Management of Severely III Aneurysm
Patients: a Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 285
Seifert, V., Trost, H. A., Stolke, D., Dietz, H.: Strategy of Surgical Treatment in Severely III Patients After
Aneurysmal Subarachnoid Hemorrhage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 291
Wiebers, D.O.: Unruptured Intracranial Aneurysms - Current Concepts and Future Directions 294
Yasui, N., Suzuki, A., Hadeishi, H.: Validity of Surgical Treatment of Unr uptured Aneurysms 296
Hemesniemi, J., Rinne, J., Puranen, M., Saari, T.: The Fate of Patients with Incidental Intracavemous
Carotid Artery Aneurysms (ICCAA) ....................................................... 300
Ohmoto, T., Kinugasa, K., Asari, S., Sakurai, M.: Surgical and Endovascular Approaches to Intracavemous
Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 304
XII Contents
Mennonna, P., Ammannati, F., Bordi, L., Cagnoni, G., Gagliardi, R., Guizzardi, G. c., Mariotti, F., Morichi,
R.: Aneurysm Rests in a Surgical Series of 275 (Five Years): Incidence, Prognostic and Therapeutic
Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 310
Takeda, M., Yonekawa, Y., Miyake, H., Tsukahara, T., Kobayashi, A.: Recurrent Subarachnoid
Hemorrhage After Aneurysm Surgery ...................................................... 316
Intracranial Arteriovenous Malformations
Classification of Cerebral A VMs
Smith, K. A., Spetzler, R. F.: Classification of Arteriovenous Malformations 323
Malik, G. M., Pasqualin, A., Ausman, 1. 1.: A New Grading System for Cerebral Arteriovenous
Malformations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 328
Lehman, R., Olivier, A.: Use of the Callosal Grid System for Cortical Localization .................. 333
Hemodynamics of Cerebral A VMs and Perioperative Management
Hassler, W., Burger, R.: Hemodynamics of Cerebral Angiomas: Perioperative Angiography, Transcranial
and Intraoperative Doppler Studies ........................................................ 341
Piepgras, A., Leinsinger, G., Schmiedek, P.: Cerebrovascular Reserve Capacity in A VM Patients ...... 350
Talacchi, A., Sala, F., Pasqualin, A., Bricolo, A.: Vasodilatory Challenge with rCBF Measurement in
Patients with Cerebral A VMs: a Preliminary Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 352
Batjer, H. H., Samson, D. S., Purdy, P. D.: Clinical Evaluation of Cerebral Perfusion in A VM Patients " 356
Talacchi, A., Pasqualin, A., Sala, F., Bricolo, A.: The Role of Hemodynamic Assessment in Patients with
Cerebral A VMs ........................................................................ 364
Tamaki, N., Ehara, K., Shirakuni, T., Nagashima, T., Asada, M., Korosue, K., Fujita, K.: Selective Flow
Modulation of Proximal Feeding Arteries in Surgery of High-Flow Cerebral Arteriovenous Malformations 373
Chioffi, F., Pasqualin, A., Acerbi, G., Pavesi, G.: The Importance of Transcranial Doppler Sonography in
the Management of Cerebral A VMs: Pre-Treatment Evaluation and Post-Embolization Changes ....... 377
Young, W. L., Ornstein, E.: Peri operative Management of High-Flow Arteriovenous Malformations;
Hemodynamic Monitoring and Anesthetic Considerations ...................................... 382
U, H. S., Drummond, J. C., Todd, M. M.: Deep Barbiturate Anesthesia in the Multi-Staged Treatment of
Large Deep A VMs ..................................................................... 390
Surgery of Deep-Seated and Posterior Fossa A VMs
Stein, B. M., Solomon, R. A., Kader, A.: Medial Hemisphere and Tentorial Ring A VMs 395
Da Pian, R., Pasqualin, A., Scienza, R., Cappelletto, B., Licata, c.: Surgical Experience with Callosal-
Cingular and Inferior Limbic A VMs ....................................................... 399
Stein, B. M., Sisti, M. B., Kader, A.: Stereotactic Uses in the Treatment of Deep "Inaccessible" A VMs and
a Comparison with Radiosurgery .......................................................... 410
Yonekawa, Y., Kaku, Y., Yamashita, K., Yoshida, S., Niijima, K., Kawano, T., Taki, W.: Surgical Removal
of Thalamic Arteriovenous Malformation - Transventricular Approach, Sitting Position, Intraoperative
Angiography .......................................................................... 414
U, H. S.: Treatment of Deep Basal Cerebral Arteriovenous Malformations. . . . . . . . . . . . . . . . . . . . . . . .. 422
Samson, D., Batjer, R., Purdy, P.: The Surgery of Posterior Fossa Arteriovenous Malformations ....... 426
Contents XIII
Da Pian, R., Pasqualin, A., Scienza, R., Cappelletto, B., Barone, G.: Surgical Experience with Cerebellar
AVMs ............................................................................... 430
Embolization of Cerebral A VMs
Yonekawa, Kaku, Y., Iwata, H.: Overview of Embolic Materials and Clinical Use of EVAL 441
Purdy, P. D., Batjer, H. H., Kopitnik, T., Risser, R., Samson, D.: Use of Ethanol in Preoperative AVM
Embolization .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 446
Benati, A., Perini, S., Pasqualin, A., Pecoraro, M. G., Maschio, A., Rosta, L., Piovan, E., Zampieri, P.:
Embolization of Cerebral A VMs with Polylene Threads: Technical Procedure, Results and Complications 452
Burger, R., Hassler, W.: Transcranial Doppler Sonography After Embolization and Staged Operation of
A VMs and Balloon Occlusion of Carotid-Cavernous Sinus Fistula ............................... 463
Radiosurgery of Cerebral A VMs
Steiner, L., Lindquist, c., Karlsson, B., Guo, W., Steiner, M.: Gamma Knife Radiosurgery in Cerebral
Vascular Malfonnations ................................................................. 473
Combined Treatments for Cerebral A VMs
Stein, B. M., Pile-Spellman, J., Kader, A: The Role of Embolization in the Surgical Resection of AVMs 489
Da Pian, R., Pasqualin, A., Scienza, R., Barone, G., Perini, S., Benati, A: Further Experience in the
Treatment of Cerebral Arteriovenous Malfonnations with Embolization Plus Surgery . . . . . . . . . . . . . . .. 495
Purdy, P. D., Batjer, H. H., Kopitnik, T., Samson, D.: The Team Approach to Combined Embolization and
Resection of Arteriovenous Malfonnations .................................................. 503
Levy, D. I., Khayata, M. H., Spetzler, R. F.: Staged Occlusion of Arteriovenous Malfonnations . . . . . . .. 507
Aspoas, A R., Mendelow, A. D., Arrotegui, J., Gholkar, A.: Outcome from Multimodality. Treatment of
Arteriovenous Malfonnations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 512
Richling, B., Bavinzski, G., Gruber, A., Killer, M.: Therapeutic Strategies for Brain A VMs. An Assessment
of Benefits and Risks of Surgical and Endovascular Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 515
Management of Critical Cavernous Malformations
Hamilton, M. G., Wascher, T. M., Spetzler, R. F.: Cavernous Malfonnations of the Brain Stem 525
Gilsbach, J. M., Bertalanffy, H.: Cavernomas of the Basal Ganglia, Brain Stem and Spinal Cord. Surgical
Strategy and Results .................................................................... 533
Lombardi, D., Meyer, F. B., Scheithauer, B. W., Losa, M., Giovanelli Barilari, M.: Sellar and Parasellar
Extra-Axial Cavernous Hemangiomas ...................................................... 538
Frank, F., Fabrizi, A. P., Acciarri, N., Piazza, G., Ricci, R., Gaist, G.: Intracranial Cavernous Angiomas:
a Simple Method for Their Surgical Approach ............................................... 542
Talacchi, A., Cristofori, L., Garozzo, D., Deotto, L., Bricolo, A.: Auditory Evoked Responses and Blink
Reflex in Brain-Stem Cavernous Angiomas. Report of 7 Cases .................................. 546
Management of Vein of Galen Malformations, Dural A VMs, Venous Angiomas
Dowd, C. F., Halbach, V. V., Higashida, R. T., Fraser, K. W., Smith, T. P., Hieshima, G. B.: Endovascular
Management of Vein of Galen Malfonnations ............................................... 553