A number of options exist to minimize the invasiveness of surgical intervention for neurovascular disorders. These include techniques such as endovascu-lar therapy and stereotactic radiosurgery, which eliminate or reduce the need for traditional surgical approaches, and surgical adjuncts such as image guidance and microsurgical techniques, which reduce the invasiveness of those traditional surgical approaches.

Endovascular management of cerebrovascular disorders was first developed by Serbinenko and introduced to the Western world by Debrun (1,2). Initially used to treat carotid cavernous fistulae, endovascular techniques have advanced rapidly with the development of modern catheters and devices and currently provide therapeutic options for the management of a large number of cerebrovascular disorders. For selected cerebrovascular disorders, such as cavernous malformations, there is currently no endovascular option. Endovascular therapy may serve as an adjunct to the surgical treatment of selected conditions such as arteriovenous malformations (AVMs) to reduce the morbidity of the definitive vascular procedure or, as is the case with intracranial aneurysms, may provide a therapeutic alternative to open surgery.

Image guidance is of less value in vascular neurosurgery than in other areas of the specialty. This technique can be of great assistance in localizing vascular malformations such as AVMs or cavernous malformations that are below the surface of the brain, minimizing retraction and dissection, and more accurately placing a craniotomy. A role for image guidance in the treatment of intracranial aneurysms and any benefit of reduction in the size of the craniotomy for addressing intracranial aneurysms remain speculative.

Stereotactic radiosurgery is a minimally invasive neurosurgical option for selected neurovascular disorders. The greatest experience has been in the treatment of AVMs of the brain, for which stereotactic radiosurgery has been successful in obliterating well-selected lesions. In many instances, it is an alter-

From: Minimally Invasive Neurosurgery, edited by: M.R. Proctor and P.M. Black © Humana Press Inc., Totowa, NJ

native to open neurosurgical resection. The efficacy of stereotactic radiosurgery in the treatment of cavernous malformations is unproven and more controversial.

The most valuable minimally invasive technique in vascular neurosurgery remains microsurgery. Despite remarkable advances in endovascular therapy, it should be pointed out that the field of microsurgery is not static, and advances in this discipline continue. Use of the operating microscope, combined with appropriate microsurgical instruments and a knowledge of microneurosurgical anatomy, allows one to utilize cisternal anatomy to obtain brain relaxation and exposure of the vascular lesion with minimal or no retraction. Furthermore, sul-cal approaches to selected vascular lesions are one of the most important minimally invasive techniques in vascular neurosurgery. Skull base techniques are used to remove bone, minimize brain retraction, open surgical corridors, and bring the surgeon closer to the pathology.

The potential usefulness of each of these minimally invasive techniques varies significantly with the specific neurovascular pathology. This chapter discusses the pathological entities most commonly encountered in a neurovascu-lar practice and the role of minimally invasive procedures in the management of these disorders.

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