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considered high-risk inter ventions at other facilities. "We perform world-class, cutting-edge procedures for brain AV Ms, including embolizing or blocking off abnorma l blood vessels prior to surgery," Dr. Mangla says. " We can a lso use radiosurgery in certain cha llenging cases to help treat patients with minimal risk of functional, neurolog ic problems or mor ta lit y. In situations where you don't have a team w ith hundreds of yea rs of combined experience or combined patient cases numbering into the thousands, the risks of treatment can be significantly higher." Patients with AVMs tend to be younger, D r. P i le - S p e l l m a n not e s , a nd t he y typically experience excellent outcomes. In many cases, the AVM does not usually occu r d i rec t ly w it h i n bra i n t i s sue, but i m med iately a djacent to it . The range of treatments available depends on t he f u nction of t he nea rby bra i n structures and how safely interventions can reasonably be performed without damaging the surrounding area. OPTIONS FOR GIANT INTRACRANIAL ANEURYSMS Developing personalized management pla ns is especia lly impor ta nt in ca ring for pat ient s w it h g ia nt i nt ra cra n ia l a n e u r y s m ( G A ) , a r a r e f o r m o f a neur ysm g reater tha n 25 mi l limeters in dia meter. Specif ica l ly, determining the presence a nd size of the suspected a n e u r y s m i s a f i r s t s t e p t h a t t h e NSPC tea m t a kes before desig n i ng a treatment pla n that addresses both the emergent sit uation a nd t he patient 's long-ter m outcomes. Once t he dia g nosis of GA ha s been established a nd delineated by mea ns of MR A or CT a ng iog raphy, physicia ns m ay at t empt t o preser ve t he pa rent vessel or to occlude it . Pa rent a r ter y o c c l u s i o n m a y b e p e r f o r m e d v i a ba l lo on or c oi l emb ol i z at ion ; ot her techniques a re a lso ava i lable. Va rious stenting a nd ba lloon procedures may be uti lized when pa rent vessel occlusion is not fea sible. I n t h e m i n i m a l l y i n v a s i v e c o i l e m b o l i z a t i o n p r o c e d u r e , a neurointerventionalist inserts a catheter close to the aneurysm site, then threads a stent into the aneurysm, reinforcing the a r ter y a nd a l lev iating pressure. A lternatively, surgica lly clipping the involved artery may be used to isolate the aneurysm from blood flow, alleviating the risk of a rupture. All these procedures are technically q u it e d e m a n d i n g — w h i c h m a k e s t h e e x p e r t i s e a n d e x p e r i e n c e o f N S P C 's n e u r o i n t e r v e n t i o n a l i s t s particularly essential. While a ruptured GA needs immediate acute intervention, in other situations the clinician consults with colleag ues a n d a s s e s s e s t h e p a t i e n t 's r i s k and preferences. " T here's a spect r u m to prog nosis with rare cerebrovascular conditions," Dr. Brisman says. "A GA could have a 5% to 10% chance of causing a fatal rupture on a yea rly basis, while other disease may have only a 5% cha nce of stroke over 10 years. It depends on the extent of the disease." Patients a lso need to weig h in, he observes. Some patients will not pursue a ny procedure t hat ca r r ies a r isk of disability, even if it means living with a heightened a nnua l cha nce of death. Others want to prolong time with family and loved ones, even at the slight risk of disability that may accompany surgery. " I u sua l ly t a ke i nt o a ccou nt fou r factors," Dr. Brisman says. "The most predictive factor in whether or not I'm going to offer an operation is the age and hea lth of the patient." Nex t comes a n a ssessment of t he lesion itself. A GA of 4 centimeters, for instance, carries far greater risk than a 2.5-centimeter one. " T he t h i rd fa c t or i s my per son a l assessment of how easily I ca n repair the lesion," Dr. Brisman continues. "Each lesion is distinct in terms of how easy or difficult it would be for me to repair it with a low complication rate." Fina lly, he returns to the patient 's willing ness to ta ke on cer ta in kinds of risk. "When you offer a patient an operation scheduled for next Tuesday that might have a 4% risk of a serious complication in exchange for elimination of a 15% to 20% risk of a vascular lesion causing a serious rupture over the next 22 years of their life, that's a persona l decision," he says. "That's not a decision a physician can ma ke a lone." Jae Choi, MD, cerebrovascular neurologist at NSPC, and John Pile-Spellman, MD, FACR, interventional neuroradiologist at NSPC, discuss a plan of care for a patient with an unruptured brain aneurysm. Neurosurgeon John Grant, MD, and Dr. Choi are key members of the NSPC neurovascular team. M D N E W S . C O M /// M D N E W S L O N G I S L A N D ■ 2 0 21 0 7