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Papers by Brian Jankowitz

Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, Jan 30, 2008

The purpose of this study was to evaluate and report our anatomic results and complications assoc... more The purpose of this study was to evaluate and report our anatomic results and complications associated with stent-assisted coil embolization of intracranial aneurysms using the Neuroform stent. From September 2003 to August 2007, 127 consecutive patients (ruptured 50, 39.4%; unruptured 77, 60.6%) underwent 129 stent-assisted coil embolization procedures to treat 136 aneurysms at our institution. Anatomic results at follow-up, procedure-related complications, and morbidity/mortality were retrospectively reviewed. Stent deployment was successful in 128 out of 129 procedures (99.2%). Forty-seven patients presented with 53 procedure-related complications (37.0%, 47/127). Thromboembolic events (n=17, 13.4%) were the most common complications, followed by intraoperative rupture (n=8, 6.3%), coil herniation (n=5, 3.9%), and postoperative rupture (n=4, 3.1%). For thromboembolic events, acute intra-procedural instent thromboses were observed in two patients and subacute or delayed in-stent t...

Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, Jan 29, 2008

Stenting as adjuvant therapy for the coiling of acutely ruptured aneurysms remains controversial ... more Stenting as adjuvant therapy for the coiling of acutely ruptured aneurysms remains controversial due to the necessity of anticoagulation and antiplatelet medications. We report our experience using the Neuroform stent in the management of 41 aneurysms in 40 patients over a period of three years. For aneurysms whose open surgical risk remains excessive with a morphology that would preclude complete embolization, the risks of stenting may be warranted.

Journal of neurointerventional surgery, 2012

Coiling of wide neck, bifurcation aneurysms often requires creative techniques to ensure optimal ... more Coiling of wide neck, bifurcation aneurysms often requires creative techniques to ensure optimal and safe embolization. The Y stenting technique utilizing kissing stents provides an alternative endovascular treatment of this complex pathology. A triple wire technique was used to place side by side stents within the parent artery and extending into the bilateral bifurcation vessels. The third wire enabled placement of a microcatheter within the aneurysm, which remained trapped by the opposing stents. 9 patients obtained acceptable angiographic partial or total occlusion of their aneurysm. Follow-up was variable, ranging from none to 26 months. There were two early deaths at postprocedures day 1 and 10, with one mortality being a direct result of the intervention. One patient experienced delayed in-stent thrombosis resulting in a periprocedural morbidity and mortality of 11% and 22%, respectively. One patient required retreatment. Y stenting utilizing the triple catheter technique is ...

Cancer Research, Apr 15, 2006

Neurosurgery, Dec 1, 2010

Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling de... more Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling devices in the treatment of intracranial aneurysms. To examine the technical and anatomic factors that predict short- and long-term stent patency. We undertook a retrospective review of 161 patients who underwent coil embolization of 168 ruptured and unruptured aneurysms assisted by the use of a neck-remodeling device. One hundred twenty-seven patients had catheter-based angiographic follow-up to evaluate 133 stent-coil constructs (mean, 15.4 months; median, 12.7 months). The technique of microcatheter jailing was used in a majority of patients; nonstandard stent configurations were also used. Clinical follow-up for all patients who had catheter-based angiograms demonstrated that among 133 stent constructs, a total of 9 (6.8%) had an in-stent event: 6 acute or subacute thrombosis (4.5%) and 3 delayed stenosis or occlusion (2.3%). Seven of these constructs were associated with a symptomatic event (5.3%). A significantly higher rate of in-stent events was seen with the use of constructs to treat anterior communicating artery aneurysms. When all patients are considered, including those who did not receive catheter-based follow-up imaging, 2 of 168 procedures (1.2%) resulted in the death of a patient, and procedural morbidity was 14.9%. From these results and those in the published literature, in-stent complication rates are low in carefully selected patients. The use of dual antiplatelet therapy, sensitivity assays, and glycoprotein IIb/IIIa inhibitors may decrease the rate of acute and chronic in-stent complications.

ABSTRACT Objective: To design and manufacture a smart guidewire using nitinol materials, as well ... more ABSTRACT Objective: To design and manufacture a smart guidewire using nitinol materials, as well as evaluated the device functionality, such as bending performance, trackability, thermal effects, and thrombogenic response. Methods: Two types of nitinol material were partially used to enhance the guidwire trackability. A proposed smart guidewire system uses either one- or two-way shape-memory alloy nitinol (1W-SMA, 2W-SMA) wires (0.015”, 381μm nitinol wire, NCD, CA, USA). Bending stiffness was measured using in vitro test system, which contains the NI USB-9162 data logger and LabViewTM Signal Express 2010 (National Instruments, TX, USA). Temperature distribution and displacement were evaluated via recording a 60Hz movie using a SC325 camera (FLIR Systems, Australia). Hemocompatibility was evaluated by scanning electron microscopy after one heating cycle of nitinol under the Na-citrate porcine whole blood (Lampire Biological Lab., PA, USA) circulation. Results: Prototypes have been successfully developed and tested. A smart guidewire showed 30 degrees bending after applying or disconnecting electrical current. While the temperature of the nitinol wires increased more than 70°C, the surrounding temperature with the commercially available catheter coverings showed below human body temperature showing 30~33°C. There was no significant platelet attachment or blood coagulation when the guidewire operates. Conclusion: Novel smart guidewires have been developed using shape memory alloy nitinol, which may represent a novel alternative to typical commercially available guidewires for interventional procedures.

BMJ Case Reports, 2015

The endovascular management of giant aneurysms often proves difficult with standard techniques. O... more The endovascular management of giant aneurysms often proves difficult with standard techniques. Obtaining distal access to allow catheter reduction is often key to approaching these aneurysms, but several anatomic challenges make this task unsafe and not feasible. Obtaining distal anchor points and performing catheter reduction maneuvers using adjunctive devices is not a novel concept, however using the Solitaire in order to do so may have some distinct advantages compared with previously described methods. Here we describe our novel Solitaire salvage technique, which allowed successful reduction of a looped catheter within an aneurysm in three cases. While this technique is expensive and therefore best performed after standard maneuvers have failed, in our experience it was effective, safe, and more efficient than other methods.

Journal of neurointerventional surgery, 2014

Percutaneous transfemoral arterial procedures rely on a variety of vascular closure methods. We s... more Percutaneous transfemoral arterial procedures rely on a variety of vascular closure methods. We studied closure success and complications after using the Mynx vascular closure device in cerebral neurovascular procedures. We prospectively analyzed patients undergoing diagnostic cerebral angiogram or neurointervention with arteriotomy closure using the Mynx device. Patient demographics and procedural factors were recorded. Statistical analyses compared groups and identified predictors of device failure and complication. A total of 766 patients, 59% women, mean age 55.5 years (SD 14.2), mean body mass index (BMI) 29.1 kg/m(2) (SD 7.4), underwent 937 neurovascular procedures in a 10 month period. Device success was achieved in 92% of patients; lower BMI, higher number of antithrombotic medications, larger sheath size, and performance of a neurointerventional procedure predicted Mynx failure. Complications occurred in 2.45% of procedures, with older age, lower BMI, higher number of antit...

Journal of neurosurgery. Pediatrics, 2008

Onyx-18 is a relatively new liquid embolic agent. The initial success with this polymer will resu... more Onyx-18 is a relatively new liquid embolic agent. The initial success with this polymer will result in increased utilization in children, but its use and safety in the pediatric population have not been firmly established. Between December 2005 and January 2008, the cerebral vascular malformations in 6 children were embolized using Onyx-18. The ages of the patients ranged from 1 day to 12 years. Pathological types of the vascular malformations included 4 arteriovenous malformations and 2 vein of Galen malformations. Clinical presentations included intracranial hemorrhage in 2 patients, papilledema in 1 patient, and high-output heart failure in 3 patients. In 6 pediatric patients, 21 embolization procedures were performed utilizing a combination of Onyx-18, platinum coils, and Embosphere microspheres. The average estimated size reduction for the arteriovenous malformations was 60%. Total obliteration of a malformation was achieved in 1 patient. Two patients received adjuvant radiosur...

Journal of neurosurgery, 2007

A split cord malformation (SCM) is a rare congenital disorder involving a division of the spinal ... more A split cord malformation (SCM) is a rare congenital disorder involving a division of the spinal cord that results in two distinct hemicords divided by bone, cartilage, or a fibrous septum. Cutaneous manifestations of SCMs are common, including hypertrichosis, dimples, hemangiomas, nevi, lipomas, and sinus tracts. In this report, the authors describe cutaneous manifestations of SCMs in three patients, including a rare report of near fully formed digits overlying the SCM.

World Neurosurgery, 2012

We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, deco... more We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, decompressive hemicraniectomy (DHC), or DHC with a strokectomy (DHC+S) on outcome after malignant supratentorial infarction. We conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n = 18), DHC (n = 17), or DHC+S (n = 33) at our institution from 2002 to 2008. End points included functional outcome measured by the modified Rankin Scale and incidence of mortality at 1 year. Mean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At 1 year, the median modified Rankin Scale score was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (P = 0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome. In patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection.

Journal of neurointerventional surgery, 2014

Large vessel occlusive disease portends a poor prognosis unless recanalization is rapidly achieve... more Large vessel occlusive disease portends a poor prognosis unless recanalization is rapidly achieved. Endovascular treatment is typically performed via a transfemoral approach, but catheterization of the occluded vessel can be problematic in cases of extensive vessel tortuosity. A retrospective review of a prospectively maintained database identified 7 patients who underwent acute endovascular reperfusion therapy via transcervical approach. We identified 7 patients. Admission NIHSS ranged from 8-27 and recanalization occurred between 7-49 min of carotid access. Prior to carotid access, 20-90 min were spent attempting target vessel catheterization via the transfemoral approach. All occlusions were in the left MCA. In 87.5% of patient, TICI2b/3 recanalization was achieved. Neck hematoma formation occurred in one case requiring elective intubation. At 2 months followup, all patients had survived with mRS 0-4 except for one patient who had a large infarct despite recanalization. Transcerv...

Journal of Neurological Surgery Part B: Skull Base, 2013

Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually per... more Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may utilize the same techniques through an alternative corridor. The aim of this manuscript is to report a series of patients who underwent EEA for microsurgical clipping of intracranial aneurysms. We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures were discussed. Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal ICA (n=9) and vertebrobasilar system (n=2). The ICA aneurysms projected medially whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all cases. In all cases, aneurysms were completely occluded. Among complications, three patients had postoperative CSF leakage and two further complicated with meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms. EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.

Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, Jan 30, 2008

The purpose of this study was to evaluate and report our anatomic results and complications assoc... more The purpose of this study was to evaluate and report our anatomic results and complications associated with stent-assisted coil embolization of intracranial aneurysms using the Neuroform stent. From September 2003 to August 2007, 127 consecutive patients (ruptured 50, 39.4%; unruptured 77, 60.6%) underwent 129 stent-assisted coil embolization procedures to treat 136 aneurysms at our institution. Anatomic results at follow-up, procedure-related complications, and morbidity/mortality were retrospectively reviewed. Stent deployment was successful in 128 out of 129 procedures (99.2%). Forty-seven patients presented with 53 procedure-related complications (37.0%, 47/127). Thromboembolic events (n=17, 13.4%) were the most common complications, followed by intraoperative rupture (n=8, 6.3%), coil herniation (n=5, 3.9%), and postoperative rupture (n=4, 3.1%). For thromboembolic events, acute intra-procedural instent thromboses were observed in two patients and subacute or delayed in-stent t...

Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences, Jan 29, 2008

Stenting as adjuvant therapy for the coiling of acutely ruptured aneurysms remains controversial ... more Stenting as adjuvant therapy for the coiling of acutely ruptured aneurysms remains controversial due to the necessity of anticoagulation and antiplatelet medications. We report our experience using the Neuroform stent in the management of 41 aneurysms in 40 patients over a period of three years. For aneurysms whose open surgical risk remains excessive with a morphology that would preclude complete embolization, the risks of stenting may be warranted.

Journal of neurointerventional surgery, 2012

Coiling of wide neck, bifurcation aneurysms often requires creative techniques to ensure optimal ... more Coiling of wide neck, bifurcation aneurysms often requires creative techniques to ensure optimal and safe embolization. The Y stenting technique utilizing kissing stents provides an alternative endovascular treatment of this complex pathology. A triple wire technique was used to place side by side stents within the parent artery and extending into the bilateral bifurcation vessels. The third wire enabled placement of a microcatheter within the aneurysm, which remained trapped by the opposing stents. 9 patients obtained acceptable angiographic partial or total occlusion of their aneurysm. Follow-up was variable, ranging from none to 26 months. There were two early deaths at postprocedures day 1 and 10, with one mortality being a direct result of the intervention. One patient experienced delayed in-stent thrombosis resulting in a periprocedural morbidity and mortality of 11% and 22%, respectively. One patient required retreatment. Y stenting utilizing the triple catheter technique is ...

Cancer Research, Apr 15, 2006

Neurosurgery, Dec 1, 2010

Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling de... more Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling devices in the treatment of intracranial aneurysms. To examine the technical and anatomic factors that predict short- and long-term stent patency. We undertook a retrospective review of 161 patients who underwent coil embolization of 168 ruptured and unruptured aneurysms assisted by the use of a neck-remodeling device. One hundred twenty-seven patients had catheter-based angiographic follow-up to evaluate 133 stent-coil constructs (mean, 15.4 months; median, 12.7 months). The technique of microcatheter jailing was used in a majority of patients; nonstandard stent configurations were also used. Clinical follow-up for all patients who had catheter-based angiograms demonstrated that among 133 stent constructs, a total of 9 (6.8%) had an in-stent event: 6 acute or subacute thrombosis (4.5%) and 3 delayed stenosis or occlusion (2.3%). Seven of these constructs were associated with a symptomatic event (5.3%). A significantly higher rate of in-stent events was seen with the use of constructs to treat anterior communicating artery aneurysms. When all patients are considered, including those who did not receive catheter-based follow-up imaging, 2 of 168 procedures (1.2%) resulted in the death of a patient, and procedural morbidity was 14.9%. From these results and those in the published literature, in-stent complication rates are low in carefully selected patients. The use of dual antiplatelet therapy, sensitivity assays, and glycoprotein IIb/IIIa inhibitors may decrease the rate of acute and chronic in-stent complications.

ABSTRACT Objective: To design and manufacture a smart guidewire using nitinol materials, as well ... more ABSTRACT Objective: To design and manufacture a smart guidewire using nitinol materials, as well as evaluated the device functionality, such as bending performance, trackability, thermal effects, and thrombogenic response. Methods: Two types of nitinol material were partially used to enhance the guidwire trackability. A proposed smart guidewire system uses either one- or two-way shape-memory alloy nitinol (1W-SMA, 2W-SMA) wires (0.015”, 381μm nitinol wire, NCD, CA, USA). Bending stiffness was measured using in vitro test system, which contains the NI USB-9162 data logger and LabViewTM Signal Express 2010 (National Instruments, TX, USA). Temperature distribution and displacement were evaluated via recording a 60Hz movie using a SC325 camera (FLIR Systems, Australia). Hemocompatibility was evaluated by scanning electron microscopy after one heating cycle of nitinol under the Na-citrate porcine whole blood (Lampire Biological Lab., PA, USA) circulation. Results: Prototypes have been successfully developed and tested. A smart guidewire showed 30 degrees bending after applying or disconnecting electrical current. While the temperature of the nitinol wires increased more than 70°C, the surrounding temperature with the commercially available catheter coverings showed below human body temperature showing 30~33°C. There was no significant platelet attachment or blood coagulation when the guidewire operates. Conclusion: Novel smart guidewires have been developed using shape memory alloy nitinol, which may represent a novel alternative to typical commercially available guidewires for interventional procedures.

BMJ Case Reports, 2015

The endovascular management of giant aneurysms often proves difficult with standard techniques. O... more The endovascular management of giant aneurysms often proves difficult with standard techniques. Obtaining distal access to allow catheter reduction is often key to approaching these aneurysms, but several anatomic challenges make this task unsafe and not feasible. Obtaining distal anchor points and performing catheter reduction maneuvers using adjunctive devices is not a novel concept, however using the Solitaire in order to do so may have some distinct advantages compared with previously described methods. Here we describe our novel Solitaire salvage technique, which allowed successful reduction of a looped catheter within an aneurysm in three cases. While this technique is expensive and therefore best performed after standard maneuvers have failed, in our experience it was effective, safe, and more efficient than other methods.

Journal of neurointerventional surgery, 2014

Percutaneous transfemoral arterial procedures rely on a variety of vascular closure methods. We s... more Percutaneous transfemoral arterial procedures rely on a variety of vascular closure methods. We studied closure success and complications after using the Mynx vascular closure device in cerebral neurovascular procedures. We prospectively analyzed patients undergoing diagnostic cerebral angiogram or neurointervention with arteriotomy closure using the Mynx device. Patient demographics and procedural factors were recorded. Statistical analyses compared groups and identified predictors of device failure and complication. A total of 766 patients, 59% women, mean age 55.5 years (SD 14.2), mean body mass index (BMI) 29.1 kg/m(2) (SD 7.4), underwent 937 neurovascular procedures in a 10 month period. Device success was achieved in 92% of patients; lower BMI, higher number of antithrombotic medications, larger sheath size, and performance of a neurointerventional procedure predicted Mynx failure. Complications occurred in 2.45% of procedures, with older age, lower BMI, higher number of antit...

Journal of neurosurgery. Pediatrics, 2008

Onyx-18 is a relatively new liquid embolic agent. The initial success with this polymer will resu... more Onyx-18 is a relatively new liquid embolic agent. The initial success with this polymer will result in increased utilization in children, but its use and safety in the pediatric population have not been firmly established. Between December 2005 and January 2008, the cerebral vascular malformations in 6 children were embolized using Onyx-18. The ages of the patients ranged from 1 day to 12 years. Pathological types of the vascular malformations included 4 arteriovenous malformations and 2 vein of Galen malformations. Clinical presentations included intracranial hemorrhage in 2 patients, papilledema in 1 patient, and high-output heart failure in 3 patients. In 6 pediatric patients, 21 embolization procedures were performed utilizing a combination of Onyx-18, platinum coils, and Embosphere microspheres. The average estimated size reduction for the arteriovenous malformations was 60%. Total obliteration of a malformation was achieved in 1 patient. Two patients received adjuvant radiosur...

Journal of neurosurgery, 2007

A split cord malformation (SCM) is a rare congenital disorder involving a division of the spinal ... more A split cord malformation (SCM) is a rare congenital disorder involving a division of the spinal cord that results in two distinct hemicords divided by bone, cartilage, or a fibrous septum. Cutaneous manifestations of SCMs are common, including hypertrichosis, dimples, hemangiomas, nevi, lipomas, and sinus tracts. In this report, the authors describe cutaneous manifestations of SCMs in three patients, including a rare report of near fully formed digits overlying the SCM.

World Neurosurgery, 2012

We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, deco... more We sought to evaluate the impact of a craniotomy for strokectomy (CS) with bone replacement, decompressive hemicraniectomy (DHC), or DHC with a strokectomy (DHC+S) on outcome after malignant supratentorial infarction. We conducted a retrospective cohort study of cases of malignant supratentorial infarction treated by CS (n = 18), DHC (n = 17), or DHC+S (n = 33) at our institution from 2002 to 2008. End points included functional outcome measured by the modified Rankin Scale and incidence of mortality at 1 year. Mean age, gender, side, vessel, and time from ictus to surgery were not statistically different between treatment groups. Stroke volume was significantly higher in the CS group. Operative time and blood loss were significantly higher in the DHC+S group. At 1 year, the median modified Rankin Scale score was 4 and overall survival was 71%. Functional outcomes and mortality for both the CS and DHC+S groups were not significantly different from the DHC group (P = 0.24). After adjusting for patient age, stroke volume, and time to surgery, there was no significant difference in outcome. In patients with malignant supratentorial infarction, a strokectomy alone may be equivalent to a decompressive hemicraniectomy with or without brain resection.

Journal of neurointerventional surgery, 2014

Large vessel occlusive disease portends a poor prognosis unless recanalization is rapidly achieve... more Large vessel occlusive disease portends a poor prognosis unless recanalization is rapidly achieved. Endovascular treatment is typically performed via a transfemoral approach, but catheterization of the occluded vessel can be problematic in cases of extensive vessel tortuosity. A retrospective review of a prospectively maintained database identified 7 patients who underwent acute endovascular reperfusion therapy via transcervical approach. We identified 7 patients. Admission NIHSS ranged from 8-27 and recanalization occurred between 7-49 min of carotid access. Prior to carotid access, 20-90 min were spent attempting target vessel catheterization via the transfemoral approach. All occlusions were in the left MCA. In 87.5% of patient, TICI2b/3 recanalization was achieved. Neck hematoma formation occurred in one case requiring elective intubation. At 2 months followup, all patients had survived with mRS 0-4 except for one patient who had a large infarct despite recanalization. Transcerv...

Journal of Neurological Surgery Part B: Skull Base, 2013

Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually per... more Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may utilize the same techniques through an alternative corridor. The aim of this manuscript is to report a series of patients who underwent EEA for microsurgical clipping of intracranial aneurysms. We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures were discussed. Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal ICA (n=9) and vertebrobasilar system (n=2). The ICA aneurysms projected medially whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all cases. In all cases, aneurysms were completely occluded. Among complications, three patients had postoperative CSF leakage and two further complicated with meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms. EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.