State-of-the-art and emerging technologies for atrial fibrillation ablation.

Catheter ablation is an important treatment modality for patients with atrial fibrillation (AF). Although the superiority of catheter ablation over antiarrhythmic drug therapy has been demonstrated in middle-aged patients with paroxysmal AF, the role the procedure in other patient subgroups-particularly those with long-standing persistent AF-has not been well defined. Furthermore, although AF ablation can be performed with reasonable efficacy and safety by experienced operators, long-term success rates for single procedures are suboptimal. Fortunately, extensive ongoing research will improve our understanding of the mechanisms of AF, and considerable funds are being invested in developing new ablation technologies to improve patient outcomes. These technologies include ablation catheters designed to electrically isolate the pulmonary veins with improved safety, efficacy, and speed, catheters designed to deliver radiofrequency energy with improved precision, robotic systems to address the technological demands of the procedure, improved imaging and electrical mapping systems, and MRI-guided ablation strategies. The tools, technologies, and techniques that will ultimately stand the test of time and become the standard approach to AF ablation in the future remain unclear. However, technological advances are sure to result in the necessary improvements in the safety and efficacy of AF ablation procedures.

State of the art head and neck imaging for the endovascular specialist.

Recent technologic advances including multidetector CT, dynamic CT angiography, high-field MR imaging, four-dimensional MR angiography, and physiologic studies, such as perfusion imaging, have revolutionized the imaging work-up of head, neck, and skull base lesions. These techniques not only provide accurate diagnostic information, but also help plan endovascular therapy. The future holds great promise for interventional neuroradiologists because excellent imaging tools are becoming available that are capable of providing morphologic, hemodynamic, and physiologic information. Furthermore, availability of faster, real-time guidance systems and hybrid systems improves the ability to perform procedures not only in a rapid and safe manner but also with great precision.

Percutaneous thermal ablation in the head and neck: current role and future applications.

Patients with recurrent head and neck cancer have poor quality of life and suffer dismally from debilitating symptoms. Ablative techniques offer patients an alternative, minimally invasive treatment option. As a palliative treatment, they improve quality of life with decreased pain, improved function and appearance. In addition, there is a reduction in tumor bulk and analgesia requirements. Advantages include a reduction in procedural cost, avoidance of complex repetitive surgeries, and an ability to visualize the treated area at the time of the procedure. Ablation therapies are an evolving and exciting treatment option in the head and neck, but a consensus on appropriate indications is currently unclear.

Neurointerventional management of low-flow vascular malformations of the head and neck.

Mulliken and Glowacki's seminal classification of vascular anomalies into vascular tumors (with infantile hemangiomas being paradigmatic) versus nontumorous vascular malformations has been as important in the head and neck region as elsewhere. These latter are congenital, have an equal gender incidence, virtually always grow in size with the patient during childhood, and virtually never involute spontaneously. The vascular malformations can in turn be subclassified into high-flow and low-flow. Our focus is on the low-flow malformations, which include those with venous, lymphatic, and, to a lesser extent, capillary components. We address diagnostic and clinical characteristics, particularly insofar as they relate to the structures of the head and neck, and discuss neurointerventional management in some detail.

Neurointerventional management of high-flow vascular malformations of the head and neck.

Head and neck high-flow vascular malformations are uncommon lesions whose management presents a clinical challenge. Although in some rare cases a complete cure is possible, in the vast majority the primary objective is symptom control, cosmesis improvement, and preservation of vital functions. Striving for "complete" treatment in most cases results in potentially devastating clinical and cosmetic outcome. Collateral supply via intracranial vessels is not uncommon, and scrupulous efforts to avoid complications related to inadvertent intracranial embolization or venous thrombosis are mandatory. Regardless of therapeutic goal, close long-term follow-up for lesion recurrence is necessary. Recent demonstration of syndromic associations for some subsets of HFVMs holds out the promise of the future development of medical therapy for these difficult lesions.

Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem.

Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20-30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases.

Neurosurgical suite of the future. II.

The role of imaging in diagnosis and therapy has been accepted by physicians. This favorable reception of minimally invasive procedures resulted in the recognition of the feasibility of image-guided approaches. Although radiology has combined imaging with various novel therapeutic methods, the full use of advanced imaging technology has not yet been accomplished. The current trend is the evolution of integrated therapy delivery systems in which advanced imaging modalities are closely linked with high performance computing. Obviously, the operating room of the future will accommodate various instruments, tools and devices, which are attached to the imaging systems and controlled by image-based feedback.