Use of Simple Neck Extension to Improve Guiding Catheter Accessibility in Tortuous Cervical Internal Carotid Artery for Endovascular Embolization of Intracranial Aneurysm: A Technical Note.

BACKGROUND: In endovascular embolization of intracranial aneurysms, a tortuous cervical internal carotid artery can limit guiding catheter access to a sufficiently high position. Although intermediate distal access catheters can go beyond the tortuous segment of internal carotid arteries, they may increase the risk of procedure-related complications, require significantly complex technical procedures, and limit the use of adjunctive techniques. Using simple neck extension alone, we successfully improved guiding catheter access in 2 patients. METHODS: Through a provocative test, we confirmed suitability of manual neck extension in 2 patients with severe posterior curvature of a tortuous internal carotid artery. Intraoperatively, we manually extended the neck and stretched the curvatures. We guided a 6F guiding catheter superiorly and performed coil embolization with an occlusion balloon catheter in 1 case and with the balloon-assisted neck remodeling technique in 1 case. RESULTS: Coil embolization was completed without any adverse events in both cases. CONCLUSIONS: The simple neck extension technique successfully improved accessibility of the guiding catheter. As the need for safe and highly skilled intervention increases, our technique may be useful because it can reduce procedure-related complications and allow balloon-assisted techniques.

An Isolated Posterior Spinal Aneurysm Resection in Which Intraoperative Electrophysiological Monitoring Was Successfully Used to Locate the Lesion and to Detect the Possibility of Ischemic Complications.

STUDY DESIGN: A case report. OBJECTIVE: To report the successful use of electrophysiological monitoring in the surgical resection of a ruptured spinal artery (SA) aneurysm to locate the lesion, and to predict ischemic complications. SUMMARY OF BACKGROUND DATA: Isolated aneurysm of the posterior SA is an extremely rare event without established treatment and diagnosis procedures. Reports describing the surgical intervention of aneurysm of the posterior SA using electrophysiological monitoring are scant. METHODS: We performed the surgical resection of a dissected posterior SA aneurysm in an older patient who presented with spinal subarachnoid hemorrhage using intraoperative electrophysiological monitoring. RESULTS: Intraoperatively, motor evoked potentials decreased over 50% when a distal site of the lesion was clipped, indicating that site was the posterior SA. This lead to further investigation of the vascular anatomy around the lesion, which revealed the descending part of the posterior SA buried deeply in a thick thrombus. Clipping and resection were successful, and ischemia of the posterior SA was avoided. The postoperative clinical course was good, and there was no recurrence or long-term squeal. CONCLUSION: Electrophysiological monitoring might be useful when intraoperative anatomical findings of the hemodynamic structure are inadequate. Moreover, in our case, intraoperative changes in motor evoked potentials indicated the risk to occlude one of posterior SAs, although it is said that posterior circulation of spinal cord has ischemic tolerance.