Stent-Assisted Coil Embolization of Ruptured Aneurysms in the Acute Stage: Advantages and Disadvantages.

Objective: In the acute stage of ruptured cerebral aneurysms, limited devices are available, making the treatment difficult. We aimed to evaluate the outcomes of the coil embolization with stenting for the ruptured cerebral aneurysms in the acute stage. Methods: We assessed 22 cases treated with stenting among 134 of 169 consecutive patients with subarachnoid hemorrhages undergoing an endovascular treatment between April 2014 and December 2021, of which 134 underwent an embolization during the acute stage. A stent was used in the patients wherein the treatment with the balloon-assisted or double catheter technique was difficult. Stenting was performed under the loading of two or more antiplatelet agents. Results: The mean age of the patients was 68.9 years, of which five were male and 14 (63.6%) had severe grade (World Federation of Neurosurgeons grade IV, V). The aneurysm site was the anterior communicating artery in four cases, internal carotid artery in nine, middle cerebral artery in two, vertebrobasilar artery in six, and posterior cerebral artery in one. The aneurysm shape was saccular in 13 cases, dissection in seven, and fusiform in two. Stents were used for wide-neck aneurysms in 12 cases, vascular preservation in seven, and rescue in three. The mean maximum diameter was 9.6 mm. The mean neck size was 6.4 mm. Complete occlusion and neck remnant were found in eight and seven cases, respectively. The perioperative complication rate was 45.5% (thromboembolism in five cases, stent occlusion in two, re-bleeding in two, and cerebral hemorrhage in one). The outcomes included modified Rankin Scale 0-2 in seven cases, 4-5 in five, and 6 in nine. Stent-related death occurred in one case. The rate of morbidity and mortality was 18.2%. Although stents were used in the acute stage of rupture, they were used for the right reasons. However, a high rate of complications occurred: two cases of re-bleeding, in which an incomplete occlusion was a factor. Conclusion: Stent placement in patients with the acute ruptured cerebral aneurysms should be carefully determined and efforts should be made to reduce the embolic and hemorrhagic complications. However, it may be an effective treatment option when other options could be extremely difficult.

A Case Report Using Goose Neck Microsnare for Severe Cervical Internal Carotid Artery Occlusion with Dolichoarteriopathy.

Objective: We report the use of a Goose Neck microsnare for cervical internal carotid artery (ICA) occlusion in a patient with dolichoarteriopathy in whom it was difficult to achieve recanalization. Case Presentation: A 65-year-old woman underwent thrombectomy for a tandem lesion of left M1 occlusion and left cervical ICA occlusion. Recanalization of left M1 occlusion was achieved. For left cervical ICA occlusion, we attempted multiple thrombectomy using an existing device, but a hard clot with mobility was caught due to dolichoarteriopathy, which made thrombectomy difficult. Using a Goose Neck microsnare, we were able to capture the thrombus and achieve recanalization. Conclusion: Thrombectomy by capturing the thrombus using a Goose Neck microsnare may be useful for capturing hard clots with mobility when it is difficult to achieve recanalization with existing devices.

T-Stent or Half T-Stent-Assisted Embolization of Wide-Necked Aneurysms at the Internal Carotid-Posterior Communicating Artery Bifurcation.

Objective: We report the usefulness and pitfalls of coil embolization using the T or half T-stent technique for aneurysms located at internal carotid artery-posterior communicating artery (ICA-P-com) bifurcation in which the neck is wide and the P-com must be kept patent due to it being the fetal-type with a hypoplastic P1 segment. Case Presentations: Two cases were treated using the T-stent technique and two were treated using the half T-stent technique. The average age of the patients was 70.3 years and all were females. One aneurysm ruptured. The average size of aneurysms and neck was 12 mm and 8.5 mm, respectively, in the T-stent group, and 7.4 mm and 6.7 mm, respectively, in the half T-stent group. An S- or pigtail-shaped microcatheter (MC) was used to navigate into the P-com. Stent deployment was successful in all the cases. Retreatment was required in one case treated using the T-stent technique due to major recurrence. Conclusion: T or half T-stent-assisted coil embolization can be an alternative endovascular treatment method for wide-necked ICA-P-com aneurysms in which the P-com must be kept patent due to it being the fetal-type with a hypoplastic P1 segment.

[A Case of Erdheim-Chester Disease that was Difficult to Differentiate from Meningioma].

OBJECTIVE: Erdheim-Chester disease(ECD)is a rare type of non-Langerhans histiocytosis. We report a surgical case of ECD with multiple lesions at the falx cerebri, tentorium cerebelli, and in the suprasellar region, with a literature review. CASE REPORT: A 70-year-old woman presented with frequent falling and difficulty in standing. Her past medical history revealed ovarian cystectomy, transient thrombocytopenia, hypertension, left lower leg pain, and overactive bladder. Her head CT and MRI findings revealed well-defined mass lesions, suspected of meningioma, at the falx cerebri and tentorium cerebelli. Craniotomy and near total resection of the tumor at the falx cerebri was performed, leaving a hard portion of the tumor on the right falx. Intraoperative findings showed a solid and hard tumor, which was extremely difficult to decompress. Although the histopathological diagnosis was originally a metaplastic meningioma, considering her complaints of lower leg pain, we suspected ECD and performed a right tibial biopsy. The right tibial biopsy revealed ECD. Twenty-two months after the operation, the patient exhibited a marked enlargement of the tentorium lesion and a new lesion in the suprasellar region. Resection of the tentorial lesion was performed. The second intraoperative findings were similar to those of the first. The histopathological diagnosis of the tentorial lesion was ECD. After the surgeries, steroid therapy and radiation therapy were performed, but only with temporary improvement. CONCLUSION: ECD is a rare disease; therefore, accumulation of clinical data to establish its treatment is necessary.

Distance Between the Falciform Ligament and Distal Dural Ring as a Surgical Landmark for the Treatment of Paraclinoid Aneurysms.

OBJECTIVE: It is difficult to completely comprehend the anatomy of the structures surrounding the paraclinoid region before aneurysm and tumor treatment therein. When treating paraclinoid aneurysms, it is important to determine the location of the aneurysm as intradural or extradural. Thus, accurate prediction of the position of the distal dural ring (DDR) is necessary. To this end, we focused on the falciform ligament (FL), which is easily visualized on images based on its anatomic features. We measured the distance between the FL and the DDR in patients undergoing paraclinoid aneurysm operations. METHODS: Between January 2017 and July 2018, 15 patients who underwent clipping for paraclinoid aneurysm treatment were retrospectively identified. The distance between the FL and the DDR was measured using a microscale at the time of the operation. RESULTS: The patients comprised 14 women and 1 man. The mean aneurysm diameter was 7.29 ± 2.21 mm and the median size was 6.5 mm. Eleven of the aneurysms were on the left and 4 were on the right side. The mean distance between the FL and the DDR was 3.50 ± 0.17 mm and the median distance was 3.50 mm. The distance between the FL and the DDR was almost the same across cases (3.5 mm). CONCLUSIONS: The position of the FL can be easily predicted using preoperative three-dimensional computed tomography angiography based on its anatomic features. In this study, the DDR was located 3.5 mm proximal to the FL along the internal carotid artery. This information is useful for predicting the position of the DDR.

Is surgical parent artery occlusion effective for intracranial aneurysms measuring over 10 mm in size? Result from long-term follow-up of size changes and outcomes.

BACKGROUND: There have been no long-term follow-up reports pertaining to chronological size changes in large or giant unruptured intracranial aneurysms treated with surgical parent artery occlusion (PAO). The object of this study is to investigate the utility and safety of surgical PAO by conducting a long-term follow-up of chronological aneurysm size changes and outcomes. METHODS: A retrospective study of 21 unruptured intracranial aneurysms measuring over 10 mm (20 patients) treated with surgical PAO in the period 2012-2017 was conducted. For aneurysms presenting with anterior circulation, high/low flow bypass was chosen and carried out concomitantly on the basis of preoperative balloon occlusion test results. Aneurysm size before and after surgery was evaluated chronologically using maximum diameter measurements taken from the same slice of MRI T2-weighted images. Moreover, post-surgery outcomes were evaluated according to a modified Rankin scale (mRS) at discharge. RESULTS: PAO aiming for blind-alley formation was performed in 20 of 21 aneurysms (95.2%). Aneurysm size reduction was confirmed in 20 aneurysms (95.2%) after proper PAO, with an average reduction rate of 63.1% (range, 28-95%), during an average follow-up period of 27 months (range, 4-54 months). Eighteen (90.4%) of the 20 patients with 21 aneurysms returned to previous life with mRS score 0-2. With regard to preoperative symptoms, diplopia and visual impairment had improved in three patients (50%) and one patient (100%), respectively. Ischemic complications had occurred in five patients, two (9.6%) of whom were symptomatic and three (14.3%) were asymptomatic. The mortality rate in this study was 0%. CONCLUSIONS: Surgical PAO for unruptured intracranial aneurysms measuring over 10 mm has been shown to be an effective method of treatment, eliciting a reduction in aneurysm size.

Preoperative Embolization of Meningiomas: Differences in Surgical Operability and Histopathologic Changes Between Embosphere and N-butyl 2-cyanoacrylate.

OBJECTIVE: This study aimed to examine whether there is a difference in the difficulty of extirpation after use of Embosphere versus n-butyl 2-cyanoacrylate (NBCA) for the embolization of meningiomas. METHODS: Study subjects were 20 patients with meningioma who underwent embolization using either NBCA or Embosphere from April 2012 to December 2016. The difficulty of extirpation was compared and assessed in terms of objective indices, such as operative duration, perioperative bleeding, and Simpson grade, and in terms of subjective indices such as "impression on operative field" and "hardness of tumors" that the surgeon assessed using 3-point scales (dry, moderate, bloody, and soft, moderate, hard, respectively). Pathologic findings, including ischemia, necrosis, and inflammatory changes, were assessed. RESULTS: No significant differences were found between the 2 groups regarding the mean values of operative duration (P = 0.27), perioperative bleeding (P = 0.23), and Simpson grade (P = 0.39). On the other hand, there was a significant difference with respect to the "impression on operative field" and "hardness of tumors," with reports of dry (54%; P = 0.034) and soft (81%; P = 0.0001), respectively, in the Embosphere group exceeding those of the NBCA group. The pathologic findings showed that although ischemic change (P = 0.43) and necrosis (P = 0.79) were observed in both groups, perivascular inflammation was observed only in the NBCA group (P = 0.006). CONCLUSIONS: No relative merits were found regarding objective indices, whereas the Embosphere group had superior "ease of extirpation" as reported by the surgeon.

Supine No-Retractor Method in Microvascular Decompression for Hemifacial Spasm: Results of 100 Consecutive Operations.

Objectives In microvascular decompression (MVD) for hemifacial spasm (HFS), the patient is placed in the lateral or park-bench position that is complicated and uncomfortable for anesthesiologists, nurses, and even the patient. Careless retraction of the cerebellum by a spatula could be the major cause of surgical complications. In our method, a patient is laid supine avoiding the complicated positioning. The subfloccular approach from a small cranial window sited on the more lateral and basal side of the occipital cranium enables the surgeon to reach all the segments of the facial nerve root without a spatula. We introduce our surgical procedures in detail along with our excellent results. Methods A total of 100 consecutive patients experiencing primary HFS were operated on with MVD by a single surgeon in our institution from August 2012 to April 2014. Results Overall, 94 patients showed the complete disappearance or a satisfactory alleviation of HFS. De novo neurologic deficits were not encountered after surgery including hearing impairment. In 47 cases, multiple offending vessels were observed in multiple possible affected sites in addition to the root entry/exit zone. Conclusions We believe this approach is superior for the safe and precise decompression of any part of the facial nerve root.

Gene analysis and dynamics of tumor stem cells in human glioblastoma cells after radiation.

Glioblastoma is the most malignant central nervous system tumor. Patients with glioblastoma are treated with a combination of surgery, radiotherapy and chemotherapy; however, this effect is not satisfactory with regard to the prognosis. It is reported that the tumor stem cells affect recurrence, and radio- and chemotherapy resistance of the tumor, and that these cells play an important role in tumorigenesis and tumor progression. Using human glioblastoma cell lines (T98G and A172), irradiated (0, 30, 60 Gy) glioblastoma cells were prepared under the same conditions as clinical therapy. We analyzed cell proliferation rate, side population analysis by fluorescence-activated cell sorting and isolation of CD133⁺ cells, and performed genetic analysis (human stem cells) on these cells. We also investigated the difference in gene expression in the cells after radiation. The stem cell-related genes were highly expressed in the CD133⁺ cells compared with the CD133⁻ cells, suggesting that the cancer stem cells may be located in these CD133⁺ cells. In the T98G cell line, the cell proliferation rate of 30-Gy irradiated cells was higher than those of non-irradiated cells and 60-Gy irradiated cells. Stem cell-related genes were highly expressed in 30-Gy irradiated CD133⁺ T98G cells. In conclusion, we suggest that CD133⁺ cells may strongly affect tumor proliferation and the resistance against radiation therapy.

Programmable shunt valves: in vitro assessment of safety of the magnetic field generated by a portable game machine.

Cerebrospinal fluid (CSF) shunts are frequently used to treat hydrocephalus. The use of a programmable shunt valve allows physicians to easily change the opening pressure. Since patients with adjustable CSF shunt valves may use portable game machines, the permanent magnets in these machines may alter the shunt valve programmed settings or permanently damage the device. This study investigated the risk of unintentional valve adjustment associated with the use of game machines in patients with programmable CSF shunt valves. Four adjustable valves from 4 different manufacturers, Sophysa Polaris model SPV (Polaris valve), Miethke proGAV (proGAV), Codman Hakim programmable valve (CHPV), and Strata II small valve (Strata valve), were evaluated. Magnetic field interactions were determined using the portable game machine, Nintendo DS Lite (DS). The maximum distance between the valve and the DS that affected the valve pressure setting was measured by x-ray cinematography. The Polaris valve and proGAV were immune to unintentional reprogramming by the DS. However, the settings of the CHPV and Strata valves were randomly altered by the DS. Patients with an implanted shunt valve should be made aware of the risks posed by the magnetic fields associated with portable game machines and commonly used home electronics.