The Potential Role of Preoperative Posterior Cerebral Artery Involvement in Predicting Postoperative Transient Neurological Deficits and Ischemic Stroke After Indirect Revascularization in Patients With Moyamoya Disease.

OBJECTIVE: Transient neurological deficits (TNDs) are known to develop after direct bypass for Moyamoya disease and may be risk factors for subsequent stroke. However, the factors involved in the development of TNDs and stroke after indirect revascularization alone, including their association with subsequent stroke, remain unclear. The purpose of this study was to investigate this issue. METHODS: The subjects of the study were 30 patients with Moyamoya disease who underwent a total of 40 indirect revascularization procedures at our institution. Clinical and radiological data were collected retrospectively. To examine factors associated with the development of postoperative TND/stroke/asymptomatic disease, the clinical characteristics of each group were statistically compared. RESULTS: The mean age at surgery was 7 years (range 1-63). TNDs developed after surgery in 9 out of 40 patients (22.5%). Stroke in the acute postoperative period occurred in 3 patients (7.5%), all of whom experienced cerebral infarctions. Demographic data and preoperative clinical information were not different between the groups. However, posterior cerebral artery involvement on preoperative imaging was significantly associated with the development of TNDs and stroke (P = 0.006). Furthermore, postoperative stroke was associated with unfavorable outcomes (P = 0.025). CONCLUSIONS: Posterior cerebral artery involvement is significantly associated with the occurrence of TNDs. In contrast, TNDs after indirect revascularization have little relationship with the subsequent development of stroke. TNDs usually resolve without new strokes, and a better understanding of this particular pathology could help establish an optimal treatment regimen.

Transvenous embolization via the facial vein for intraorbital dural arteriovenous fistula: illustrative case.

BACKGROUND: Intraorbital arteriovenous fistula (IOAVF) is a rare type of intracranial fistula that presents with ocular signs similar to those of cavernous sinus dural arteriovenous fistula. The treatment of IOAVF is based on the vascular architecture of each case due to its infrequent occurrence. The authors report the case of an IOAVF that was successfully treated with embolization via the facial vein, with good outcomes. OBSERVATIONS: A 78-year-old woman presented with left eyelid swelling, pulsatile ocular protrusion, and left ocular conjunctival hyperemia. Ophthalmological evaluation revealed elevated intraocular pressure; time-of-flight magnetic resonance angiography revealed a dilated left superior ophthalmic vein. Digital subtraction angiography showed an arteriovenous shunt in the left superior orbital fissure, which was treated using transvenous coil embolization. The patient experienced immediate improvement in left ocular protrusion and conjunctival hyperemia. Ophthalmological evaluation 1 month after treatment showed normal intraocular pressure in the left eye. No neurological symptoms were observed, and there was no recurrence of the arteriovenous shunt 3 months postoperatively. LESSONS: The authors report a rare case of IOAVF treated with embolization via the facial vein with a good outcome. A thorough understanding of the vascular architecture using three-dimensional images is useful for determining endovascular access and procedures.

Transarterial embolization and transvenous embolization for transverse-sigmoid sinus dural arteriovenous fistulas with cortical venous reflux: A comparative study.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR) carry a high risk for neurological sequelae or death. Recently, transverse-sigmoid sinus DAVFs were shown as good indications for transarterial embolization (TAE) with ONYX. Here, we compared the effectiveness and safety of conventional transvenous embolization (TVE) with those of TAE with ONYX for transverse-sigmoid sinus DAVFs with CVR. METHODS: Sixty-one patients with transverse-sigmoid sinus DAVFs were treated from April 2013 to May 2020. Among them, 37 patients with CVR were included. Transarterial embolization and TVE were compared in terms of complete occlusion and residual CVR immediately after treatment, complications with worsening modified Rankin Scale (mRS) ≥ 1, amount of contrast media used during treatment, radiation exposure, and surgical procedure time. RESULTS: Ten patients were treated with 10 TAEs using ONYX and 27 patients with 29 TVEs. Transarterial embolization and TVE showed no differences in the overall complete occlusion rate (80% [8/10 patients] vs. 80% [23/27], respectively), whereas the residual rate of existing CVR was 10% (1/10 patient) vs. 3.4% (1/27) in the TAE and TVE groups, respectively. No complications with worsening mRS ≥1 occurred in either group. Among the parameters of amount of contrast media, radiation dose, and operative time, only radiation dose in the TAE group was lower than that in the TVE group (median: 2239 mGy vs. 3268 mGy, respectively; p = 0.07). CONCLUSION: For transverse-sigmoid sinus DAVFs with CVR, TAE treatment reduced radiation exposure. However, both TAE and TVE achieved high complete occlusion rates and low complication rates.

Differences in gaze behaviors between trainees and experts during endovascular therapy for cerebral aneurysms: a preliminary study using a cerebral aneurysm model.

In the neuroendovascular field, the training of operators has become an important issue. Recently, eye-tracking technology has been introduced into various fields of medical education. This study aimed to apply eye-tracking technology to the training of neuroendovascular therapy. Six neurosurgeons, including three neuroendovascular specialists and three trainees, at our institution and related facilities participated in the study. Eye movement was recorded by the eye-tracking device during the microcatheter navigation and coil placement into the silastic aneurysm model under biplane X-ray fluoroscopy. Eye-tracking analysis during neuroendovascular therapy was feasible in all six subjects. In microcatheter navigation, specialists tended to more frequently switch their attention between frontal and lateral images than trainees. In coil embolization, the overall gaze frequency tended to increase, and the average fixation duration tended to decrease as the number of experienced cases increased. Inexperienced operators tend to fix their gaze when they are operators than when they are assistants. More experienced operators tended to look at the microcatheter longer in the coil insertion task. The eye-tracking analysis may be useful for operator training in neuroendovascular therapy. Experts may have moved their eyes more frequently than trainees to gaze at the right place. In the future, it will be necessary to collect gaze data for more operators in various tasks.

Abnormal foreshortening of a Flow Re-Direction Endoluminal Device caused by in-stent thrombosis immediately after deployment.

Thromboembolic complications are a concern in the treatment of cerebral aneurysms using a flow diverter. In this study, we report a case of abnormal foreshortening of a Flow Re-Direction Endoluminal Device (FRED) caused by in-stent thrombosis immediately after its deployment. A 72-year-old woman had a large cavernous carotid aneurysm, which caused ptosis and diplopia. FRED deployment was planned, and dual antiplatelet therapy was initiated 2 weeks before the procedure. Under systemic heparinization, FRED was deployed with local compaction over the aneurysm orifice. Cone-beam computed tomography subsequently revealed slightly poor wall apposition at the proximal side. While the balloon catheter was prepared for angioplasty, the stent became abnormally foreshortened, the proximal side slipped into the aneurysm, and the internal carotid artery became occluded. FRED was removed using a snare wire, and recanalization was obtained. The lumen of the removed FRED was filled with thrombus. The antiplatelet therapy was changed to triple regimen, and a Pipeline Flex embolization device was placed 1 month later. At that time, no thromboembolic complications were noted. It was considered that thrombotic occlusion was followed by foreshortening of FRED on the distal side because of antegrade blood flow. Multiple factors, such as increased mesh density by locally compacted stent deployment, slightly poor wall apposition, clopidogrel resistance, and the dual-layer structure of FRED, may have been involved in thrombus formation.

The preoperative focal cerebral blood flow status may be associated with slow flow in the bypass graft after combined surgery for moyamoya disease.

Background: The aim of this study was to investigate the association between early postoperative slow flow in bypass grafts and preoperative focal cerebral blood flow (CBF) in patients who underwent combined surgery for moyamoya disease (MMD). Methods: The subjects were 18 patients (22 surgeries) who underwent single photon emission computed tomography (SPECT) before surgery. The CBF value of the middle cerebral artery territory was extracted from the SPECT data, and the value relative to the ipsilateral cerebellar CBF (relative CBF, or RCBF) was calculated. The association between RCBF and early postoperative slow flow in the bypass graft was investigated. In addition, the correlation between the revascularization effect and preoperative RCBF was analyzed. Results: In four of 22 surgeries (18.2%), slow flow in the bypass graft was identified in the early postoperative period. Preoperative RCBF in the slow flow and patent groups was 0.86 ± 0.15 and 0.87 ± 0.15, respectively, with no significant difference (P = 0.72). The signal intensity of four slow-flowed bypasses was improved in all cases on magnetic resonance angiography images captured during the chronic phase (mean of 3.3 months postoperatively). The revascularization scores were 2 ± 0.82 and 2.1 ± 0.68 in the slow flow and patent groups, respectively, and did not differ significantly (P = 0.78). A significant correlation was not observed between preoperative RCBF and the revascularization effect. Conclusion: No significant association was observed between preoperative RCBF and early postoperative slow flow in bypass grafts in patients with MMD undergoing combined surgery. Given the high rate of improved depiction of slow-flowed bypass in the chronic postoperative phase, the conceptual significance of an opportune surgical intervention is to maintain CBF by supporting the patient's own intracranial-extracranial conversion function.

Surgical disconnection of a hypoglossal canal dural arteriovenous fistula demonstrating rapid progression of medulla oblongata disturbance: illustrative case.

BACKGROUND: Dural arteriovenous fistulas of the hypoglossal canal (HCDAVFs) with dominant drainage to perimedullary veins are extremely rare. These patients are prone to develop slow and progressive myelopathy, however, their clinical course has not been fully elucidated. We report an unusual case of HCDAVF in which the patient demonstrated rapid progression of hemiplegia and respiratory insufficiency. OBSERVATIONS: An 82-year-old woman demonstrated motor weakness of the left extremities. T2-weighted magnetic resonance imaging showed a high intensity area in the right medulla oblongata and angiography revealed HCDAVF with dominant drainage to the anterior medullary vein through the anterior condylar vein. Within 3 days, her hemiparesis and respiratory function worsened, and she needed mechanical ventilation. Considering that venous congestion in the medulla oblongata could cause the symptoms, we immediately performed surgical obliteration of the anterior condylar vein. The disappearance of HCDAVF was confirmed by angiography and the patient was weaned from mechanical ventilation 3 days postoperatively. Her left hemiplegia gradually resolved and she was independent in daily life 8 months after the operation. LESSONS: HCDAVFs with dominant drainage to the perimedullary veins can demonstrate rapid progression of medulla oblongata disturbance. Early disconnection should be considered to provide an opportunity for substantial recovery.

Contrast-Enhanced Magnetic Resonance Imaging Suggested a Possibility of Transvenous Embolization in the Superior Petrosal Sinus Dural Arteriovenous Fistula: A Case Report.

Objective: Superior petrosal sinus dural arteriovenous fistula (SPS-DAVF) is a rare subtype of intracranial DAVF that sometimes leads to hemorrhagic symptoms following deep venous drainage. Here we report the case of SPS-DAVF with retrograde venous reflux to the cerebellar vein. Preoperative contrast-enhanced MRI was a decisive factor in a safe and effective treatment. Case Presentation: A 37-year-old woman was referred to our hospital with abnormal MRI findings, which was performed when she had a mild headache during her check-up. DSA revealed left-sided SPS-DAVF, which was diagnosed as Cognard type IIb. Both CTA and DSA could not detect the whole SPS but only the shunt pouch. Using contrast-enhanced MRI, we were able to visualize the presence of the SPS and its continuity within the shunt pouch. 3D-T1 turbo spin echo (SPACE) showed a low-intensity area in the SPS, which was not seen in the 3D-T1 fast field echo (FFE). During the procedure, there was a point where it was difficult to advance the microcatheter, which coincided with the low-intensity area. We achieved effective transvenous embolization from the occluded venous access by devising a surgical technique. Conclusion: In addition to the contrast-enhanced 3D-T1 FFE, 3D-T1 SPACE might provide beneficial information for endovascular therapy in the evaluation of venous sinuses, which could not be detected by standard examinations.

Comparison of hemodynamic stress in healthy vessels after parent artery occlusion and flow diverter stent treatment for internal carotid artery aneurysm.

OBJECTIVE: De novo aneurysms generally develop in healthy vessels after parent artery occlusion for large internal carotid artery (ICA) aneurysm, possibly owing to increased hemodynamic stress in the remaining vessels. In recent years, there has been a shift toward flow diverter stent treatment. However, there is a lack of direct evidence and data that prove this change in hemodynamic stress in healthy vessels after parent artery occlusion and flow diverter stent treatment. The authors compared hemodynamic stress in healthy-side vessels before and after parent artery occlusion and flow diverter treatments. METHODS: The authors included patients who underwent 3D cine phase-contrast MRI before and after large ICA aneurysm treatment. Spatially and temporally averaged volume flow rates and spatially averaged systolic wall shear stress (WSS) in healthy-side ICA distal to the posterior communicating artery (C1 segment according to Fisher's classification) were measured before and after parent artery occlusion and flow diverter treatments. RESULTS: Seventeen patients were included (5 patients in the parent artery occlusion group and 12 in the flow diverter group). At 1-2 months after treatment, median volume flow rate in healthy-side ICA increased from 5.36 ml/sec to 6.28 ml/sec (total increase 117%, p = 0.04) in the parent artery occlusion group and from 4.65 ml/sec to 4.93 ml/sec (total increase 106%, p = 0.02) in the flow diverter group. In the parent artery occlusion group, median WSS in the C1 segment of the healthy-side ICA increased from 3.91 Pa to 5.61 Pa (total increase 143%, p = 0.08); however, no significant increase was observed in the flow diverter group (4.29 Pa to 4.57 Pa [total increase 107%, p = 0.21]). CONCLUSIONS: Postoperatively, volume flow rate and WSS in the C1 segment of the healthy-side ICA significantly increased in the parent artery occlusion group. Therefore, the parent artery occlusion group was more prone to de novo aneurysm than the flow diverter group.

Evaluation of the differences in pressure applied to the vessel wall by different types of balloon remodeling microcatheters in an experimental model.

BACKGROUND: We examined compliance differences among balloon remodeling microcatheters, which have not been established previously. METHODS: Straight and 120° angulated vascular models were created in a 3 mm diameter tube with 3 mm hole (vascular model A), a tube with a 4 mm hole (vascular model B), and a 4 mm diameter tube (vascular model C). We compared the pressure exerted when each balloon was herniated 1 or 2 mm between three compliant balloons (SHOURYU SR, TransForm C, and Scepter C) and four super-compliant balloons (HyperForm, SHOURYU HR, TransForm SC, and Scepter XC). RESULTS: In vascular model A, there was a significant difference in the pressure exerted by compliant balloons and super-compliant balloons in both the straight and angulated models. In the straight model (1 and 2 mm), the lowest pressure was exerted by HyperForm (super-compliant balloons group) and SHOURYU SR (compliant balloons group). The lowest pressure was exerted in the angulated model by HyperForm (super-compliant balloons group) and Scepter C (compliant balloons group). The Scepter balloon exerted higher pressure in the straight model than other balloon remodeling microcatheters but less in the angulated model. In vascular model B, the pressure decreased in all balloons compared with model A. In vascular model C, the pressure increased in all balloons compared with model A. CONCLUSIONS: Pressure differed across balloon remodeling microcatheters. In addition, vessel shape and diameter, and hole size, affected the results. Our findings can help select balloon remodeling microcatheters.

Structure and reaction mechanism of binary Ni-Al oxides as materials for lithium-ion battery anodes.

A nanometer sized solid solution of NiO and Al2O3 was synthesized by calcination of Ni-Al layered double hydroxides (LDHs). The crystal structure of the obtained compound was determined by XRD and XAFS analyses: Ni2+ and Al3+ ions are located at the metal ion site of the rock salt structure and a certain amount of cation vacancies are also introduced for charge compensation. The electrochemical properties of the Ni-Al binary metal oxide as an anode material for lithium ion batteries were examined by the constant current charge-discharge test. Ni-Al oxide showed higher charging capacity in comparison with pristine NiO. In particular, the capacity in the lower voltage region (below 1.5 V), the limited capacity in this region is the weak point of the conversion anode, was improved to 540 mA h g-1 that is about twice that of pristine NiO. This improvement in the capacity in the lower voltage region is concluded to be due to the redox activity of Al3+ ions during the charge-discharge on the basis of the results of electrochemical measurements and ex situ XAFS measurements at the Ni and Al edge. The reaction mechanism of this compound is investigated using ex situ XRD and XAFS methods. For the charge (reduction) in the higher voltage region (OCV-1.0 V), lithium ion intercalation into the cation vacancy sites and/or lithium ion adsorption on the surface of particles are proceeding. For the charge in the lower voltage region (1.0-0.03 V), conversion reaction occurs by the reduction of Ni2+ and Al3+ ions to metal particles with surface electrolyte interface (SEI) layer formation. For the discharge in the lower voltage region (0.03-1.5 V), only Al metal particles are oxidized to Al3+ ions and some intermediate complexes are formed. For the discharge in the higher voltage region (1.5-3.0 V), the lattice of the Ni-Al binary oxide solid solution is reconstructed with the oxidation of Ni to Ni2+.

Triggering of Carotid Sinus Reflex during Deployment of the Flow-diverter Device.

The carotid sinus reflex (CSR) is a rare complication of the Pipeline Embolization Device (PED) deployment. No study has assessed the potential risk factors in a case series. The purpose of this study was to examine CSR triggering during PED deployment. Thirty-seven consecutive patients who underwent PED deployment were included. All procedures were performed under local anesthesia with mild sedation. We retrospectively analyzed patient characteristics, PED deployment time, and vital signs during the procedure. The vital signs included the pulse rate (PR) and systolic blood pressure (SBP) obtained at three timepoints (pre-deployment, during deployment, post-deployment). We examined the triggering of the CSR during PED deployment by comparing the vital signs at the three timepoints. Moreover, risk factors for CSR were analyzed with univariate analysis. The patients' average age was 66.3 years. The average size of the aneurysm was 18.0 mm. Six patients (16.2%) showed a decline in the SBP or PR defined as CSR. One patient had a transient cardiac arrest and two had severe transient bradycardia. Deployment into the ophthalmic segment of the internal carotid artery (C2 segment) aneurysm (p = 0.022), prolonged PED deployment time more than 14.5 minutes (p = 0.005), and an acute angle of the anterior genu less than 51.5 degrees (p = 0.005) were risk factors in triggering CSR. CSR may be triggered during PED deployment under local anesthesia with mild sedation. Deployment to the C2 segment aneurysm, prolonged PED deployment time, and an acute angle of the anterior genu were associated with CSR triggering.

Evaluation of the Straightening Phenomenon of Various Types of Coils.

The straightening phenomenon is known as a cause of catheter kickback in the late phase of coil embolization. The mechanism is supposed to be the relative shortage of the stretch resistance (SR) line, and it occurs when a coil is folded too small. Among many SR coils available, there should be a coil-specific tendency to cause this phenomenon. Here, we conducted an in-vitro experiment to know which coil is the most resistant to the straightening phenomenon. We developed an experimental model to reproduce the straightening phenomenon. Five different coils (Axium Prime, ED Coil, Hypersoft, SMART Coil, and Target 360 nano) of the same size (3 mm × 6 cm) were investigated for five times each. Resistance to the straightening phenomenon, which is represented by the insertion length at the onset of the phenomenon, was compared among coil types. The straightening phenomenon was successfully observed in all insertions. Insertion lengths were significantly different among coil types (p = 0.013). The insertion length of ED was the longest (mean ± SD, 27.0 ± 8.3 mm), which means the most resistant to the phenomenon. Axium was second (21.6 ± 7.0 mm), followed by Target (15.8 ± 6.9 mm), Hypersoft (13.8 ± 5.8 mm), and SMART (12.4 ± 4.7 mm). Difference between ED and Hypersoft (p = 0.037) and difference between ED and Smart (p = 0.018) were significant. ED coil was the one with the most resistance to the straightening phenomenon. Selecting the optimal coil is the key to avoid the phenomenon.

Anterior Communicating Artery Aneurysm with a Peculiar Angiographic Appearance: A Case Study.

We describe a case of pulsatile anterior communicating artery aneurysm (A-com AN) with a peculiar angiographic appearance. An 81-year-old man was referred to the department of neurosurgery for a large A-com AN artery aneurysm, which was detected incidentally. The patient hoped not to be treated but to be followed up. After 4 months, magnetic resonance imaging (MRI) revealed the presence of a cerebral edema and hematoma around the aneurysm, and partial thrombus in the upper wall of the aneurysm was suspected. Based on these findings, the patient underwent an immediate coil embolization a day after admission. However, the portion of the neck remnant increased in size after the first procedure. Therefore, 8 months after the initial procedure, he was treated with stent coil embolization. Contrary to the first procedure, angiographic evaluation revealed an active pulsating aneurysm. Moreover, MRI revealed the presence of a partial thrombus in the upper neck segment of the aneurysm, with an intensity that changed over time. The patient underwent cautious treatment and was discharged without any symptoms. This is the first case study to reveal an A-com AN with active pulsation and the relationship between the pulsatile portion of the aneurysm and thrombosed portion by MRI.

Streak Metal Artifact Reduction Technique in Cone Beam Computed Tomography Images after Endovascular Neurosurgery.

Cone beam computed tomography (CBCT) images are degraded by artifacts due to endovascular implants. We evaluated the use of streak metal artifact reduction technique (SMART) in non-contrast CBCT images after endovascular neurosurgery obtained from 148 patients (125 with aneurysm and 23 with dural arteriovenous fistula [dAVF]). Three neurosurgeons evaluated the cistern and brain surface visibility in CBCT images with and without SMART correction based on a 4-point scale (1, excellent; 2, good; 3, limited; and 4, insufficient). Significant improvement in visibility was achieved when the median scores improved from 4 or 3 to 2 or 1 or from 2 to 1. Metal artifact reduction in adjacent slices without metal and new artifacts after SMART correction was also examined. A significant improvement was achieved regarding the visibility of the cistern in 90 (60.8%) images and of the brain surface in 108 (73.0%) images. Metal size (cistern: odds ratio [OR], 0.91 per 1 mm increase; 95% confidence interval [CI], 0.83-0.99), irregular metal shape (cistern: OR, 0.18; 95% CI, 0.05-0.60 and brain surface: OR, 0.15; 95% CI, 0.05-0.45), and infratentorial lesions (cistern: OR, 0.37; 95% CI, 0.14-0.96 and brain surface: OR, 0.30; 95% CI, 0.11-0.80) were negatively correlated with improved visibility. Metal artifact reduction in adjacent slices without metal was obtained in 25.6% and 34.8% of images with aneurysm and dAVF, respectively. New artifacts after SMART correction were found in 4.8% and 13.0% of images with aneurysm and dAVF, respectively. SMART is especially effective for supratentorial small aneurysms.

Short-segment Internal Trapping for Symptomatic Thrombosed Large Fusiform Vertebral Artery Aneurysms (Bird's Nest Trapping): A Technical Note.

Internal trapping with coils is an established treatment of symptomatic large non-branching thrombosed fusiform vertebral artery aneurysms (VAA). However, when perforators arise near the aneurysm neck, parent artery occlusion has a high risk of causing medullary infarction. As an alternative treatment, we performed short-segment internal trapping of the artery using n-butyl-2-cyanoacrylate (NBCA) and coils (bird's nest trapping). Before treatment, perianeurysmal perforators are carefully detected using high-resolution three-dimensional rotational angiography (3DRA). Double microcatheters are advanced to the distal portion of the aneurysm through a balloon guiding catheter where coils are deployed without tight packing. Then, NBCA is injected into the coil mass, taking care to preserve perforators and significant branches. The same maneuver is repeated in the proximal portion of the aneurysm. Coil placement is avoided within the middle of the aneurysm; however, if necessary, only a small number of coils are placed to prevent worsening of mass effect. Two quinquagenarian males presented with a large thrombosed fusiform VAA that caused symptoms due to mass effect. In each case, perforators arose from the parent artery and short-segment internal trapping with NBCA and coils was performed. Symptoms improved after treatment and follow-up imaging confirmed aneurysm shrinkage with no long-time recurrence. In symptomatic large fusiform VAAs where the distance from the lesion to important perforators is extremely short, internal trapping using a combination of NBCA and coils can be more useful than conventional internal trapping.

Development and clinical evaluation of a contactless operating interface for three-dimensional image-guided navigation for endovascular neurosurgery.

PURPOSE: In endovascular neurosurgery, the operator often acquires three-dimensional (3D) images of the cerebral vessels. Although workstation reoperation is required in some situations during treatment, it leads to time loss because a sterile condition cannot be maintained and treatment must be temporarily interrupted. Therefore, a workstation reoperating system is required while maintaining the desired sterility. METHODS: A contactless operating interface using Kinect to control 3D images was developed via gesture recognition for endovascular neurosurgery and was applied to a 3D volume rendering technique (VRT) image reconstructed at the workstation. The left-hand movement determines the assigned functions, whereas the right-hand movement is used like a computer mouse to pan and zoom in/out. In addition to the interface, voice commands were used and assigned to digital operations, such as image view changes and mode signal changes. RESULTS: This system was used for the actual endovascular treatment of cerebral aneurysms and cerebral arteriovenous malformations. The operator and gesture were recognized without any problems. Using voice operation, it was possible to expeditiously set the VRT image back to the reference angle. Furthermore, it was possible to finely adjust gesture operations, including mouse operation, and treatment was completed while maintaining sterile conditions. CONCLUSION: A contactless operating interface was developed by combining the existing workstation system with Kinect and voice recognition software, allowing surgeons to perform a series of operations, which are normally performed in a console room, while maintaining sterile conditions.

Analysis of relationship between superior hypophyseal artery visualization and preservation and postoperative visual field deficit in paraclinoid aneurysm.

Direct surgery for paraclinoid aneurysms can result in visual field deficit owing to compromised blood flow to the superior hypophyseal artery (SHA). However, it is rarely visualized in angiography, and discussions regarding its preservation in the field of neuro-endovascular treatment are limited. Biplane angiographic suite with high spatial resolution has been used at our institution since 2014. Since then, there were a few cases where SHAs could be visualized via digital subtraction angiography. We retrospectively analyzed the relationship between the presences and abscence of SHAs in paraclinoid aneurysms and post-procedural visual field deficit. Sixty-three paraclinoid aneuryms treated by neuro-endovascular procedure in 2014-2018 at our neurosurgery department were analyzed. Pre- and post-procedural multiplanar reconstruction imagings of three-dimensional rotation angiography were analyzed to retrospectively investigate the SHAs. SHAs were visualized in 26 patients (41%) and the median number of pre-procedurally visualized SHAs was 0 (interquartile range 0-1). Their origins were the aneurysmal necks in 11 patients (42%). In two of the 11 cases, they were noticed before coil embolization and were able to be preserved after the procedure. In the remaining nine cases, they were not pre-procedurally detected, and coiling was normally conducted. Visual field deficit occurred in one of these nine cases, but symptoms were transient, and the patient fully recovered. Because SHAs could be visualized in >40% cases and no visual field defects occurred in cases that SHAs could be identified and preserved preoperatively, we recommend their preservation during coil embolization for paraclinoid aneurysms.

Case-control study of postprocedural arterial puncture site hemorrhage after neuroendovascular treatment.

Puncture site hemorrhage following femoral artery catheterization is a significant cause of morbidity. The aim of this case-control study was to identify predictors of postprocedural arterial hemorrhage at the puncture site. We retrospectively reviewed 255 patients who underwent endovascular treatment at our institution over a 23-month period and classified them into a hemorrhage group and a non-hemorrhage group. Puncture site hemorrhage occurred in 15 patients (5.9%). Clinical factors associated with a significantly increased risk of puncture site bleeding included patients whose postoperative activated clotting time of ≥300 seconds before removal of the sheath (9 patients, 11.8%; P<0.05), those who received triple antiplatelet therapy (n=4, 17.4%; P<0.05) and the group administered heparin postoperatively (7 patients, 13.2%; P<0.05). The effects of low on-treatment platelet reactivity, i.e., P2Y12 reaction units <95%, sheath size, hemostasis method used, and operating time were not clinically significant. Our findings suggest an increased risk of puncture site hemorrhage in patients who either had an activated clotting time ≥300 seconds before the postoperative removal of the sheath, had received triple antiplatelet therapy, or were administered heparin postoperatively.