Safety and efficacy of the endoscopic transsphenoidal transclival approach performed using direct cortical stimulation for pontine cavernous malformations.

OBJECTIVE: Surgical treatment of brainstem cavernous malformations (CMs) is challenging. Surgery using the endoscopic transsphenoidal transclival approach (eTSTCA) is reported as a useful alternative for ventral brainstem CMs. However, CMs located in the ventral midline of the brainstem are rare, and only a small number of case reports on these CMs treated with the eTSTCA exist. The efficacy and safety of the eTSTCA have not yet been fully examined. METHODS: A retrospective analysis was performed for 5 consecutive patients who underwent surgery via the eTSTCA for treating ventral pontine CMs. RESULTS: The average maximum CM diameter was 26.0 mm (18-38 mm). All patients underwent MR-diffusion tensor imaging, which confirmed that the corticospinal tract (CST) deviated posteriorly or laterally to the CM. Direct brainstem cortical stimulation was performed to localize the CST before making the cortical incision. After the excision of the CM, the cavity was filled with artificial CSF to make an aqueous surgical field (wet-field technique) for observing the tumor cavity and confirming complete hemostasis and resection. Total removal was achieved in all patients. The preoperative modified Rankin Scale score was 3 in 3 patients and 4 in 2 patients, whereas it was 1 in 2 patients and 0 in 3 patients 3 months after surgery. Postoperative CSF leakage was observed in 1 patient, and transient abducens nerve palsy was observed in 1 patient. No other intra- or postoperative complications were observed. CONCLUSIONS: MR-diffusion tensor imaging and direct brainstem cortical stimulation were useful to ascertain the proximity of the CST to the CM. The endoscope provides a clear view even underwater, and it was safe and effective to observe the entire CM cavity and confirm complete hemostasis without additional retraction of the brainstem parenchyma, including the CST. The eTSTCA provides a direct access point to the lesion and may be a safer alternative treatment for patients whose CST deviates laterally or posteriorly to the CM.

Cuban policosanol improves high-density lipoprotein cholesterol efflux capacity in healthy Japanese subjects.

Policosanol supplementation has been reported to increase high-density lipoprotein (HDL)-cholesterol (HDL-C). However, the association between Cuban policosanol supplementation and HDL cholesterol efflux capacity (CEC), an important function of HDL, remains unclear. We performed a lipoprotein analysis investigating 32 Japanese healthy participants (placebo, n = 17 or policosanol supplementation for 12 weeks, n = 15) from a randomized Cuban policosanol clinical trial. First, HDL CEC and HDL-related factors were measured before and after policosanol supplementation. Then, through electron microscopy after ultracentrifugation and high-performance liquid chromatography, HDL morphology and subclass were analyzed, respectively. Finally, the effects of policosanol supplementation regarding HDL function, HDL-related factors, and HDL morphology/component were examined. Cuban policosanol considerably increased the HDL CEC and HDL-C and apolipoprotein A-I (ApoA-I) levels. Furthermore, policosanol supplementation led to larger HDL particles, increased cholesterol content in larger HDL particles, and reduced triglyceride content in smaller HDL particles. In participants with high baseline HDL-C levels, the policosanol effects for HDL CEC are observed. HDL CEC fluctuation induced by policosanol was highly associated with HDL-C and ApoA-I changes. In conclusion, for the first time, we demonstrated that policosanol supplementation increased the HDL CEC in healthy participants.

Endoscopic Trans-Mini-Cylinder Biopsy for Intraparenchymal Brain Lesions.

OBJECTIVE: The biopsy procedure is intended to obtain an adequate specimen volume from the targeted area while ensuring minimal damage to the normal brain. We performed navigation-guided endoscopic biopsy using a small-diameter cylinder to reduce the invasiveness of the biopsy procedure and ensure a sufficient amount of tissue is collected. We examined whether it is possible to reduce brain tissue injury by using a small-diameter cylinder and improve safety and effectiveness by using an endoscope to directly observe the lesion and achieve hemostasis. METHODS: Patients who underwent endoscopic biopsy surgery using a 6-mm-diameter cylinder for intraparenchymal lesions were enrolled in this study. Postoperative hematoma formation and the extent of trajectory scarring were assessed. RESULTS: Fifty-two procedures performed on 51 patients were analyzed in this study. Postoperative neurological deterioration was not observed in any patient. A pathological diagnosis was made for all patients. Postoperative computed tomography revealed no hematoma after 49 procedures and a small hematoma after 3 procedures, and no patients required additional treatment. A postoperative trajectory scar less than 5 mm in diameter was observed after 30 procedures, a scar of 5-10 mm was observed after 19 procedures, a scar larger than 10 mm was observed after 3 procedures at 1 week after surgery, and 40, 6 and 0 scars were observed at 3 months after surgery. CONCLUSIONS: Endoscopic biopsy using a small-diameter cylinder is a possible alternative biopsy technique for intraparenchymal lesions. This surgical technique is useful, especially in patients at risk of hemorrhagic complications.

Effect of cilia-induced surface velocity on cerebrospinal fluid exchange in the lateral ventricles.

Ciliary motility disorders are known to cause hydrocephalus. The instantaneous velocity of cerebrospinal fluid (CSF) flow is dominated by artery pulsation, and it remains unclear why ciliary dysfunction results in hydrocephalus. In this study, we investigated the effects of cilia-induced surface velocity on CSF flow using computational fluid dynamics. A geometric model of the human ventricles was constructed using medical imaging data. The CSF produced by the choroid plexus and cilia-induced surface velocity were given as the velocity boundary conditions at the ventricular walls. We developed healthy and reduced cilia motility models based on experimental data of cilia-induced velocity in healthy wild-type and Dpcd-knockout mice. The results indicate that there is almost no difference in intraventricular pressure between healthy and reduced cilia motility models. Additionally, it was found that newly produced CSF from the choroid plexus did not spread to the anterior and inferior horns of the lateral ventricles in the reduced cilia motility model. These findings suggest that a ciliary motility disorder could delay CSF exchange in the anterior and inferior horns of the lateral ventricles.

Case of a Pregnant Woman with Capillary Hemangioma of the Parasellar Region.

Here we report a rare case of capillary hemangioma (CH) in a 28-year-old woman suffering from gradual worsening diplopia at 28 weeks of pregnancy. Magnetic resonance imaging (MRI) showed a mass lesion (about 3 cm in diameter) in the right parasellar region. We decided to observe as she was pregnant, and had no symptoms other than right abducent nerve palsy. Fortunately, her symptoms did not worsen until delivery. Computed tomography, enhanced MRI, and angiography after delivery revealed that the lesion was highly calcified and vascularized. A dorsum sellae meningioma or highly calcified pituitary adenoma was suspected and the endoscopic transsphenoidal approach was used for tumor removal. The postoperative course was uneventful. The histological diagnosis was CH. Intracranial CHs or CHs of skull are rare vascular tumors. These tumors are reportedly more common in female patients and may change in size in adults according to menstrual cycle and pregnancy. Only six cases, including that of the present study, were diagnosed during the perinatal period. Some of them experienced rapid symptom progression and tumor growth in their course; thus, we should pay further attention to pregnant or peripartum patients with brain tumor, suspected hemangiomas.

Intermittent Exercise at Lactate Threshold Induces Lower Acute Stress than Its Continuous Counterpart in Middle-to-Older Aged Men.

This study aimed to compare the degree of exhaustion and trophic effects between continuous exercise (CE) and intermittent exercise (IE) at lactate threshold (LT) intensity. Seven healthy men (age: 43-69 years) performed the following three experimental tests in a randomized crossover order: (1) control; (2) CE, performed as a 20-min of cycling at LT intensity; and (3) IE, performed as 20 sets of a one-min bout of cycling at LT intensity with a 30-s rest between every two sets. Heart rate (HR), blood lactate concentration (LA), rating of perceived exertion (RPE), catecholamines, cortisol, growth hormone, insulin-like growth factor (IGF)-1, and brain-derived neurotrophic factor (BDNF) were measured. The sampling timing in each test was as follows: 10 min before the onset of exercise, at the 25%, 50%, and 100% time points of exercise, and at 10 min after exercise. IE was found to be accompanied by a lower degree of exhaustion than CE in measures of HR, LA, RPE, catecholamines, and cortisol. In terms of trophic effects, both of IGF-1 and BDNF increased in CE, while a marginal increase of BDNF was observed in IE. The results indicated that IE induces lower stress than CE, but may not be effective for inducing trophic effects.

A novel endoscopic ventriculocisternostomy and stenting technique with a transparent acryl puncture needle for a trapped temporal horn: a technical report and literature review.

Trapped temporal horn is a rare type of noncommunicating focal hydrocephalus, and no standard treatment has been established yet for trapped temporal horn. Recent studies have shown the efficacy of endoscopic ventriculocisternostomy by opening the choroidal fissure; however, some surgical complications were reported during the procedure. Thus, we aimed to report a novel endoscopic ventriculocisternostomy and stenting technique for trapped temporal horn. In this technique, a 5.8-mm transparent acryl puncture needle with a 2.7-mm 0° rigid endoscope was used to open the choroidal fissure. It can fenestrate the choroidal fissure under real-time endoscopic observation of the critical neurovascular structures over the choroidal fissure. Moreover, the dull tip of the needle is less likely to injure the critical neurovascular structures, resulting in safer ventriculocisternostomy than the previously reported technique. Then, a stent is placed along the tract to prevent future obstruction of the stoma. Six trapped temporal horns in four patients were treated using the technique. All the patients showed improved symptoms with no surgical complications. None of the patients showed recurrence of trapped temporal horn during the mean follow-up period of 39.3 months. The combination of endoscopic ventriculocisternostomy and stenting with a transparent acryl puncture needle is a safe and effective treatment option for trapped temporal horn.

Importance of Hydrostatic Pressure and Irrigation for Hemostasis in Neuroendoscopic Surgery.

Recently neurosurgical operations have been carried out with water irrigation such as endoscopic third ventriculostomy and tumor resections in ventricles. Water irrigation is one of several published methods that promote hemostasis; however, not enough experimental evidence exists on its efficacy. In this study, we investigate whether hydrostatic pressure and persistent irrigation promote hemostasis in neuroendoscopic surgery. We dissected tails of 12-16-week-old C57BL/6 male mice at 5 mm proximal from the tip and checked for bleeding times under dry and wet conditions at pressures of 0 cmH2O, 10 cmH2O, 15 H2O, and 20 cmH2O without persistent irrigation to bleeding point and 10 cmH2O with persistent irrigation. We then examined the dissected edge with hematoxylin-eosin staining and measured the size of vessels. The average bleeding time of each group is as follows: dry: 203.4 sec, wet: 164.4 sec, 5 cmH2O: 138.6 sec, 10 cmH2O: 104.6 sec (P <0.001), 20 cmH2O: 56 sec (P <0.001), and 10 cmH2O with persistent irrigation: 72.8 sec (P <0.01 compared to 10 cmH2O without persistent irrigation). The maximum caliber of mice's tail artery was 50-60 µm. Hydrostatic pressure and irrigation are important factors contributing to hemostasis.

Novel Endoscopic Technique for Inserting a Sheath into a Slit Ventricle: The Water-Slide Technique.

BACKGROUND: The efficacy and safety of endoscopic procedures for slit ventricle syndrome (SVS) have been presented in recent studies. However, inserting a sheath into a target ventricle is essential in the beginning of endoscopic procedures for SVS, and this maneuver is challenging owing to the quite narrow ventricular space. We report a novel flexible endoscopic technique, the water-slide technique, that can effectively guide a sheath into a slit ventricle without the use of other adjunctive devices, such as a neuronavigation system and an ultrasound machine. METHODS: Ten endoscopic procedures using the water-slide technique were performed in 9 patients with SVS. All patients had undergone ventriculoperitoneal shunt placement. Using the technique, the sheath was first placed on the flexible endoscope. The endoscope was then inserted into the lateral ventricle along the tract around the pre-existing ventricular catheter with irrigation of artificial cerebrospinal fluid via the working channel of the endoscope. After the endoscope reached the ventricle, the sheath was inserted into the ventricle along the endoscope. The endoscope was then used as a stylet. The endoscopic procedure was performed afterward. Continuous irrigation of artificial cerebrospinal fluid via the working channel is important when using this technique. RESULTS: In all cases, the sheath was successfully introduced to the slit ventricle without the use of adjunctive devices. There were no postoperative complications correlated with the maneuver. CONCLUSIONS: This novel endoscopic technique is effective and safe for inserting a sheath into a target ventricle in the management of SVS.

A Case of Primary Leptomeningeal Lymphoma Presenting with Hydrocephalus Characterized by Disproportionately Large Fourth Ventricle.

Primary leptomeningeal malignant lymphoma (PLML) is a rare variant of primary central nerve system malignant lymphoma (PCNSL) which is restricted to leptomeninges. The lesions of PLML can often be detected as abnormal enhancement on the surface of central nervous system or the ventricular wall on magnetic resonance imaging (MRIs). Cerebrospinal fluid (CSF) evaluation together with such MRI findings provides the definitive diagnosis of PLML. Here, we present a 45-year-old female case of PLML in which hydrocephalus with disproportionately large fourth ventricle was observed at presentation with gait instability. Head MRI revealed no abnormal enhancement and CSF cytology was negative, leaving the cause of hydrocephalus undetermined. Endoscopic third ventriculostomy (ETV) was effectively performed for hydrocephalus and her symptoms disappeared. Nearly 2 years later, she was brought to emergent room due to unconsciousness with the recurrence of hydrocephalus. MRI showed expanded fourth ventricle and abnormal enhancement on the ventricular wall. The endoscopic surgery for improving CSF flow was successful and inflammatory change was endoscopically observed on the ventricular wall involving aqueduct. Pathological diagnosis of the specimen from the ventricular wall proved B-cell lymphoma. Because neither brain parenchymal masses nor systemic tumors were identified, she was diagnosed with PLML and treated by high-dose methotrexate. She was in a stable state 2 years after the diagnosis of PLML. We report and discuss the characteristics of this case.

Fully Endoscopic Transcylinder Trans-Magendie Foraminal Approach for Fourth Ventricular Cavernoma: A Technical Case Report.

BACKGROUND: Neuroendoscopy offers wide and close surgical views with fine illumination, even in deep surgical sites. Furthermore, transcylinder surgery has the advantage that a tubular retractor can protect critical neurovascular structures in the surgical corridor. These advantages of neuroendoscopy and transcylinder surgery can contribute to safer and less invasive surgical approaches for deep-seated fourth ventricular lesions, for which various critical neurovascular structures exist along the surgical route. CASE DESCRIPTION: A 54-year-old man with a fourth ventricular cavernoma underwent tumor resection via the endoscopic transcylinder trans-Magendie foraminal approach. A 6.8-mm transparent sheath (cylinder) was introduced into the fourth ventricle via the foramen of Magendie without incisions in the inferior medullary velum or the tela choroidea, resulting in the minimal retraction of and trauma to critical neurovascular structures in the surgical corridor. Under the view of a 2.7-mm rigid neuroendoscope, the lesion was completely removed with preservation of a venous anomaly on the ventral side of the aqueduct of Sylvius. Neuroendoscopy could offer a fine surgical view even under continuous irrigation with artificial cerebrospinal fluid; it prevented collapse of the fourth ventricle and facilitated anatomic understanding by the surgeons. The postoperative course was uneventful. CONCLUSIONS: Our novel approach can be an effective surgical option for fourth ventricular lesions with minimal cerebellar retraction and injury.

An Institutional Retrospective Study of Coil Loop Herniation and its Management.

INTRODUCTION: Endovascular coiling is a method of aneurysm embolization. Sometimes coil loops herniate in the lumen after deployment of the coil. It is usually seen in wide-necked aneurysms. It can cause migration of the coil and thromboembolic complications. There are different methods such as the use of a balloon, stent, and coil retriever to treat coil loop herniation. There are very few case series on coil loop herniation management. Most series are about the use of a stent/balloon for reposition. We are going to describe simple, novel techniques to treat coil loop herniation. MATERIALS AND METHODS: In the last five years, 13 aneurysms out of 325 coiled aneurysms had coil loop herniation. We used three different techniques in these patients according to our selection criteria. The first technique was loop trap with another coil, the second was balloon and coil-plasty to trap, and the third was rescue stent and flow control. RESULTS: The first, second, and third techniques were successfully used in five, five and three patients, respectively. There was a complete reposition of herniated coil and thus embolization of aneurysm in all cases. All patients recovered completely without any thromboembolic complications. CONCLUSIONS: We recommend the use of these techniques according to the proper selection criteria.

Double-balloon Trapping for Coil Embolization of Ruptured Internal Carotid Artery Aneurysm: A Novel Technique.

INTRODUCTION: Endovascular treatment of complex ruptured aneurysms in the internal carotid (IC) artery is extremely challenging. Navigation of double-balloon catheters becomes all the more difficult in tortuous vessels. PATIENTS AND METHODS: A 57-year-old female with more than three times previously ruptured left IC artery aneurysm with subarachnoid hemorrhage had a left IC small aneurysm with a neck of 3.2 mm. Proximal and distal balloons were inflated in left IC artery in respect to the aneurysm, to prevent further rupture during navigation of the microcatheter and first coil. DISCUSSION: The technique uses two balloons placed proximal and distal to the ruptured aneurysm, to reduce further bleeding, just as the application of temporary clips, followed by inertion of coils rapidly to obliterate the aneurysm. CONCLUSION: It is a novel technique of double-balloon trapping of proximal and distal segment of IC artery with aneurysm coiling technique as an alternative to balloon-assisted coiling and stent-assisted coiling in patients with ruptured aneurysm.

Peel-off resection of the pituitary gland for functional pituitary adenomas: pathological significance and impact on pituitary function.

PURPOSE: Functional pituitary adenomas (FPAs) lacking a well-defined pseudocapsule can invade the adjacent pituitary gland. In such situations, peel-off resection of the adjacent pituitary gland after selective adenomectomy might lead to complete tumor removal, resulting in optimal endocrinological outcomes. Here, we present the significance of peel-off resection of the pituitary gland in patients with FPA in whom complete extracapsular tumor removal cannot be achieved. METHODS: We performed a retrospective review of 21 patients with FPA who underwent transsphenoidal surgery (TSS). After selective adenomectomy, peel-off resection of the adjacent pituitary gland was performed in 13 patients because complete extracapsular resection could not be achieved, while peel-off resection was not performed in the remaining 8 patients because complete extracapsular resection was accomplished. The clinical outcomes of these groups were compared. The pituitary tissues obtained by peel-off resection were pathologically examined for tumor cells. RESULTS: Early postoperative biochemical remission was achieved in 20 patients (95.2%). Anterior pituitary functions were not aggravated postoperatively in any patient: however, transient diabetes insipidus (DI) occurred in 2 patients. There were no statistically significant differences in the clinical outcomes of the two groups. A pseudocapsule was pathologically detected in the adjacent anterior pituitary even in patients in whom no pseudocapsule was intraoperatively detected. Tumor cells were pathologically detected in 7 (58.3%) of 12 pituitary tissues examined. CONCLUSIONS: Peel-off resection of the pituitary gland, which can remove a small tumor cell remnant in the adjacent pituitary, might maximize the effectiveness of TSS with minimal impact on postoperative pituitary function.

Removal of the Medial Wall of the Cavernous Sinus for Functional Pituitary Adenomas: A Technical Report and Pathologic Significance.

BACKGROUND: Removal of the medial wall of the cavernous sinus (MW) is challenging for neurosurgeons. We describe a practical method of endoscopic MW removal via endonasal transsphenoidal approach to minimalize intraoperative blood loss and postoperative morbidities. We also present the pathologic significance of this technique for functional pituitary adenomas (FPAs). METHODS: We performed MW removal in patients with FPA with no well-defined pseudocapsule and a tumor in direct contact with the MW. The MW was judged to have tumor invasion based on the intraoperative appearance, and it was removed regardless of the appearance of MW involvement. Intraoperative findings and postoperative clinical, endocrinologic, and pathologic outcomes were retrospectively reviewed. RESULTS: Fourteen patients underwent MW removal for FPA, including 12 patients with acromegaly and 2 with Cushing disease. Mean intraoperative blood loss was 170 mL (range, 32-400 mL), and none of the patients required blood transfusion. Among the 7 patients without intraoperative apparent MW involvement, 4 (57.1%) had pathologically confirmed tumor invasion into the MW (occult invasion). Biochemical remission by surgery alone was achieved in 13 patients (92.9%). Transient oculomotor palsy occurred in 1 patient (7.1%). CONCLUSIONS: Occult tumor invasion into the MW was often detected in patients with FPA without a well-defined pseudocapsule but in direct contact with the MW. Our technique can enhance the effectiveness of surgery with minimal postoperative morbidities.

Relationship between Abducens Nerve Palsy and Local Hematoma in a Case Series of Ruptured Vertebral Artery Dissecting Aneurysm.

BACKGROUND: Abducens nerve palsy associated with subarachnoid hemorrhage (SAH) has rarely been reported. Its frequency, mechanism of palsy, association with aneurysmal location, and clinical course are poorly described. The purpose of our study was to evaluate patients with abducens nerve palsy caused by SAH occurring from ruptured vertebral artery (VA) dissecting aneurysm and to find aneurysmal location using initial computed tomography (CT) and its association with clinically detected cranial nerve palsy. METHODS: Fourteen patients of SAH due to ruptured VA dissecting aneurysm were treated at our hospital from January 2011 to May 2015. The clinical courses and CT findings were reviewed retrospectively. RESULTS: Abducens nerve palsy was observed in 77.8% of cases after excluding patients with decreased levels of consciousness. Clots within the prepontine cistern were significantly thicker in cases of VA dissecting aneurysm than in case of supratentorial aneurysm (P = 0.002). CONCLUSION: The findings of our study indicated that ruptured VA dissecting aneurysms, even in cases of angio-negative SAH, are likely to present with abducens nerve palsy.

Effectiveness of Goreisan in Preventing Recurrence of Chronic Subdural Hematoma.

BACKGROUND: Burr-hole irrigation surgery is now recognized as a widespread simple technique for the treatment of chronic subdural hematoma (CSDH). However, recurrence of CSDH is sometimes experienced after initial surgery. Recently, it has been reported that goreisan is effective in preventing CSDH recurrence. MATERIALS AND METHODS: Methods: We studied patients with CSDH who received burr-hole irrigation at our hospital between January 2011 and December 2014. We divided these patients into three groups. The first group was given goreisan during the early phase after burr-hole irrigation. The second group was given goreisan when there was a visual tendency of recurrence, as observed in the course of computed tomography imaging for outpatients. The third group was not given any drug. RESULTS: The recurrence rate was compared between each group. The recurrence rate was significantly lower in the early goreisan administration group (5% vs. 12%, P = 0.046). There was a decreased tendency of recurrence in the goreisan-administered group compared with the group that was not administered any drug, but this was not statistically different (6.1% vs. 12%, P = 0.082). The recurrence period in the goreisan-administered group was longer than that in the group that was not administered any drug (39.9 ± 12.1 vs. 27.45 ± 8.5, P = 0.017). CONCLUSIONS: Goreisan is effective in preventing recurrence of CSDH after burr-hole irrigation.

A Stent-Retrieving into an Aspiration Catheter with Proximal Balloon (ASAP) Technique: A Technique of Mechanical Thrombectomy.

OBJECTIVE: The best technique for the first attempt at mechanical thrombectomy for acute ischemic stroke is a still matter of debate. In this study, we evaluate the efficacy of a stent-retrieving into an aspiration catheter with proximal balloon (ASAP) technique that uses a series of thrombus extraction by withdrawing the stent retriever into the aspiration catheter and continuous aspiration from the aspiration catheter at the first attempt. METHODS: We performed a retrospective analysis of 42 consecutive patients with acute ischemic stroke caused by occlusions in the anterior circulation who were treated with the ASAP technique at our institution. Preoperative patient characteristic, including age, thrombus location, Alberta Stroke Program Early CT Score, National Institutions of Health Stroke Scale, and time from onset to puncture; postoperative Thrombolysis in Cerebral Infarction score; modified Rankin Scale score after 3 months; time from puncture to recanalization; the number of passes to achieve recanalization; and procedural complications, including intracranial hemorrhage, embolization to new territory, and distal embolization, were assessed. RESULTS: A Thrombolysis in Cerebral Infarction score of 2B or 3 was achieved in 40/42 patients (95.2%). Average time from puncture to the final recanalization was 21.5 minutes. Recanalization was achieved in a single attempt in 31 patients (77.5%). Embolization to new territory was observed in only 2 patients (4.8%); no patient developed distal embolization or intracranial hemorrhage including asymptomatic subarachnoid hemorrhage. Thirty-two patients (76.2%) achieved modified Rankin Scale scores of 0-2 at 3 months postoperatively. CONCLUSIONS: Our ASAP technique showed fast recanalization, minimal complications, and good clinical outcomes in this case series.

8-F balloon guide catheter for embolization of anterior circulation aneurysms: an institutional experience in 152 patients.

The use of 8-F balloon guide catheter (BGC) for proximal flow control was previously shown to prevent distal embolic complications during mechanical clot retrieval in patients with acute ischemic stroke. In this retrospective study, the utility of 8-F BGCs for proximal flow control during endovascular coiling of anterior circulation aneurysms was investigated. Patients who underwent endovascular coiling for anterior circulation aneurysms between August 2013 and December 2016 were retrospectively analyzed. Among a total of 152 patients included in this series, 64 patients presented with aneurysmal rupture, whereas the aneurysms were detected incidentally or due to mass effects in the remaining patients. 8-F BGCs were successfully navigated in all patients. The balloon was inflated during navigation in 19 patients. Inflation of the catheter balloon during coil embolization was required in 34 patients; this was performed as an emergency maneuver in six of these patients. Thromboembolic complications occurred in one patient. 8-F BGC can be effectively used for proximal flow control during endovascular treatment of anterior circulation aneurysms. The other advantages included improved navigation of tortuous arterial anatomy, coil stabilization during aneurysmal coiling, and freedom to utilize aneurysmal neck-remodeling balloons for additional adjunctive techniques or to deploy rescue stents. This novel approach might be safely and effectively used in patients undergoing endovascular treatment for anterior circulation aneurysms.

Hemispheric divided coiling technique for coil embolization of middle- and large-sized intracranial aneurysms.

Despite major developments in treating intracranial aneurysms by endovascular coil embolization, complete occlusion of the entire aneurysmal neck remains a problem. We present a novel endovascular strategy for middle- and large sized aneurysms called the "hemispheric divided coiling technique" and compare the short-term follow-up results of this technique with those of conventional coil embolization. Ten patients (mean age, 69.7 ± 9.7 years) with middle- or large-sized ruptured or unruptured intracranial aneurysms (mean maximum aneurysmal diameter, 12.09 ± 3.6 mm) were treated by the hemispheric divided coiling technique, in combination with various adjunctive techniques. We compared the initial occlusion grade, volume embolization ratio, and recurrence rate in this group of patients (hemispheric group) with the results from 20 previous cases (conventional group: mean age, 62.8 ± 9.8 years; mean maximum aneurysmal diameter, 11.43 ± 3.5 mm). The mean volume embolization ratio of the hemispheric group was significantly higher than that of the conventional group (42.3% vs. 31.1%). The hemispheric divided coiling technique achieved a high volume embolization ratio for middle- and large sized intracranial aneurysms, with a low recurrence rate.