Embolization of the middle meningeal artery vs. second surgery-treatment response and volume course of recurrent chronic subdural hematomas.

BACKGROUND: Despite multiple studies on the embolization of the middle meningeal artery, there is limited data on the treatment response of recurrent chronic subdural hematomas (CSDH) to embolization and on the volume change. METHODS: We retrospectively compared the treatment response and volume change of recurrent CSDHs in a conventional group (second surgery) with an embolization group (embolization as stand-alone treatment) during the time-period from August 2019 until June 2022. Different clinical and radiological factors were assessed. Treatment failure was defined as necessity of treatment for second recurrence. Hematoma volumes were determined in the initial CT scan before first surgery, after the first surgery, before retreatment as well as in an early (1 day-2 weeks) and in a late follow-up CT scan (2-8 weeks). RESULTS: Fifty recurrent hematomas after initial surgery were treated either by second surgery (n = 27) or by embolization (n = 23). 8/27 (26,6%) surgically treated and 3/23 (13%) of the hematomas treated by embolization needed to be treated again. This leads to an efficacy in recurrent hematomas of 73,4% in surgically treated and of 87% in embolized hematomas (p = 0.189). In the conventional group, mean volume decreased significantly already in the first follow-up CT scan from 101.7 ml (SD 53.7) to 60.7 ml (SD 40.3) (p = 0.001) and dropped further in the later follow-up scan to 46.6 ml (SD 37.1) (p = 0.001). In the embolization group, the mean volume did decrease insignificantly from 75.1 ml (SD 27.3) to 68 ml (SD 31.4) in the first scan (p = 0.062). However, in the late scan significant volume reduction to 30.8 ml (SD 17.1) could be observed (p = 0.002). CONCLUSIONS: Embolization of the middle meningeal artery is an effective treatment option for recurrent CSDH. Patients with mild symptoms who can tolerate slow volume reduction are suitable for embolization, whereas patients with severe symptoms should be reserved for surgery.

Endovascular treatment for cerebral venous sinus thrombosis - a single center study.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disorder. The majority of these patients respond favorably to systemic anticoagulation. However, a subset of patients will deteriorate clinically, despite optimal medical therapy. METHODS: Retrospective single center study of 28 consecutive CVST patients treated with systemic anticoagulation and additional endovascular therapy. RESULTS: Median age was 37.5 years (range 15-76 years), there were 21 (75%) women, and 20 (71%) had thrombosis involving ≥2 venous sinuses. Intracranial hemorrhage (ICH) was present at admission in 18 patients (64%). Endovascular therapy consisted of local thrombolysis in 26 (93%) patients; 9 patients (32%) had additional mechanical thrombectomy, and in 2 (7%) patients thrombectomy alone was performed. Complete recanalization at end of the final intervention was achieved in 15 patients (54%), partial recanalization in 11 patients (39%), whereas there was no recanalization in 2 patients (7%). On follow-up imaging, conducted between 3 and 6 months, recanalization further improved to 76%, 19% and 5%, respectively. A favorable outcome (mRS ≤ 2) was achieved in 63% of patients at 3 months, which improved to 79% at 6 months. Post-procedural ICH or volume expansion of preexisting ICH was seen in 9 patients (32%). In total 5 patients died (18%). CONCLUSIONS: Systemic anticoagulation with the addition of endovascular therapy with local thrombolysis and/or mechanical thrombectomy is a potential strategy to obtain recanalization in patients with CVST who deteriorate clinically despite medical therapy or are comatose. Endovascular therapy may increase the risk of ICH.

Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions: A Collaborative Pooled Analysis.

Background and Purpose- Antiplatelet agents could be used in the setting of endovascular therapy for tandem occlusions to reduce the risk of de novo intracranial embolic migration, reocclusion of the extracranial internal carotid artery lesion, or in-stent thrombosis in case of carotid stent placement but have to be balanced with the intracerebral hemorrhagic transformation risk. In this study, we aim to investigate the impact of acute antiplatelet therapy administration on outcomes during endovascular therapy for anterior circulation tandem occlusions. Methods- This is a retrospective analysis of a collaborative pooled analysis of 11 prospective databases from the multicenter observational TITAN registry (Thrombectomy in Tandem Lesions). Patients were divided into groups based on the number of antiplatelet administered during endovascular therapy. The primary outcome was favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days. Results- This study included a total of 369 patients; 145 (39.3%) did not receive any antiplatelet agent and 224 (60.7%) received at least 1 antiplatelet agent during the procedure. Rate of favorable outcome was nonsignificantly higher in patients treated with antiplatelet therapy (58.3%) compared with those treated without antiplatelet (46.0%; adjusted odds ratio, 1.38 [95% CI, 0.78-2.43]; P=0.26). Rate of 90-day mortality was significantly lower in patients treated with antiplatelet therapy (11.2% versus 18.7%; adjusted odds ratio, 0.47 [95% CI, 0.22-0.98]; P=0.042), without increasing the risk of any intracerebral hemorrhage. Successful reperfusion (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate was significantly better in the antiplatelet therapy group (83.9% versus 71.0%; adjusted odds ratio, 1.89 [95% CI, 1.01-3.64]; P=0.045). Conclusions- Administration of antiplatelet therapy during endovascular therapy for anterior circulation tandem occlusions was safe and was associated with a lower 90-day mortality. Optimal antiplatelet therapy remains to be assessed, especially when emergent carotid artery stenting is performed. Further randomized controlled trials are needed.

Thrombectomy in Acute Stroke With Tandem Occlusions From Dissection Versus Atherosclerotic Cause.

BACKGROUND AND PURPOSE: Tandem steno-occlusive lesions were poorly represented in randomized trials and represent a major challenge for endovascular thrombectomy in acute anterior circulation strokes. The impact of the cervical carotid lesion cause (ie, atherosclerotic versus dissection) on outcome of tandem patients endovascularly treated remains to be assessed. METHODS: We retrospectively analyzed individual data of prospectively collected consecutive tandem patients treated with endovascular thrombectomy. The primary outcome was favorable outcome at 90 days (modified Rankin Scale score of 0-2). Secondary efficacy outcomes included successful reperfusion (modified Thrombolysis in Cerebrovascular Infarction scores of 2b-3), time to reperfusion, and safety outcomes encompassed procedural complications, symptomatic intracerebral hemorrhage, and 90-day mortality. RESULTS: Among the 295 included patients, 65 had cervical carotid dissection and 230 had cervical carotid atherosclerotic cause. The rate of favorable outcome was 56.3% in the dissection group versus 47.6% in the atherosclerotic arm (center-, age-, and admission National Institutes of Health Stroke Scale-adjusted odds ratio, 1.08; 95% confidence interval, 0.50-2.30; P=0.85). No significant differences were observed in secondary outcomes. The rates of successful reperfusion, symptomatic intracerebral hemorrhage, and 90-day mortality were 78.5% versus 74.5% (P=0.13), 4.6% versus 5.2% (P=1.0), and 7.8% versus 15.3% (P=0.94) in the dissection versus atherosclerotic groups, respectively. The median procedural time was 76 minutes (interquartile range, 52-95 minutes) in the dissection group and 67 minutes (interquartile range, 45-98 minutes) in the atherosclerotic group (P=0.24). CONCLUSIONS: We found no differences in the outcomes of patients with anterior circulation tandem atherosclerotic and dissection lesions treated with endovascular thrombectomy. Further studies are warranted.

Endovascular thrombectomy and post-procedural headache.

BACKGROUND: We investigated the prevalence of post-procedural headache in patients who have undergone thrombectomy for ischemic stroke, and correlated history of migraine with risk of peri-procedural complications. A total of 314 patients underwent thrombectomy at the Danish National Hospital from January 2012 to December 2014. Eligible subjects were phone-interviewed using a purpose-developed semi-structured questionnaire according to the International Classification of Headache Disorders 3, beta version criteria. FINDINGS: Among 96 eligible subjects, there was a significant decrease in migraine (p = 0.022) within the first 3 months after EVT compared to 1 year before treatment, which was further evident at interview time (on average 1.6 years after EVT, p = 0.013). A minority of patients experienced headaches for the first time within 3 months of their EVT (migraine 2, TTH 9), which persisted at interview time for subjects with migraine. Out of 12 subjects with peri-procedural complications, 2 had a history of migraine with aura. CONCLUSION: Thrombectomy leads to a significant decrease in previously known migraine, and new onset of headache in a small subset of patients. A history of migraine does not appear to predispose to peri-procedural complications.

Post procedure headache in patients treated for neurovascular arteriovenous malformations and aneurysms using endovascular therapy.

BACKGROUND: Though endovascular therapy (EVT) is increasingly applied in the treatment of intracranial vascular lesions, little is known about the effect of EVT on post-procedure headache. We aimed to investigate the prevalence of headache in patients who have undergone EVT for cerebral arteriovenous malformations (AVMs) and aneurysms. METHODS: A total of 324 patients underwent EVT treatment for aneurysms and AVMs at the Danish National Hospital from January 2012 to December 2014. We applied strict exclusion criteria in order to minimize the effect of other factors on headache occurrence, e.g., craniotomy. Eligible subjects were phone-interviewed using a purpose-developed semi-structured questionnaire. Headaches were classified according to ICHD-III beta criteria. RESULTS: The 59 patients underwent treatment of aneurysms (n = 43), cranial dural fistulas (n = 11), and AVMs (n = 5). There was a significant increase in overall headache (p = 0.017) and tension-type headache (TTH) (p = 0.012) within the first 3 months after EVT compared to 1 month before EVT. However, at interview time (median 2.5 years post-EVT), the increase in overall headache, migraine, and tension-type headache was not statistically significant. A minority of patients experienced headaches for the first time within 3 months of their EVT (migraine 4, TTH 10). At interview time, 50 % of these new headaches still persisted. CONCLUSION: Our results suggest a temporary increase in headache in the first 3 months after EVT, which normalizes over time. Clinicians may use this knowledge to better inform their patients of functional outcomes after their EVT procedure.

Thrombectomy in acute basilar artery dissection: A case report.

A 34-year-old patient was admitted with unclear coma and stretch synergisms. CT-imaging was strongly suspicious of basilar artery dissection, this was confirmed on subsequent DSA. The patient was lysed and a complex thrombectomy was performed. Despite sufficient recanalization, the patient unfortunately died shortly after. To the best of our knowledge, this is the first description of an acute basilar artery dissection treated by thrombectomy.

Coating (Coating to Optimize Aneurysm Treatment in the New Flow Diverter Generation) study. The first randomized controlled trial evaluating a coated flow diverter (p64 MW HPC): study design.

BACKGROUND: Due to its high efficacy, flow diversion is increasingly used in the management of unruptured and recanalized aneurysms. Because of the need for perioperative dual antiplatelet treatment (DAPT), flow diversion is not indicated for the treatment of ruptured aneurysms. To overcome this major limitation, surface modification-'coating'-of flow diverters has been developed to reduce platelet aggregation on the implanted device, reduce thromboembolic complications, and facilitate the use of coated flow diverter treatment in patients with single antiplatelet treatment (SAPT). COATING (Coating to Optimize Aneurysm Treatment in the New Flow Diverter Generation) is a prospective, randomized, multicenter trial that aims to determine whether the use of the coated flow diverter p64 MW HPC under SAPT is non-inferior (or even superior) to the use of the bare flow diverter p64 MW under DAPT in relation to thromboembolic and hemorrhagic complications. METHODS: Patients with unruptured or recanalized aneurysms for which endovascular treatment with a flow diverter is indicated will be enrolled and randomly assigned on a 1:1 ratio to one of two treatment groups: p64 MW HPC with SAPT or p64 MW with DAPT. RESULTS: The primary endpoint is the number of diffusion-weighted imaging lesions visualized via MRI assessed within 48 hours (±24 hours) of the index procedure. Secondary primary endpoints are comparing safety and efficacy in both arms. CONCLUSIONS: This randomized controlled trial is the first to directly compare safety and efficacy of coated flow diverters under SAPT with bare flow diverters under DAPT. TRIAL REGISTRATION NUMBER: http://clinicaltrials.gov/ - NCT04870047.

Multimodal recanalization therapy in acute basilar artery occlusion: long-term functional outcome and quality of life.

BACKGROUND AND PURPOSE: Multimodal recanalization therapy in patients with acute basilar artery occlusion provides high recanalization rates. A substantial subset of treated patients survives with only minor or moderate functional handicap. However, long-term functional outcome and quality of life in these patients have rarely been systematically analyzed. METHODS: In this monocentric retrospective study, we analyzed mortality, long-term functional outcome (modified Rankin Scale), and quality of life (36-Item Short-Form Health Survey questionnaire) in all consecutive patients who had been treated for acute basilar artery occlusion in our institution between December 2002 and December 2009. RESULTS: Ninety-one patients (57 male; median age, 65 years; range, 20-89 years) were treated by multimodal recanalization therapy. This included intravenous thrombolysis (n=32) with consecutive on-demand intra-arterial therapy (n=23) or intra-arterial therapy alone (n=59). The overall recanalization rate was 89%. After a median observation time of 4.2 years (range, 0.5-7.4 years), the mortality rate was 59%. Among the 35 survivors, 26 patients (74%) had a good or moderate long-term functional outcome (modified Rankin Scale ≤3). Health-related quality of life was better than that of unselected patients with stroke. Backward stepwise logistic regression identified intravenous thrombolysis (P=0.002) and female sex (P=0.001) as predictors of favorable functional long-term outcome (modified Rankin Scale ≤3). Coma at admission (Glasgow Coma Scale ≤8) was associated with poor outcome (modified Rankin Scale ≥4; P=0.036). CONCLUSIONS: Long-term survival is achieved in approximately 40% of patients with basilar artery occlusion treated with multimodal recanalization therapy. Approximately 75% of the survivors have a favorable functional long-term outcome with an acceptable quality of life.

Near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT): are they complementary or competitive imaging techniques in aneurysm surgery?

BACKGROUND: In this pilot study we compared advantages and drawbacks of near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT) to investigate if these are complementary or competitive methods to acquire immediate information about blood vessels and potential critical impairment of brain perfusion during vascular neurosurgery. METHODS: A small subset of patients (n = 10) were prospectively enrolled in this feasibility study and received ICGVA immediately after placement of the aneurysm clips. An intraoperative cranial CT angiography (iCTA) was followed by dynamic perfusion CT scan (iCTP) using a 40-slice, sliding-gantry, CT scanner. The vascular patency of major (aneurysm bearing) arteries, visualisation of arising perforating arteries and brain perfusion after clip application were analysed with both techniques. RESULTS: The ICGVA was able to visualise blood flow and vascular patency of all major vessels and perforating arteries within the visual field of the microscope, but failed to display vessels located within deeper areas of the surgical field. Even small coverage with brain parenchyma impaired detection of vessels. With iCTA high image quality could be obtained in 7/10 cases of clipped aneurysms. Intraoperative CTA was not sufficiently evaluable in one PICA aneurysm and one case of a previously coiled recurrent aneurysm, due to extensive coil artefacts. Small, perforating arteries could not be detected with iCTA. Intraoperative CTP allowed the assessment of global blood flow and brain perfusion in sufficient quality in 5/10 cases, and enabled adequate intraoperative decision making. CONCLUSION: A combination of ICGVA and iCT is feasible, with very good diagnostic imaging quality associated with short acquisition time and little interference with the surgical workflow. Both techniques are complementary rather than competing analysing tools and help to assess information about local (ICGVA/iCTA) as well as regional (iCTA/iCTP) blood flow and cerebral perfusion immediately after clipping of intracranial aneurysms.

Metric-Based Simulation Training to Proficiency for Endovascular Thrombectomy in Ischemic Stroke.

Ischemic stroke is one of the leading causes of death and long-term disability in the West. Mechanical revascularization techniques are considered the standard of care for large vessel occlusive stroke. Traditional apprenticeship models involve doctors training their skills on patients. Simulation platforms have long been recognized as an alternative to this. There has however been very little robust assessment of the training outcomes achieved on some of these platforms. At best, these simulations increase understanding of the procedural process and may help improve some technical skills; at worst they may instill bad habits and poor technique. The prerequisite of any simulation process must be to teach what to do, with which devices, in the correct sequence as well as what not to do. It should provide valid metric-based feedback to the trainee that is objective, transparent, and fair for formative and summative performance feedback. It should deliver a training program that measures the performance progress of trainees against expert benchmarks-benchmarks that represent an evidence-based peer-reviewed standard. In this paper, we present a perspective for PBP training for thrombectomy based on our experience with the process of procedure characterization, metric validation, and early experience of using this approach for proficiency training. Patient outcomes are not only determined by optimal performance in the Angio Suite but also by an efficient patient procedure pathway. There will be value in utilizing the PBP training standard not only for the procedure itself but also for the constituent elements of the stroke pathway to further improve treatment outcomes for ischemic stroke patients.

Case report: Flattening of the tectal plate in obstructive hydrocephalus with auto-ventriculostomy.

BACKGROUND: Obstructive hydrocephalus in adulthood can be caused by stenosis in the aqueductal area. Chronic changes lead to a dilatation of the lateral ventricles and ballooning of infratentorial recesses. In rare cases a rupture of the floor of the third ventricle (so-called spontaneous ventriculostomy) has been described in the literature.Case presentation: We present two cases of chronic obstructive hydrocephalus due to aqueductal stenosis in adult patients. Magnetic resonance imaging included phase-contrast-imaging and revealed significant flow through the floor of the third ventricle in keeping with spontaneous ventriculostomy. In addition to other typical changes associated with chronic hydrocephalus, a distinct flattening of the tectal plate could be identified in one case. CONCLUSION: We present two cases of spontaneous ventriculostomy in patients with chronic hydrocephalus. To our knowledge, flattening of the tectal plate has not yet been described in the literature and may be caused by continuous cerebrospinal fluid-pulsation.

Case report: Scattered intraventricular lesions on MRI following epidermoid cyst resection.

Local recurrence after epidermoid cyst surgery is a frequently reported complication, but intraventricular spread after surgery has not yet been described in literature. We present the case of a 61-year-old male patient with steadily progressive headaches after surgical excision of an epidermoid cyst in the right cerebellopontine angle about two months ago. The MRI showed multiple intraventricular FLAIR-hyperintensities with diffusion restriction, suggestive of scattered remnants of the epidermoid cyst. We recommend early postoperative MRI-scans after cranial epidermoid surgery, which should be carefully inspected not only for local remnants but also rare complications like intraventricular spread.

Assessing the feasibility of mapping the tibialis anterior muscle with navigated transcranial magnetic stimulation in neuro-oncologic patients.

Mapping the lower extremity with navigated transcranial magnetic stimulation (nTMS) still remains challenging for the investigator. Clinical factors influencing leg mapping with nTMS have not been fully investigated yet. The aim of the study was to identify factors which influence the possibility of eliciting motor evoked potentials (MEPs) from the tibialis anterior muscle (TA). Patient records, imaging, nTMS examinations and tractography were retrospectively evaluated. 48 nTMS examinations were performed in 46 brain tumor patients. Reproducible MEPs were recorded in 20 patients (41.67%). Younger age (p = 0.044) and absence of perifocal edema (p = 0.035, Cramer's V = 0.34, OR = 0.22, 95% CI = 0.06-0.81) facilitated mapping the TA muscle. Leg motor deficit (p = 0.49, Cramer's V = 0.12, OR = 0.53, 95%CI = 0.12-2.36), tumor entity (p = 0.36, Cramer's V = 0.22), tumor location (p = 0.52, Cramer's V = 0.26) and stimulation intensity (p = 0.158) were no significant factors. The distance between the tumor and the pyramidal tract was higher (p = 0.005) in patients with successful mapping of the TA. The possibility to stimulate the leg motor area was associated with no postoperative aggravation of motor deficits in general (p = 0.005, Cramer's V = 0.45, OR = 0.63, 95%CI = 0.46-0.85) but could not serve as a specific predictor of postoperative lower extremity function. In conclusion, successful mapping of the TA muscle for neurosurgical planning is influenced by young patient age, absence of edema and greater distance to the CST, whereas tumor entity and stimulation intensity were non-significant.

Initial clinical experience with a novel mechanical thrombectomy device-the ThrombX retriever.

BACKGROUND AND PURPOSE: The ThrombX Retriever is a novel mechanical thrombectomy device that adjusts the distance between two mesh segments to axially hold thrombus. A post-market study assessed safety and performance in acute ischemic stroke patients with large artery occlusion. METHODS: A single-arm prospective multi-center study enrolled patients at 5 European Centers. Patients had a symptomatic large-artery occlusion of the intracranial Internal Carotid or the Middle Cerebral Artery, M1 segment. The primary outcome measure was the modified treatment in cerebral infarction (mTICI) score, on the immediate post-procedure angiogram after up to three device passes. Key secondary outcome measures were the mTICI score after a single pass and functional independence, defined as an mRS score ≤ 2 at 90 days. RESULTS: Thirty patients (16 Females, mean age 72 years), with NIHSS 4-25 (mean 15.5) were treated. Twenty-eight (93%) achieved mTICI 2b-3 within 3 passes, and 24 (80%) were with the first pass (FP). FP mTICI 2c-3 reperfusion was achieved in 19 (63%) cases. Seventeen of 24 (71%) patients treated with a balloon guide and the ThrombX Retriever had a FP mTICI 2c-3 reperfusion. After all interventions, mTICI 2b-3 was seen in 30 (100%) patients. Twenty-one of the 29 (73%) patients with 90-day follow-up were functionally independent (mRS≤2). No device-related serious adverse events were observed. CONCLUSION: This preliminary study suggests the ThrombX Retriever is safe and has a high rate of substantial reperfusion. A larger prospective trial to assess the device effectiveness is planned.

Trigeminal neuralgia due to neurovascular compression: high-spatial-resolution diffusion-tensor imaging reveals microstructural neural changes.

PURPOSE: To preoperatively detect, by using diffusion-tensor imaging coregistered with anatomic magnetic resonance (MR) imaging, suspected microstructural tissue changes of the trigeminal nerves in patients with trigeminal neuralgia (TN) resulting from neurovascular compression. MATERIALS AND METHODS: The study was approved by the institutional review board, and written informed consent was obtained from all patients. Twenty patients (mean age, 51.3 years) with TN and evidence of neurovascular contact were examined with use of a 3.0-T MR unit combined with an eight-channel head coil before undergoing surgical decompression. A single-shot diffusion-tensor echo-planar sequence was used along 15 different diffusion directions, with a b value of 1000 sec/mm(2) and a section thickness of 2 mm. For anatomic correlation, 0.6-mm isotropic three-dimensional fast imaging employing steady-state images were acquired for coregistration with the functional diffusion-tensor maps. After region of interest placement, mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated for each nerve by using the paired-sample two-tailed t test (with P < .005 indicating significance) and compared with surgical findings. RESULTS: FA was significantly lower (P = .004) on the trigeminal neuralgia-affected side (mean FA, 0.203) than on the contralateral side (mean FA, 0.239). ADCs were nearly identical between the normal and TN-affected nerve tissues. CONCLUSION: These findings suggest that diffusion-tensor imaging enables the identification and quantification of anisotropic changes between normal nerve tissue and TN-affected trigeminal nerves. Coregistration of anatomic three-dimensional fast imaging employing steady-state imaging and diffusion-tensor imaging facilitates excellent delineation of the cisternal segments of the trigeminal nerves.

Waffle-cone technique with Solitaire™ AB remodeling device: endovascular treatment of highly selected complex cerebral aneurysms.

INTRODUCTION: To evaluate patients with complex aneurysms who underwent waffle-cone stent-assisted coil embolization. METHODS: From February 2008 to February 2010, consecutive data were collected from 80 patients with aneurysms treated with the Solitaire™ AB Remodeling Device followed by a standard coiling procedure using bare or/and bioactive coils. Six of these patients were treated using the "waffle-cone-technique" placing the distal end of a stent directly into the base of a bifurcation aneurysm and coiling through the expanded and cone-shaped distal end of the stent allowing for preservation of parent artery patency. The aneurysms were located at the P3 segment of the posterior cerebral artery (n = 1), the middle cerebral artery bifurcation (n = 1), the basilar tip (n = 2), and the AComAnt (n = 2). Four patients underwent follow-up (2-7 months, mean 4.5 months). RESULTS: Waffle-cone positioning of the Solitaire™ AB Remodeling Device was obtained in all cases without technical problems. No permanent procedural morbidity was observed. In all patients, a Raymond class 2 occlusion was obtained and five patients left the hospital with a good clinical status (mRS0 n = 3, mRS1 n = 1) or no new neurologic deficits (mRS4 n = 1). One patient with SAH III died due to severe vasospasms. Due to major recanalization during follow-up, retreatment was necessary or is planned in four cases; one asymptomatic intimal hyperplasia was observed 8 weeks after initial treatment. CONCLUSION: The waffle-cone technique may enhance the possibilities of the endovascular treatment of these complex aneurysms. Due to the high rate of recanalization requiring endovascular retreatment, stringent angiographic and clinical follow-up is warranted.

Non-visualizable stent-occlusion after treatment of a fusiform PCA-aneurysm-a case report.

We report the case of a 17-year-old woman with extensive subarachnoidal hemorrhage due to a ruptured fusiform aneurysm of the right PCA (posterior cerebral artery). Endovascular treatment was successfully performed using a LVIS-EVO-Stent (Microvention Incorporation, Tustin, USA) as well as several coils. Short-term angiographic follow-up demonstrated extensive aneurysm progression and dilatation of the coil package, the stent could no longer be visualized and was not passable. Despite excellent distal vascular perfusion, a non-visible stent occlusion was suspected and subsequent occlusion of the patent artery was performed. We conclude that rapid progression of fusiform aneurysms after stent-assisted coiling may lead to expansion of the coil packages and non-assessability of the stent. Even with excellent distal perfusion, a stent-occlusion should be suspected in these cases. Therefore, we suggest short-term angiographic follow-up, especially after deploying multiple coil packages in fusiform aneurysms.

Therapeutic Potential of Selenium in Glioblastoma.

Little progress has been made in the long-term management of malignant brain tumors, leaving patients with glioblastoma, unfortunately, with a fatal prognosis. Glioblastoma remains the most aggressive primary brain cancer in adults. Similar to other cancers, glioblastoma undergoes a cellular metabolic reprogramming to form an oxidative tumor microenvironment, thereby fostering proliferation, angiogenesis and tumor cell survival. Latest investigations revealed that micronutrients, such as selenium, may have positive effects in glioblastoma treatment, providing promising chances regarding the current limitations in surgical treatment and radiochemotherapy outcomes. Selenium is an essential micronutrient with anti-oxidative and anti-cancer properties. There is additional evidence of Se deficiency in patients suffering from brain malignancies, which increases its importance as a therapeutic option for glioblastoma therapy. It is well known that selenium, through selenoproteins, modulates metabolic pathways and regulates redox homeostasis. Therefore, selenium impacts on the interaction in the tumor microenvironment between tumor cells, tumor-associated cells and immune cells. In this review we take a closer look at the current knowledge about the potential of selenium on glioblastoma, by focusing on brain edema, glioma-related angiogenesis, and cells in tumor microenvironment such as glioma-associated microglia/macrophages.