Frequency and predictors of endoleaks and long-term patency after covered stent placement for the treatment of intracranial aneurysms: a prospective, non-randomised multicentre experience.

OBJECTIVE: We investigated immediate/late endoleaks and long-term patency following stent-graft placement for treatment of intracranial aneurysms located within the distal internal carotid artery (ICA) or vertebral artery (VA). METHODS: Forty-five aneurysms in 41 patients receiving covered stents in three centres were followed. Outcome measures included aneurysm occlusion rate, endoleaks, late in-stent stenosis rate, clinical improvement, neurological deficiencies and death. RESULTS: Total aneurysm exclusion was achieved in 69.2% (n = 27), with 30.8% (n = 12) experiencing immediate residual endoleaks. Angiographic follow-up (mean 43.5 ± 14.3 months) revealed that 87.2% (n = 34) were completely occluded with only 12.8% (n = 5) showing residual endoleaks. Predictors of immediate endoleaks in our patient group were stent number (P = 0.023) and stent diameter (P = 0.022), while predictors of late endoleaks in our patient group were stent diameter (P = 0.035) and stent angulation (P = 0.021). Late in-stent stenosis rates were 18.0 ± 13.3 and 29.0 ± 18.5% compared with the period immediately following implantation at 2- and 6-year follow-ups respectively. Smoking (P = 0.017) and stent angulation (P = 0.020) were predictors of late in-stent stenosis. CONCLUSION: Treating intracranial aneurysms with Willis stent-grafts has an acceptable immediate and late occlusion rate and long-term stented artery patency rate.

[Long-term efficacies of sinus skeletonization plus abnormal venous reflux interruption in the treatment of parasinus dural arteriovenous fistula].

OBJECTIVE: To retrospectively explore the long-term efficacies of sinus skeletonization plus abnormal venous reflux interruption in the treatment of dural arteriovenous fistula interfering major dural sinus. METHODS: Among 15 consecutively treated patients, the lesions were located in superior sagittal sinus (n = 7), medial segment of transverse sinus (n = 3) and lateral transverse and sigmoid sinus (n = 5). And 40% of them clinically presented with intracranial hypertension and 13.3% with hemorrhage. Preoperatively, Gamma knife therapy and transarterial occlusion were used in 1 case each. All underwent sinus skeletonization plus abnormal venous reflux interruption if any. Interfered sinus was preserved in 12 cases. In another 3 cases, completely occluded segment of sinus was resected after skeletonization. RESULTS: Surgical mortality was none. At discharge, the symptoms were relieved or disappeared in 12 cases. Follow-up study was available in 11 cases over a mean period of 6 years. A Karnofsky performance status (KPS) score of 90 or more was achieved in 8 cases and a KPS score of 80, 60 or 40 was found in 1 case each. Digital subtract angiography was performed in 9 cases and computed tomographic angiography in 1 case after operation. Cure was achieved in 7 cases and 3 cases had minimal residue without recurrence. CONCLUSION: Sinus skeletonization may stably block most blood supply to fistula so as to offer cure or long-term control of dural arteriovenous fistula.

Comparative study of covered stent with coil embolization in the treatment of cranial internal carotid artery aneurysm: a nonrandomized prospective trial.

To evaluate whether Willis covered stent implantation yielded angiographic and clinical results were better than those with coil embolization. Eighty-nine patients with cranial internal carotid artery (CICA) aneurysms were treated nonrandomly with covered stents (n = 43, group A) or coil embolization (n = 46, group B). Data on the technical success, procedure time, initial and final angiographic results, and final clinical outcomes were collected and analyzed at >6 months post-procedure. Covered stent placement and coil embolization were successful in all patients, except for one patient in group A. The initial angiographic results showed complete occlusion in 34 group-A patients (80.9%; 95% CI: 69%, 93%) and 24 group-B patients (52.2%; 95% CI: 37%, 67%) (P = 0.004). The final angiographic results indicated complete occlusion in 39 group A patients (39/41, 95.1%; 95% CI: 88%, 102%) and 22 group B patients (48.9%; 95% CI: 34%, 64%) (P < 0.001). The average procedure time was shorter in group A than that in group B (P < 0.001). CICA aneurysm treatment with covered stents yielded better intermediate-term angiographic outcome than those with the recommended approach of coil embolization. (ClinicalTrials.gov number, NCT01029938).

[Relationship between characteristic geometry and risk of rupture in cerebral saccular aneurysm].

OBJECTIVE: To explore the relationship between the characteristic geometry and the risk of rupture in cerebral saccular aneurysm. METHODS: The clinical features of 473 cerebral saccular aneurysm patients with complete materials of cerebral angiography, 426 with ruptured aneurysm and 47 with unruptured aneurysm, were analyzed retrospectively. The relation of depth, neck width, and aspect ratio (AR) of aneurysms to the risk of rupture were analyzed. RESULTS: The mean depth, neck width, and the AR of the patients with ruptured aneurysm were (5.9+/-3.0) mm, (3.0+/-1.2) mm, and (2.1+/-0.9), all significantly lower than those of the unruptured aneurysm patients [(8.0+/-4.2) mm, (4.8+/-2.4) mm, and (1.7+/-0.6) respectively, all P<0.01]. CONCLUSION: AR is not correlated with the location of aneurysms, but reflects the geometrical and hemodynamic features of cerebral saccular aneurysms very well. High AR may be useful in predicting imminent aneurysmal rupture. But by now, no definitive AR level is accepted in discriminating between unruptured and ruptured aneurysms.

[Surgical treatment for the giant aneurysms of middle cerebral artery].

OBJECTIVE: To discuss the surgical treatment of the giant aneurysms of middle cerebral artery. METHODS: Clinical data, surgical methods and outcomes were analyzed in 17 giant aneurysms of middle cerebral artery treated from January 2001 to March 2008. CT scan, CTA, MRA, DSA and 3D-DSA were performed before operations so that we could comprehend the location, size, and shape of aneurysms and compensatory circulation of collateral branches to design the individualized treatment options. All patients had been surgically treated mostly by modified pterional approach, of which, direct clipping of the aneurysms was accomplished in 4 patients, aneurysms trapping or removal after trapping in 4, aneurysms excision or trapping combined with vessels reconstruction in 7, and aneurysms wrapping in 2 cases. RESULTS: CT and MRI revealed the shape and size of aneurysms clearly, while DSA and 3D-DSA could demonstrate the aneurysm's neck and relationship with the adjacent structure. Postoperative neurological function was evaluated according to Glasgow Outcome Scale when patients were discharged. Twelve patients had excellent neurological outcomes. However 4 patients were moderately disabled and one were severely disabled. No patient was dead postoperatively. CONCLUSIONS: It is necessary to perform elaborate imaging before operations for individualized surgical planning. The temporary occlusion of the parent artery and elimination of intra-aneurysmal thrombus are helpful to clipping the aneurysmal neck. Vessels reconstruction is a new and effective method of treating the giant aneurysms of middle cerebral artery.

Tentorial dural arteriovenous fistulas.

BACKGROUND: Tentorial dural arteriovenous fistula is uncommon but is a life-threatening lesion. We present our experience with 5 patients with TDAVFs, review the relevant literature, and present the rationale of our current management strategy. METHOD: The data of 5 patients with TDAVFs treated in Huashan Hospital, Shanghai, China, between June 2002 and May 2003 were reviewed retrospectively, including their illness history, neuroimaging, operation records, and follow-up data. RESULTS: There were 3 females and 2 males with ages from 25 to 52 years (average, 38 years). Clinical manifestations were acute SAH in 2 patients and progressive neurologic deficits in 3 patients. Magnetic resonance imaging and DSA were major diagnostic and follow-up modalities. All cases belonged to Borden classification type 3. A tentorial marginal type was present in 3 cases, a tentorial lateral type in 1 case, and a tentorial medial type in 1 case. Preoperative transarterial embolization was done in 3 patients. All patients underwent craniotomy with the coagulation of the fistulas and surrounding tentorial dura mater, and the disconnection of leptomeningeal venous drainage. The surgical approaches were via transanterior petrous approach in 3 cases, subtemporal intradural approach in 1 case, and unilateral occipital and transtentorial approach in 1 case. All patients had clinical improvement. There was no surgical mortality and morbidity. Postoperative DSA confirmed obliteration of TDAVFs in 3 cases; MRI demonstrated the thrombosis of venous aneurysm and disappearance of previous brainstem edema in 1 case, and partial thrombosis of venous aneurysm in another case. Follow-up study ranging from 2 to 3 years (average, 2.5 years) showed no recurrence, and all patients have resumed their normal activities. CONCLUSIONS: Tentorial dural arteriovenous fistulas are aggressive vascular lesions causing SAH and progressive neurologic deficits. Prompt diagnosis and definite treatment are mandatory. Obliteration of the fistulas and/or leptomeningeal venous drainage should be the goal of treatment. Microsurgical procedures with/without endovascular intervention are the best choice of treatment.

[Clinical experience of 70 cases of cerebral arteriovenous malformations embolization with Onyx, a novel liquid embolic agent].

OBJECTIVE: To report our clinical experience of using Onyx, a new liquid embolic agent, to treat cerebral arteriovenous malformations (AVMs) as well as its efficacy. METHODS: Seventy cases were placed with 6F sheath in the femoral artery after Seldinger puncture and 6F guiding catheter was introduced into the internal carotid artery or vertebral artery, then a microcatheter was navigated into the nidus of AVMs. Slow injection of Onyx under fluoroscopic control was performed to embolize cerebral AVMs using the "plug and push" technique. RESULTS: Thirteen AVM cases (18.6%) were totally occluded by Onyx and 5 cases of which didn't recurrence at 6-month after operation. Thirty-eight cases (54.3%) were subtotally occluded, while another 19 cases (27.1%) were partially embolized. Severe cerebral hemorrhage occurred in 4 cases, 2 of which had mild to severe hemiplegia after operation, and one died. Mild hemiplegia was also found in 1 case due to functional area embolization, and visual field deficit in 2 cases. CONCLUSIONS: Onyx has unique and distinctive superiority in treating cerebral AVMs. Nonetheless, the correct embolization technique should be learned to achieve good clinical results and avoid complications.

Risk factors for intracranial aneurysm in a Chinese ethnic population.

BACKGROUND: Intracranial aneurysm (IAN) is a protruding bubble or a sac on a brain artery that balloons out over time, which may lead to spontaneous subarachnoid hemorrhage (SAH), ultimately disability and mortality. Current research indicates that the disease is due to multiple causes, including environmental factors and various congenital abnormalities of blood vessels. Apart from congenital predisposition, various high-risk factors such as sex, age, hypertension, and atherosclerosis are involved in the formation of intracranial aneurysms. The aim of this study was to investigate the risk factors associated with the formation of sporadic intracranial aneurysms in Chinese Han ethnic patients. METHODS: A total of 251 patients with intracranial aneurysm and 338 patients with other cerebral diseases (control group) were enrolled in this study. Single factor and logistic regression model were used to analyze the association of intracranial aneurysms with age; sex; cigarette smoking; alcohol or cocaine consumption; history of hypertension, coronary artery disease, diabetes mellitus and inherited connective tissue disease; and the levels of fasting blood glucose and blood fat. The data expressed as mean +/- standard deviation were processed with the statistical software SPSS13. Quantitative and qualitative data were analyzed by the independent-sample t test, and the chi-square test respectively. Logistic regression method was used to analyze the multiple factors. RESULTS: In the 251 patients, 163 (64.94%) were at age of 40 to 60 years. Sex (OR, 1.41; 95% CI, 1.01 - 1.96), cigarette smoking (OR, 1.81; 95% CI, 1.06 - 3.10), hypertension (OR, 2.32; 95% CI, 1.30 - 4.16) and fasting blood glucose were significantly associated with intracranial aneurysm (P < 0.05). Intracranial aneurysm was correlated with alcohol consumption, coronary artery disease, and the level of blood lipids (P > 0.05). Using logistic regression analysis, we identified female sex and advanced age as significant risk factors for sporadic intracranial aneurysms. CONCLUSIONS: Sporadic intracranial aneurysms mostly occur in people aged 40 to 60 years. Feminine, cigarette smoking, and hypertension are independent risk factors for the disease, and the gender is the most significant factor. Advanced age can increase the effect of these risk factors.

[Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm].

OBJECTIVE: To evaluate clinical strategy and effect of early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm. METHODS: Seventy-five patients presenting with anterior circulating aneurysmal subarachnoid hemorrhage (SAH) underwent early-mid-phase (within 3 days or 3-10 days) microsurgical clipping at Huashan Hospital between January 2001 and August 2004. Glasgow outcome scale (GOS) was conducted to evaluate patients' outcomes. RESULTS: Of 81 intracranial aneurysms, 77 lesions were clipped successfully, and 4 were wrapped. Good outcome was achieved in 53 cases, mild disability in 9 cases, severe disability in 7 cases, persistent vegetative state in 3 cases, and 3 patients (4%) died after surgery. The difference of GOS was statistically significant between patients in Hunt and Hess Grade I-III and Grade IV-V. However, there was no significant difference between early surgery and metaphase surgery. CONCLUSIONS: Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm is considered the feasible opinion.

Extraventricular neurocytoma of the sellar region: case report and literature review.

INTRODUCTION: The extraventricular neurocytoma of the sellar region (EVNSR) is a rare disease, it is difficult to make exact diagnosis of and operate on patients. Retrospectively analysed the clinical manifestations, image features, therapy methods and outcomes among patients with EVNSR, to investigate the epidemiological characteristics, image features, diagnosis, treatment and prognosis. CASE DESCRIPTION: A 25-year-old man man with 7-month worsening vision of left eye, was confirmed EVNSR after subtotally resection from the neurosurgical department of Deji hospital. DISCUSSION AND EVALUATION: Nine cases of EVNSR were reported from this article and elsewhere. Ages of these patients were ranging from 25 to 66 (with an average of 45.67). The male-female ratio was 1-2. All EVNSR patients had visual damage. Images showed the tumors were in the sellar and suprasellar regions. Preoperatively, all patients were misdiagnosed as other diseases: such as pituitary tumor, craniopharyngioma, and meningioma. For tumor removal treatment, five patients received transpterional approach, one received subfrontal approach and three received transnostril-transsphenoidal approach. EVNSR was confirmed by pathological tests. The tumor was completely removed in one patient. During the 12-24 month postoperative follow up period, the recurrence or metastasis of the tumor was found in two patients. CONCLUSIONS: EVNSR is a rare disease. It occurs mostly in middle-aged women. EVNSR is likely to be misdiagnosed as pituitary adenoma preoperatively. The histological examination would help confirm the diagnosis. Using transpterional approach to remove tumor will help the prognosis, especially among patients with normal pituitary function. Both postoperative radiotherapy and long-term follow-up are recommended.

[Application and reliability of balloon occlusion test in treatment of cerebrovascular diseases].

OBJECTIVE: To study the reliability of applying balloon occlusion test (BOT) to evaluate the compensation capacity of cerebral collateral circulation, and investigate the validity of different criterion about BOT and techniques to improve the security of BOT. METHODS: A retrospective analysis was conducted on the results of 86 patients, 39 males and 47 females, aged 49.8 (13 - 72), 67 suffering from intracranial aneurysm and 19 from traumatic carotid cavernous fistula, who received BOT, and on the results of 38 of the 66 patients who accepted artery occlusion after the BOT. RESULTS: The positive rate of diagnosis was 10.47% and the negative rate was 89.53% by conventional BOT; whereas the positive rate of diagnosis was 36.05% and the negative rate was 63.95% with combined cross circulation and conventional test. The brain ischemia rate after cerebral artery occlusion therapy was 8.33%. The BOT-related complication rate was 3.49%. CONCLUSION: (1) The current BOT technique can basically provide reliable results. (2) The cross circulation test and hypotensive provocative test can effectively improve the specificity of BOT. (3) More perfect BOT criterion for the prediction of cerebral tolerance is still to be worked out. Combination of the conventional method and advanced imaging technique and search for an objective and quantificational criterion would be of reward.

[Cerebral revascularization in treatment of intractable aneurysms].

OBJECTIVE: To evaluate the effectiveness of cerebral revascularization in the treatment of intractable aneurysms and to discuss the indications, surgical techniques, and the outcome of the revascularization. METHODS: During the recent 4-year period, 9 radical artery grafts were performed in patients with intractable or giant internal carotid artery (ICA) aneurysms. The indications for cerebral revascularization included parent vessel occlusion during the treatment of the intractable aneurysms with poor collateral circulation or the young patients. Modified techniques were taken to use the main trunk of superficial temporal artery (STA) as donor, while M3 branches near the bifurcation of the M2 segment of the middle cerebral artery (MCA) were chosen as the recipient arteries. STA-Radial artery (RA)-MCA bypass was followed by parent vessel occlusion via chronic cervical ICA ligation or balloon occlusion. RESULTS: Postoperative angiography demonstrated the patency of the grafts in eight cases. The procedure of the parent vessels occlusion was uneventful in these patients. Follow-up showed the patients were in excellent conditions after successful treatment of aneurysms. Significantly delayed filling of the graft was revealed in one patient, who could not tolerate balloon occlusion test and occlusion of parent artery failed. CONCLUSIONS: Extracranial-to-intracranial bypass followed by parent vessel occlusion is a safe and effective method to treat intractable ICA aneurysms. Radical artery as graft can offer high-flow revascularization with less complications. Combined surgical and endovascular treatment might be the future direction for the treatment of the difficult aneurysms.

[Diagnosis and treatment of tentorial dural arteriovenous fistulae].

OBJECTIVE: Tentorial dural arteriovenous fistulae are uncommon but life-threatened lesions. We present our experience of 5 cases with tentorial dural arteriovenous fistulae, review the relevant literature and present the rationale of our current management strategy. METHODS: The data of five patients with tentorial DAVF treated in Huashan Hospital between June 2002 and May 2003 were reviewed retrospectively, including their ill history, neuroimagings, operation records and follow-up data. RESULTS: There were 3 females and 2 males with age from 25 to 52 years (average, 42.6 years). Clinical manifestations were acute subarachnoid hemorrhage in 2 cases, progressing neurological deficits in 3 cases. MRI and DSA were major diagnostic and follow-up modalities. Borden classification type II was in 1 case, type III in 4 cases. According to DAVF location, tentorial marginal type were in 3 cases, tentorial lateral type 1 case, tentorial medial type 1 case. Two patients had transarterial embolization preoperatively. All patients underwent craniotomy with the coagulation of the nidus and tentorium, disconnection of leptomeningeal venous drainage. The surgical approaches were via trans-anterior-petrous approach in 3 cases, transpterional subdural approach 1 case, transoccipital and transtentorial approach 1 case. All patients had clinical improvement, there was no surgical mortality and morbidity. Postoperative DSA confirmed obliteration of DAVF in 3 cases, MRI demonstrated the thrombosis of venous aneurysm and the disappearance of previous brainstem edema, partial thrombosis of venous aneurysm in 1 case. Follow-up study ranging from 1 to 2 year showed no recurrence and all patients resume their full activities. CONCLUSIONS: Tentorial DAVF is an aggressive vascular lesion, causing subarachnoid hemorrhage and progressive neurological deficits. Prompt diagnosis and definite treatment for tentorial DAVF are mandatory. Obliteration of the nidus and/or leptomeningeal venous drainage should be the goal of treatment. Microsurgical procedures with/without endovascular intervention are the best choice of treatment.

[Embolization of intracranial aneurysms with new mechanically detachable coils].

OBJECTIVE: To primarily embolize intracranial aneurysms with new-developed mechanically detachable coils, which is called Detachable Coil System (DCS). METHODS: Five intracranial aneurysms were embolized with DCS, in which 2 were giant aneurysms. DCS with J coils were initially used to make baskets in giant aneurysms, and then other kinds of coils were utilized to pact the aneurysmal cavity. Whereas, spiral coils were mostly used in smaller aneurysms. Coils of DCS were detached by rotating the delivering wire after the coils were satisfactorily positioned in aneurysms. RESULTS: Two of the 5 cases were totally occluded with DCS. Two was sub-totally embolized. Pushing, withdrawal, and adjusting of DCS were safe and efficient. Detachment of DCS was fast. In one case of wide-necked giant aneurysm, coils could not stay inside the aneurysm, which was treated by occlusion of the parent artery. CONCLUSIONS: DCS is a new addition to the interventional radiologist's armamentarium. Detachment is faster. J coils are suitable for giant aneurysms for its unique way of coiling. But more evaluation depends on accumulation of the clinical usage.

Gradual and controlled decompression for brain swelling due to severe head injury.

Patients suffering from uncontrollable intracranial hypertension due to posttraumatic brain swelling (BS) generally either die or survive in an extremely disabled state. Decompressive craniectomy (DC) with dural augmentation may be the best method to assist these patients. However, the efficacy of DC on functional outcomes remains controversial. One of the factors contributing to poor outcomes could be intraoperative brain extrusion, which is an acute potential complication of DC. The authors have adopted a new surgical technique for traumatic BS that can prevent and control massive intraoperative BS (IOS). In the past 3 years, the authors have used a unique technique, called "gradual and controlled decompression", in the treatment of posttraumatic BS. This procedure consists of creating numerous small dural openings and removing clots; enlarging fenestration in the frontal and temporal basal regions to detect and treat brain contusion; making U-shaped, discontinuous, small dural incisions around the circumference of the craniotomy; and performing an augmentation duraplasty through the discontinuous small opening with dural prosthetic substances. This technique has been employed in 23 patients suffering from posttraumatic BS. In all cases, IOS was prevented and controlled through gradual stepwise decompression, and expanded duraplasty was performed successfully. This new surgical approach for posttraumatic BS can prevent severe extrusion of the brain through the craniotomy defect and allows the gradual and gentle release of the subdural space. Further clinical studies should be conducted to estimate the impact of this new technique on morbidity and mortality rates.

Superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis in treating moyamoya disease: surgical techniques, indications and midterm follow-up results.

BACKGROUND: Surgical interventions for moyamoya disease include direct and indirect revascularizations. This study aimed to evaluate the therapeutic effect of superficial temporal artery-middle cerebral artery bypass combined with an indirect revascularization procedure, encephalo-duro-myo-synangiosis, in the treatment of moyamoya disease. METHODS: From October 2005 to November 2009, we performed this combined revascularization procedure in 111 patients with different types and stages of moyamoya disease. The superficial temporal artery, middle meningeal artery and the deep temporal artery were evaluated for individualized surgical planning in these cases. The integrity of the deep temporal artery and the middle meningeal artery network, and the pre-existing spontaneous anastomoses of the distal branches of the external carotid artery with the cortical arteries were well preserved. The mean follow-up time was 72.5 months, all clinical and radiological data were retrospectively reviewed. RESULTS: A total of 198 stomas were performed in 122 hemispheres, all remaining patent until the last follow-up. The encephalo-duro-myo-synangiosis resulted in extensive anastomoses of the deep temporal artery (100%), the middle meningeal artery (90.9%), and the sphenopalatine artery (39.8%) with the cortical arteries, respectively. The superficial temporal artery, deep temporal artery, and the middle meningeal artery were significantly thickened in 88 patients as determined by digital subtraction angiography at follow-up. The relative cerebral blood flow increased significantly within one week after the operation. At 6 months post the operation, the relative cerebral blood flow was further increased by 15.5% from the gradual formation of anastomoses as a result of indirect revascularization. Transient ischemic attacks were effectively reduced or totally arrested. The neurological deficits significantly improved in 37 patients, with the National Institutes of Health Stroke Scale scores lowered by 2-8. There was no rehemorrhage in hemorrhagic moyamoya disease patients. CONCLUSION: This study showed that the superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis can achieve good therapeutic effect in the treatment of moyamoya disease.

Treatment strategies for complex internal carotid artery (ICA) aneurysms: direct ICA sacrifice or combined with extracranial-to-intracranial bypass.

OBJECTIVE: Direct surgery for complex internal carotid artery (ICA) aneurysms can be difficult. In certain situations, sacrificing the parent artery is a unique way to obliterate the aneurysm and extracranial-to-intracranial (EC-IC) bypass is indispensable to prevent postoperative cerebral ischemia. This article discusses the indications for direct ICA occlusion, and the strategies, techniques, and outcomes in a series of patients treated for complex ICA aneurysms in a single institution. METHODS: During a 7-year period, 49 patients with complex ICA aneurysms underwent direct ICA sacrifice, or ICA sacrifice combined with EC-IC bypass. The appropriate type of bypass was determined by the results of balloon occlusion test and computed tomographic perfusion. The technique of ICA sacrifice used was selected based on the evaluation of retrograde filling of the aneurysm during balloon occlusion test. RESULTS: Ten patients underwent direct ICA sacrifice and no ischemia-related complications were evident during the 5-12 months of follow-up. A total of 39 patients were treated by ICA sacrifice combined with EC-IC bypass, including 21 cases of superficial temporal artery-radial artery-middle cerebral artery and 18 cases of external carotid artery-radial artery-middle cerebral artery. ICA sacrifice was achieved in 38 patients by using prolonged occlusion (25 cases) or acute occlusion (13 cases). Five patients presented with minor ischemia after surgery, but four patients recovered completely. Two patients developed brain swelling postoperatively and one developed intracranial hemorrhage, which required evacuation of the hematoma. CONCLUSION: Balloon occlusion test combined with computed tomographic perfusion can be an efficient way to evaluate the compromised cerebrovascular reserve in patients with complex ICA aneurysms after ICA occlusion. In conjunction with EC-IC bypass, ICA proximal occlusion or trapping can be an effective treatment strategy.

Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature.

Dural arteriovenous fistula of the sphenobasilar sinus is a true but rare lesion that connects the meningeal arteries from both the external and internal carotid arteries to the superficial middle cerebral vein (SMCV) and dural sinus. It must be distinguished from other dural arteriovenous fistulas (DAVFs) of the middle cranial fossa, such as cavernous DAVFs and sphenoparietal sinus DAVF, because of differences in the treatment and outcome between these DAVFs. Two patients with sphenobasilar sinus DAVFs reported in the literature have been identified, but they did not simultaneously harbor intracranial meningiomas. To the best of the authors' knowledge, the patient described here is the first case that concomitantly harbors a sphenobasilar sinus DAVF and intracranial meningioma. A 42-year-old man presented with acute subarachnoid hemorrhage. Angiography demonstrated a DAVF of the sphenobasilar sinus with a giant venous aneurysm of the SMCV. After transarterial embolization, the fistula was successfully obliterated and the giant venous aneurysm was resected microsurgically. A fortuitous small meningioma at the anterior clinoid was found and removed during the operation. The patient recovered excellently and resumed his normal activities. The relevant literature is reviewed and discussed.