[Preoperative Embolization of Intracranial Meningioma].

Preoperative embolization(POE)of intracranial meningioma is performed worldwide. Although clear evidence of the effectiveness of POE has not been reported in the literature, the technique plays an important role in open surgery, especially for large or skull base meningiomas. The purposes of embolization include: 1)induction of tumor necrosis, resulting in a safer operation, 2)reduction in intraoperative bleeding, and 3)decrease in operative time. Knowledge of the functional vascular anatomy, embolic materials, and endovascular techniques is paramount to ensure safe embolization. Our standard procedure is as follows: 1)embolization is performed several days before open surgery; 2)in cases with strong peritumoral edema, steroid administration or embolization may be performed immediately prior to surgery; 3)patients undergo the procedure under local anesthesia; 4)the microcatheter is inserted as close as possible to the tumor; 5)particulate emboli are the first-line material; 6)embolization is occasionally performed with N-butyl cyanoacrylate(NBCA)glue; and 7)if possible, additional proximal feeder occlusion with coils is performed. The JR-NET study previous showed the situation regarding intracranial tumor embolization in Japan. Endovascular neurosurgeons should fully discuss the indications and strategies for POE with tumor neurosurgeons to ensure safe and effective procedures.

Endovascular Treatment for Intracranial Artery Dissections in Posterior Circulation.

Intracranial artery dissections (IADs), although uncommon, are an important cause of cerebral infarction and subarachnoid hemorrhage (SAH). Some IADs can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis. Meanwhile, others can progress to stroke that requires treatment. The incidence of IAD in the posterior circulation is higher than that in the anterior circulation. Anterior circulation dissections are more likely to develop into ischemia and posterior circulation lesions into hemorrhage. The mortality rate after IAD among patients with SAH is 19%-83%. Further, the mortality rate of IAD without SAH is 0%-3%. Patients with SAH commonly undergo surgery or receive neuroendovascular treatment (EVT) to prevent rebleeding. However, the treatment of IADs is empirical in the absence of data from randomized controlled trials. Recently, EVT has emerged and is considered for IADs because of its less invasiveness and perceived low rates of procedure-related morbidity with good efficacy. EVT strategies can be classified into deconstructive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow via the parent vessel) techniques. In particular, the number of reports on reconstructive techniques is increasing. However, a reconstructive technique for ruptured IADs has not yet been established. This review aimed to provide an overview of IADs in the posterior circulation managed with EVT by performing a literature search.

A Child with Paradoxical Cerebral Embolism in Whom Mechanical Thrombectomy Led to a Favorable Outcome.

Objective: We report a case of paradoxical cerebral embolism caused by patent foramen ovale (PFO) that was treated by the direct aspiration first pass technique (ADAPT). Case Presentation: The case involved a 12-year-old boy who had symptoms of dizziness and vomiting the day prior to being admitted to the emergency department. The following morning, consciousness disorder, dysarthria, and right paresis were observed, and he was transferred to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) lead to the diagnosis of acute cerebral infarction due to basilar artery (BA) occlusion. Mechanical thrombectomy was performed, and Thrombolysis in Cerebral Infarction (TICI) 3 was obtained. Postoperatively, his consciousness was improved, but echocardiography revealed PFO. Percutaneous PFO closure was performed at our department of pediatric cardiology. Conclusion: For our patient with paradoxical cerebral embolism of the BA caused by PFO more than 6 hours after onset, mechanical thrombectomy with ADAPT using a Penumbra 5MAX ACE68 resulted in a good outcome.