Intermediate catheter use is associated with complete occlusion and dense packing in coil embolization of unruptured cerebral aneurysms: a propensity score matched study.

BACKGROUND: An intermediate catheter (IMC) can improve the maneuverability and stability of the microcatheter. OBJECTIVE: To investigate the efficacy and safety of using an IMC in triaxial systems for coil embolization of unruptured cerebral aneurysms (UCAs). METHODS: A total of 2430 consecutive saccular UCAs (2259 patients) that underwent initial coil embolization at three institutions between November 2003 and May 2023 were retrospectively reviewed. Patients were classified into two groups: with IMC (IMC(+)) and without IMC (IMC(-)). To investigate whether IMC use increased the rate of complete occlusion and the packing density, a propensity score-matched analysis was used to control for clinical, anatomical, and procedural features. RESULTS: Ultimately, 595 (24.5%) coil embolization used an IMC. Propensity score matching was successful for 424 paired IMC(+) and IMC(-) aneurysms. Compared with the IMC(-) group, the IMC(+) group had significantly higher rate of Raymond-Roy Occlusion Classification class 1 immediately after treatment (30.0% vs 20.8%, P=0.003) and at 6 months (28.8% vs 20.0%, P=0.004) and a higher volume embolization ratio (27.2% (SD 6.5%) vs 25.9% (SD 6.2%), P=0.003). Re-treatment rates were not significantly different between the two groups (0.7% vs 0.2%, P=0.624). No significant differences in the incidences of ischemic and hemorrhagic complications and IMC-related parent artery dissection were found between the two groups. CONCLUSION: Use of IMCs in triaxial systems can provide effective and safe support in coil embolization of UCAs because complete occlusion and dense coil packing can be achieved without increased complications.

CyberKnife Radiosurgery for Spinal Intramedullary Arteriovenous Malformations: A Single-Center Experience.

BACKGROUND: Intramedullary spinal arteriovenous malformation (ISAVM, glomus type) is a type of spinal cord arteriovenous malformation, which is a rare disease known often to have a complex vascular supply interfering with that of the spinal cord, and is in complex anatomical relations with cord structures and nerve roots. Though microsurgical and endovascular treatment has mainly been the standard options, in high-risk cases with these treatments, stereotactic radiotherapy (SRT) might be the option of choice. METHODS: We retrospectively reviewed 10 consecutive patients with ISAVM who received SRT using CyberKnife at the Japanese Red Cross Medical Center (Tokyo, Japan) from January 2011 to March 2022. RESULTS: No case in this series suffered from hemorrhage after applying SRT. One case experienced neurological impairment 10 years after SRT, which we attributed to venous congestion due to the remaining lesion. No case of radiation myelopathy was observed in this series. In one case, the nidus volume reduction and loss of flow voids were obvious, though improvement in the neurological outcome was not apparent. No radiological changes were observed in the other 9 patients. CONCLUSIONS: Even in lesions without radiological changes, no hemorrhagic events were observed for an average period of 4 years. SRT may be a feasible option in treating ISAVM, especially for lesions in which microsurgical resection and endovascular treatment are inapplicable. To ascertain the safety and efficacy of this approach, further studies with more patients and longer follow-up is required.

Risk factors for recanalization of dense coil packing for unruptured cerebral aneurysms in endovascular coil embolization: Analysis of a single center's experience.

In coil embolization of cerebral aneurysms, inadequate packing is known to increase the probability of recanalization. Even tightly embolized aneurysms may be recanalized, but predictive factors for recanalization have not been fully investigated. This retrospective study aimed to identify risk factors for recanalization of treated aneurysms with a volume embolization ratio (VER) ≥ 25%. A total of 301 unruptured aneurysms in 248 patients who underwent coil embolization between March 2012 and January 2021 were analyzed. Cases involving dissecting aneurysm, intraluminal thrombosis, parent artery occlusion, intraoperative rupture, re-treatment, rupture the day after surgery, postoperative coil migration, and postoperative parent artery occlusion were excluded due to the inaccuracy of VER. A total of 105 aneurysms (34.9%) treated with VER ≥ 25% were extracted. Clinical features (age, sex, medical history, family history), anatomical features (shape, location, aneurysm size, inflow angle, and volume), procedural features (stent-assisted, Raymond-Roy occlusion classification [RROC] immediately after treatment, re-treatment rate), and follow-up period were compared between Recanalization and Non-recanalization groups. Predictors of recanalization were determined using logistic regression and receiver operating characteristic (ROC) curve analyses. Eleven aneurysms were recanalized. In multivariate analysis, RROC class 3 (odds ratio [OR] 11.0; 95% confidence interval [CI] 2.03-59.4) and aneurysm volume (OR 1.005; 95%CI 1.001-1.008) were independent predictors of recanalization. ROC curve analysis showed optimal cutoff values for aneurysm volume of 69.5 mm3 (sensitivity, 81.8%; specificity, 72.3%). In coil embolization of unruptured aneurysms that VER ≥ 25%, cases with RROC class 3 or high aneurysm volume may be associated with a higher risk of recanalization, and should be carefully followed-up.

Refractory De Novo Multiple Cerebral Aneurysms After Radiotherapy and Multistaged "Open" Surgical Treatment for Low-Grade Glioma During Long-Term Follow-Up: A Case Report and Review of the Literature.

BACKGROUND: Radiation-induced aneurysms have been previously reported; however, multiple and repeated de novo aneurysm formation chronologically and anatomically during long-term follow-up have not yet been observed. The pathogenesis of persistent radiation-induced vasculopathy is not fully understood. CASE DESCRIPTION: A 31-year-old woman presented with intraventricular hemorrhage due to rupture of a right internal carotid artery (ICA) aneurysm that developed 17 years after surgical resection of a low-grade glioma in the right frontal lobe and postoperative radiotherapy (focal, 50 Gy/25 fractions). During glioma follow-up, salvage surgery with adjuvant gamma knife therapy and chemotherapy (ranimustine, vincristine, temozolomide) were performed for recurrence of the glioma. The aneurysm was treated with endovascular coil embolization. However, she experienced repeated intraventricular hemorrhages, and angiography revealed a de novo ICA aneurysm. The de novo aneurysms were treated with endovascular surgery using coil embolization and stenting. At 2 years after the third hemorrhage, the surgical wound became dehiscent, probably due to wound infection, thus epicranial soft tissue reconstruction using vascularized skin flap was performed. Despite multistaged endovascular surgery for the ICA aneurysm, she experienced repeated subarachnoid and intraventricular hemorrhages. Angiography revealed a de novo aneurysm of the right posterior cerebral artery and basilar trunk. She underwent coil embolization and stenting. Despite active management with endovascular surgery and close follow-up, she died after an eighth consecutive intraventricular and intracerebral hemorrhage caused by a de novo large aneurysm of the posterior cerebral artery. CONCLUSIONS: To the best of our knowledge, the present study is the first to report on of refractory and recurring de novo aneurysms treated by multistaged endovascular surgery during a long-term follow-up after radiotherapy and multistaged craniotomy for glioma.

[Outcome of Coil Embolization for Subarachnoid Hemorrhage Accompanied with Intracerebral Hematoma].

OBJECT: Aneurysmal subarachnoid hemorrhage(SAH)associated with intracerebral hematoma(ICH)typically has a poor outcome. SAH with ICH tends to have a worse prognosis than SAH alone. The aim of the present study was to evaluate whether coil embolization during endovascular surgery with ventricle drainage and without ICH evacuation is an appropriate treatment. METHODS: A retrospective review was conducted between March 2012 and May 2015. Thirteen patients with SAH with ICH who underwent coil embolization were retrospectively analyzed. Modified Rankin Scale(mRS)scores were compared for postoperative clinical outcomes of different hematoma locations. RESULTS: All ruptured aneurysms in the present series of patients were treated using endovascular surgery. Six patients underwent additional ventricle drainage. Only one patient underwent craniotomy for evacuation of the hematoma following coil embolization. Despite ten out of thirteen patients(76.9%)having a preoperative SAH clinical grade, as evaluated using the World Federation of Neurosurgical Societies grading system of IV or V, six(46.2%)patients had a favorable outcome(mRS=0-2). CONCLUSIONS: Coil embolization for ruptured aneurysms, especially those located in the frontal lobe, with ICH and without cerebral herniation may be a feasible alternative and less invasive treatment.

Slow progression of calcified cerebellar metastasis from ovarian cancer: a case report and review of the literature.

The report describes a rare case of a patient with a calcified cerebellar metastasis arising from a primary ovarian cancer. The patient was a 33-year-old woman with a long history of stage IIIc ovarian cancer who had undergone transabdominal hysterectomy and bilateral oophorectomy followed by chemotherapy with gemcitabine hydrochloride. Incidentally, computed tomography (CT) revealed a cerebellar tumor with calcification. The size of the tumor gradually increased, and lateral suboccipital craniotomy was performed for gross total removal of the tumor. The histological diagnosis was ovarian mucinous adenocarcinoma. The patient's postoperative course was uneventful, and she was discharged two days after surgery. Brain metastases from ovarian cancer are rare. In the review of metastatic brain tumors arising from a primary ovarian cancer in the Department of Obstetrics and Gynecology at our institution, this phenomenon was noted in only 10 cases (0.24%) of 4,158 patients with ovarian cancer seen at our center over a period of 8 years. Moreover, only three cases of calcified metastatic brain tumor have been reported previously. In conclusion, complete tumor resection may be an acceptable approach for patients with calcified metastatic tumors both for therapeutic considerations and to obtain tissue for confirmation of histopathological diagnosis. Metastatic brain tumors can be calcified, and should be considered within the differential diagnosis of calcified intracranial lesions to avoid any delay in diagnosis or treatment.

Combined surgical and endovascular treatment of complex cerebrovascular diseases in the hybrid operating room.

BACKGROUND: Although most neurovascular diseases can be treated either by microsurgical or endovascular means, a subset of patients may require a combined approach. Patient transfer from the operating room (OR) to the angiosuite has been a fundamental drawback of this type of approach. OBJECTIVE: The purpose of this study is to report our clinical experience performing combined surgical and endovascular procedures for neurovascular diseases in the hybrid OR. METHODS: 29 patients with neurovascular diseases underwent combined endovascular and surgical procedures in a single session: 16 were scheduled combined treatment and 13 were emergency combined procedures. Of the emergency cases, three were rescue surgeries after endovascular complications. Three patients had ruptured intracranial aneurysms, eight had unruptured intracranial aneurysms, eight had arteriovenous malformations and eight had arteriovenous fistulae; two patients had either a spinal tumor or dural arteriovenous fistulae. RESULTS: All combined procedures were performed in a single session without changing the patient's surgical position. In cases of ruptured arteriovenous malformations or aneurysms with hematoma, an emergency embolization was performed to assist the surgical procedure. Combined superficial temporal artery-middle cerebral artery (STA-MCA) bypass followed by endovascular parent artery trapping were successfully performed for complex large or giant aneurysms. There were two periprocedural ischemic complications. Of the three patients who underwent surgical rescue after endovascular complications, two remained intact and one died despite immediate surgical procedures. CONCLUSION: A combined endovascular and surgical approach conducted in a hybrid OR provides a new strategy for the treatment of complex neurovascular diseases.

Robotic digital subtraction angiography systems within the hybrid operating room.

BACKGROUND: Fully equipped high-end digital subtraction angiography (DSA) within the operating room (OR) environment has emerged as a new trend in the fields of neurosurgery and vascular surgery. OBJECTIVE: To describe initial clinical experience with a robotic DSA system in the hybrid OR. METHODS: A newly designed robotic DSA system (Artis zeego; Siemens AG, Forchheim, Germany) was installed in the hybrid OR. The system consists of a multiaxis robotic C arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as an intraoperative imaging tool for various neurosurgical procedures such as aneurysm clipping and spine instrumentation. RESULTS: Five hundred one neurosurgical procedures were successfully conducted in the hybrid OR with the robotic DSA. During surgical procedures such as aneurysm clipping and arteriovenous fistula treatment, intraoperative 2-/3-dimensional angiography and C-arm-based computed tomographic images (DynaCT) were easily performed without moving the OR table. Newly developed virtual navigation software (syngo iGuide; Siemens AG) can be used in frameless navigation and in access to deep-seated intracranial lesions or needle placement. CONCLUSION: This newly developed robotic DSA system provides safe and precise treatment in the fields of endovascular treatment and neurosurgery.

New thermoreversible liquid embolic agent for embolotherapy: technical report.

INTRODUCTION: To evaluate potential feasibility of new liquid embolic agent, thermoreversible gelation polymer (TGP), for embolotherapy. METHODS: TGP is a liquid polymer that was originally developed as a cell culture medium for tissue engineering. TGP becomes liquid at temperatures lower than the sol-gel transition temperature (TT) and becomes a gel at temperatures higher than the TT. The TT can be adjusted from 10 degrees C to 40 degrees C, allowing gelation at body temperature without solvent. The renal arteries in six swine were embolized with TGP. Angiographic evaluations were obtained 0, 3 h, and 14 days after embolization. The animals were sacrificed at day 14 after angiogram. RESULTS: All renal arteries were successfully embolized with TGP using cooling catheter. No acute and chronic clinical complication was observed. Follow-up angiogram demonstrated complete or near complete occlusion of renal arteries. No untoward inflammatory response was observed in acute and chronic specimen. CONCLUSION: This embolic material has potential feasibility to be used in the treatment of cerebral arteriovenous malformations, aneurysms, or hyper vascular tumors.

Dynact soft-tissue visualization using an angiographic C-arm system: initial clinical experience in the operating room.

INTRODUCTION: DynaCT is a clinical application protocol to create computed tomographic (CT)-like images allowing soft-tissue visualization acquired from an angiography system. A cone beam three-dimensional CT reconstruction is produced from the acquisition of two-dimensional projection images by rotating the c-arm with x-ray source and image receptor around the patient. The purpose of this study is to evaluate the clinical efficacy of DynaCT in the operating room. METHODS: DynaCT was performed in 100 patients undergoing cerebral or spinal interventional procedures in the new-concept operating room. Specially designed AXIOM Artis BA (conventional image intensifier system; 55 patients; Siemens Medical Solutions, Erlangen, Germany) and AXIOM Artis dBA (flat-panel detector; 45 patients; Siemens Medical Solutions) biplane neuroangiographic systems (Siemens Medical Solutions, Germany) were installed in the operating room. The volumetric data set from the AXIOM Artis systems were reconstructed immediately on the three-dimensional workstation in the operating room. We compared DynaCT images with the use of multidetector computed tomography. RESULTS: DynaCT was performed successfully in all patients. High-contrast structures, such as bone, calcified lesions, and metallic materials, were visualized on DynaCT as well as in multidetector computed tomography for each group. Although contrast differentiation of soft tissue such as cerebral cortex, muscle, and hematoma on DynaCT were inferior to multidetector CT scans, the images were sufficiently used as intraoperative CT-like images. However, DynaCT images acquired from flat panel detector-based systems were found to be superior to those images acquired from image intensifier-based systems. Striking ring artifacts were exhibited and resulted in major limitations in the image intensifier group. CONCLUSION: DynaCT has the potential to be used as a powerful tool for endovascular and neurosurgical procedures and will open new possibilities for neurosurgical management.

Endovascular operating suite: future directions for treating neurovascular disease.

OBJECT: The purpose of this study was to evaluate initial experiences in a surgical operating room (OR) with a multipurpose angiography unit, which offers integrated neurosurgical and radiological capabilities. METHODS: A specially designed biplane digital subtraction (DS) angiography system was installed in the neurosurgery OR. The new suite, which allows three-dimensional DS angiography with C-arm for computerized tomography and microsurgery capabilities, allows the neurosurgeon to perform a wide range of neurosurgical and endovascular procedures. Three hundred thirty-two procedures were performed in the endovascular OR between November 2003 and March 2005. Patients arriving in the emergency department were transferred to the endovascular OR without delay. The neurovascular team performed diagnostic angiography followed by endovascular interventional procedures or surgery. CONCLUSIONS: The newly designed endovascular OR facilitates safe and systemic treatment of neurovascular disease.

[Endovascular treatment of large petrous internal carotid artery aneurysm associated with chronic otitis media: case report].

Aneurysms of the petrous internal carotid artery are rare, and surgical treatment of the aneurysm in the petrous bone carries high risk with procedure. We report a case of large petrous internal carotid artery aneurysm associated with otitis media. A 58-year-old female was admitted to our institution with left hearing loss and facial palsy. She had 4-year history of left exudative otitis media. Imaging studies demonstrated a 17 mm left petrous internal carotid artery aneurysm, destroying osseous partition between carotid canal and Eustachian tube, and protruding into left middle cranial fossa. Endosaccular coil embolization with balloon assist technique was performed successfully without neurological deficit. Follow up magnetic resonance angiogram demonstrated complete obliteration of the aneurysm without parent artery occlusion. Traumatic, mycotic, radiation, and congenital origin have been implicated for petrous internal carotid artery aneurysm. In a review of the literature, 11 cases of mycotic aneurysms in this location were reported and all of them were complicated with chronic otitis media. Because of its close proximity of middle ear and Eustachian tube, adventitial infection of the artery weakens the arterial wall, and gives rise to formation of aneurysm. We conclude that our case is of mycotic origin, and endosaccular coil embolization is effective and less invasive treatment.

Rapidly growing giant suprasellar tumor in a high-risk child: treatment strategy and role of neuroendoscopic surgery in slit-like ventricles.

RATIONALE: Suprasellar tumors are common in the pediatric population and exhibit a wide range of pathological appearance and behavior. Although rare, pure suprasellar germinomas carry worse prognosis than other locations. METHODS: We present a case of a 10-year-old girl treated with therapeutic anticoagulation for previous cardiac valvular replacement, who presented with rapidly growing giant (>4 cm) suprasellar germinoma. Neoadjuvant chemotheraphy was effective and the dilated ventricles became slit-like. The fine free-hand maneuver using a fine rigid-rod neuroendoscope. "Oi-Samii Handy Pro" made it possible to obtain the tissue diagnosis. RESULTS: Complete remission was achieved using neoadjuvant chemotherapy, minimally invasive neuroendoscopic surgery, then followed by specific chemoradiotherapy. CONCLUSION: The role of neuroendoscopic procedure, performed in a difficult situation with normalized size of the ventricles, was emphasized.

[A case of falcotentorial meningioma with visual allesthesia].

Visual allesthesia, in which visual images are transposed from one homonymous half-field of visual field to another, is a rare phenomenon. Palinopsia is the persistence or recurrence of visual images after the exciting stimulus object has been removed. Some authors have reported these phenomena, but these pathophysiology has not been understood. We report a right-handed 63-year-old woman, with a right falcotentorial meningioma. She paroxysmally experienced illusory transpositions of objects viewed in the right homonymous visual field into the left, and she recognized her face in it. The illusory images were palinoptic, persisting for up to a few minutes after the real objects were no longer in view. Administration of anticonvulsant medications resulted in the decrease of frequency of this phenomenon. Radiological and surgical findings revealed that the tumor was compressing the very localized visual cortex, especially the Brodmann's area 18 and 19. After resection of the tumor, visual allesthesia and palinopsia completely disappeared. These areas are associated with memory and recognition of visual images as visuopsychic area. This case provides some insight into the mechanisms of this phenomenon, and we consider that it could be caused by seizure activity in this lesion.