Impact of subcallosal artery origin and A1 asymmetry on surgical outcomes of anterior communicating artery aneurysms.

BACKGROUND: Surgical clipping of anterior communicating artery (ACoA) aneurysms remains challenging due to their complex anatomy. Anatomical risk factors for ACoA aneurysm surgery require further elucidation. The aim of this study is to investigate whether proximity of the midline perforating artery, subcallosal artery (SubCA), and associated anomaly of the ACoA complex affect functional outcomes of ACoA aneurysm surgery. METHODS: A total of 92 patients with both unruptured and ruptured ACoA aneurysms, who underwent surgical clipping, were retrospectively analyzed from a multicenter, observational cohort database. Association of ACoA anatomy with SubCA origin at the aneurysmal neck under microsurgical observation was analyzed in the interhemispheric approach subgroup (n = 56). Then, we evaluated whether anatomical factors associated with SubCA neck origin affected surgical outcomes in the entire cohort (both interhemispheric and pterional approaches, n = 92). RESULTS: In the interhemispheric approach cohort, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was stratified to have the highest probability of the SubCA neck origin by a decision tree analysis. Then, among the entire cohort using either interhemispheric or pterional approach, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was significantly associated with poor functional outcomes by multivariable logistic regression analysis (OR 6.76; 95% CI 1.19-38.5; p = 0.03) as compared with A1 symmetry group in the acute subarachnoid hemorrhage settings. CONCLUSION: Combination of A1 asymmetry and larger aneurysmal size was significantly associated with SubCA aneurysmal neck origin and poor functional outcomes in ACoA aneurysm surgery. Interhemispheric approach may be proposed to provide a wider and unobstructed view of SubCA for ACoA aneurysms with this high-risk anatomical variant.

"Clip Anchor-Assisted Coil Embolization" for Endovascular Parent Artery Occlusion of Intracranial Traumatic Aneurysm.

Traumatic cerebral aneurysms are histologically dissecting aneurysms or pseudoaneurysms, thus requiring parent artery occlusion for cure. Combination of endovascular parent artery occlusion and extracranial-intracranial bypass is considered optimal to obtain complete obliteration of the aneurysm and to avoid hemodynamic hypoperfusion. However, endovascular parent artery occlusion of the supraclinoid internal carotid artery (ICA) is at risk of ischemic complications due to distal coil protrusion to adjacent perforating arteries or distal embolism of the thrombi generated in the coil mass. A 20-year-old man presented with progressive left optic neuropathy following motor vehicle accident. Radiological examination revealed left supraclinoid ICA aneurysmal formation with dissecting change. We treated this traumatic supraclinoid ICA aneurysm by combination of endovascular parent artery occlusion and high-flow bypass in the hybrid operating room. An aneurysmal clip was applied on the ICA just distal to the aneurysm prior to coil embolization, and worked as a scaffold for subsequent filling coils and as a blockade for the distal emboli. This "clip anchor-assisted coil embolization" technique resulted in optimal parent artery occlusion for the traumatic aneurysm of the supraclinoid ICA with minimal risks of residual blood flow, intraoperative rupture, and thromboembolic complications.

The leptomeningeal ivy sign on fluid-attenuated inversion recovery images in moyamoya disease: positron emission tomography study.

BACKGROUND: The ivy sign is sometimes seen on fluid-attenuated inversion recovery (FLAIR) images in moyamoya disease (MMD). In recent studies using single-photon emission computed tomography, ivy sign proliferation correlated with decreases in cerebrovascular reserve. However, a decreased vascular reserve is not concrete. The purpose of this study was to evaluate the correlation between ivy sign proliferation and the findings of 15O gas positron emission tomography (PET). METHODS: In 19 MMD patients (12 women, age 31-69 years) with ischemic symptoms, FLAIR magnetic resonance imaging and 15O gas PET were performed. We classified the middle cerebral artery (MCA) territory into 2 regions in each hemisphere, and the degree of the ivy sign (ivy sign score) in each region was classified into 3 grades (0-2), where grade 0 indicated an absence of the ivy sign, grade 1 indicated that the ivy sign was seen on less than half of the cortical surface in each region, and grade 2 indicated that the ivy sign was seen on more than half of the cortical surface. We examined the relationship among the ivy sign score, the severity of ischemic symptoms and PET parameters in 76 MCA regions of 19 patients. RESULTS: Ivy sign scores of the regions were 0 (n = 19), 1 (n = 40), and 2 (n = 17). Total ivy sign score of a hemisphere increased as clinical symptoms became more severe. Cerebral blood flow (CBF) values were lower, cerebral blood volume (CBV) values were higher, and CBF/CBV values were lower than those of controls as symptoms became severe (p < 0.05). CBF and CBF/CBV values decreased and CBV values increased as the ivy sign score increased, and were significantly higher and lower, respectively, than control values (p < 0.05). No significant differences in cerebral metabolic rate of oxygen and oxygen extraction fraction were found between the 3 ivy sign scores. A positive correlation was found between ivy sign score and increases in CBV (p < 0.01), and a more obvious negative correlation was found between ivy sign score and decreases in CBF/CBV (p < 0.001). CONCLUSIONS: We evaluated the correlation between ivy sign proliferation and the findings of 15O gas PET. We suggested that ivy sign proliferation was associated with both dilated pial vasculature and the slow flow of developed leptomeningeal collaterals in patients with MMD.

Haptoglobin phenotype predicts cerebral vasospasm and clinical deterioration after aneurysmal subarachnoid hemorrhage.

Vasospasm (VS) and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) are thought to greatly affect prognosis. Haptoglobin (Hp) is a hemoglobin-binding protein expressed by a genetic polymorphism (1-1, 2-1, and 2-2). Our objects were to investigate whether the Hp phenotype could predict the incidence of cerebral infarction, favorable outcome, clinical deterioration by DCI, and angiographical VS after aneurysmal SAH. Ninety-five consecutive patients who underwent clipping or coil embolization were studied. Favorable functional outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. Angiographical VS was diagnosed based on cerebral angiography findings performed between days 7 and 10 after SAH. The Hp 2-2 group had a significantly greater risk of angiographical VS than that of Hp 2-1 and 1-1 groups combined on univariate (odds ratio [OR]: 3.60, confidence interval [CI]: 1.49-8.67, P = .003) and multivariate logistic regression analyses after being adjusted for age, sex, Fisher groups, and other risk factors (OR: 3.75, CI: 1.54-9.16, P = .004). The Hp 2-2 group also showed the tendency of a greater risk of clinical deterioration by DCI with marginal significance on univariate and age- and sex-adjusted analyses (univariate OR: 2.46, CI: .90-6.74, P = .080; age- and sex-adjusted OR: 2.46, CI: .89-6.82, P = .080) but not after being adjusted for other multiple risk factors. The Hp 2-2 group was not associated with the favorable 3-month outcome and cerebral infarction (univariate: P = .867, P = .209; multivariate: P = .905, P = .292). The Hp phenotype seems to be associated with a higher rate of angiographical VS and clinical deterioration by DCI but does not affect the incidence of cerebral infarction and favorable outcome.

Hybrid operating room for the treatment of complex neurovascular and brachiocephalic lesions.

BACKGROUND: We examine the impact of the installation of integrated hybrid operating rooms (ORs) that allow both surgical and endovascular procedures and are designed for less invasive and 1-stage treatment of complex neurovascular lesions. METHODS: We retrospectively analyzed our experience in the treatment of complex neurovascular lesions in a hybrid OR. RESULTS: Three patients with distal middle cerebral artery (MCA) aneurysms underwent a proximal clip occlusion or endovascular trapping with a superficial temporal artery-MCA bypass after correct localization of the recipient branch distal to the aneurysm using superselective intra-arterial infusion of indocyanine green under an operating microscope. Two patients with innominate artery stenosis were treated with retrograde stenting from the common carotid artery (CCA) with distal protection of the internal carotid artery (ICA) alone, and with antegrade stenting with dual protection of the ipsilateral ICA and the vertebral artery. Two patients with tandem stenosis of the proximal CCA and carotid bifurcation underwent 1-stage retrograde stenting combined with a carotid endarterectomy. A patient with the innominate artery and the proximal CCA stenosis underwent staged percutaneous antegrade angioplasty of the innominate artery followed by retrograde stenting of both lesions. A patient with tandem stenosis of the subclavian and innominate arteries underwent 1-stage retrograde stenting. In 2 patients with carotid stenosis that was difficult to access via the endovascular route, carotid stenting was performed by direct puncture of the proximal CCA. No patients suffered from new postoperative neurologic deficits. CONCLUSIONS: The integration of a high-end hybrid OR enables combined endovascular and surgical procedures for complex neurovascular and brachiocephalic lesions in a 1-stage treatment.

Skull metastases from extramammary Paget's disease emerging 8 years after initial treatment with no local progression: illustrative case.

BACKGROUND: The foci of distant metastasis from extramammary Paget's disease (EMPD) are the lung, liver, truncal bones, vertebrae, and brain. However, skull metastases have not been reported. OBSERVATIONS: The authors treated a patient with calvarial and skull base metastases from EMPD who had undergone wide local resection of EMPD 8 years before, and they report his clinical course. LESSONS: Because EMPD with distant metastasis is fatal, it should be recognized that EMPD can metastasize to the skull even when it seemed to be in remission for several years.

[Therapeutic strategy for secondary lung cancer].

Among 659 resected lung cancer cases from 1994 to 2009, 57 secondary lung cancers (8.6%) were evaluated. The secondary tumors were synchronous, located in the same lobe in 10, the ipsilateral different lobe in 17, and the contralateral lobe in 13, or metachronous, located in the contralateral lobe in 15, and the ipsilateral different lobe in 5. Both the tumors were removed in 49 cases. Chemotherapy, stereotactic radiotherapy (SRT), photo dynamic therapy (PDT), or best supportive care (BSC) was selected after a lobectomy or segmentectomy of the 1st tumor in 8 cases considering the patient's condition. Lobectomy or segmentectomy should be indicated for the 1st tumor considering curability. Bilobectomy is adopted for multiple cancers involving middle lobe. According to the operability or pulmonary function, the same strategy is adopted for secondary cancer. Considering the patient's condition, possibility of metastases and the tumor location and histologic type, partial resection, SRT, PDT, or BSC could be selected.

Venous Sinus Stenting for Transverse Sinus Stenosis Associated with Leptomeningeal Carcinomatosis in a Patient with Epidermal Growth Factor Receptor-Mutated Lung Cancer: A Case Report.

BACKGROUND Cerebral venous sinus obstruction associated with leptomeningeal carcinomatosis is an extremely rare complication of advanced non-small-cell lung cancer. There is little information available on the efficacy of therapeutic options because of its rarity and extremely poor prognosis. CASE REPORT A 57-year-old man presented with severe headache, vomiting, and visual loss for 1 month. Head magnetic resonance venography (MRV) showed occlusion of the left transverse sinus. Gd-enhanced MRI showed no abnormal enhancement. Lumbar puncture intracranial pressure was higher than 40 cmH2O. Positive cerebrospinal fluid tumor cytology confirmed the diagnosis of leptomeningeal carcinomatosis (LC). The headache was relieved by repeated lumbar punctures, and ventriculo-peritoneal shunt was performed. Cerebral angiography showed severe stenosis of the left transverse sinus without thrombosis, and significant delay of cerebral circulation. The transverse sinus stenosis was judged to be contributing to raised intracranial pressure, and the patient underwent left transverse sinus stent placement. After the procedure, his visual acuity improved, the visual field was enlarged, and his headache could be controlled by medication. Follow-up Gd-enhanced MRI showed dural enhancement and spinal dissemination. Because molecular biology of the surgical specimen showed epidermal growth factor receptor (EGFR)-activating mutations, he was treated with osimertinib for 2 months. He survived for 8 months following the diagnosis of LC and left transverse sinus stenosis. CONCLUSIONS Venous sinus stenting can offer an effective palliative interventional option for symptom relief of severe headache and visual symptoms, even in the end stage of malignancy.

Stage-specific role of endogenous Smad2 activation in cardiomyogenesis of embryonic stem cells.

The role of Smads and their specific ligands during cardiomyogenesis in ES cells was examined. Smad2 was activated bimodally in the early and late phases of cardiac differentiation, whereas Smad1 was activated after the middle phase. Nodal and Cripto were expressed in the early stage and then downregulated, whereas transforming growth factor-beta and activin were expressed only in the late phase. Suppression of early Smad2 activation by SB-431542 produced complete inhibition of endodermal and mesodermal induction but augmented neuroectodermal differentiation, followed by poor cardiomyogenesis, whereas inhibition during the late phase alone promoted cardiomyogenesis. Inhibitory effect of Smad2 on cardiomyogenesis in the late phase was mainly mediated by transforming growth factor-beta, and inhibition of transforming growth factor-beta-mediated Smad2 activation resulted in a greater replicative potential in differentiated cardiac myocytes and enhanced differentiation of nonmyocytes into cardiac myocytes. Thus, endogenous Smad2 activation is indispensable for endodermal and mesodermal induction in the early phase. In the late phase, endogenous transforming growth factor-beta negatively regulates cardiomyogenesis through Smad2 activation by modulating proliferation and differentiation of cardiac myocytes.

Endovascular treatment of acute ischaemic stroke in octogenarians and nonagenarians compared with younger patients.

Purpose: Endovascular therapy for emergent large vessel occlusion has been established as the standard approach for acute ischaemic stroke. However, the effectiveness and safety of endovascular therapy in the very elderly population has not been proved. Objective: To determine the safety and effectiveness of endovascular therapy in octogenarians and nonagenarians. Methods: We retrospectively reviewed all patients who underwent endovascular therapy at two stroke centres between April 2012 and July 2018. Functional outcome was assessed using the modified Rankin scale at 90 days after stroke or at discharge. A favourable outcome was defined as a modified Rankin scale score of 0-2 or not worsening of the modified Rankin scale score before stroke. Outcome was compared between younger patients (aged 46-79 years, n = 40) and octogenarians and nonagenarians (aged 80-97 years, n = 19). Results: Octogenarian and nonagenarian patients had pre-stroke functional deficit (modified Rankin scale score >1) more frequently than younger patients (57.9% vs. 20.0%, respectively, P = 0.0059). No difference was observed between very elderly and younger patients in the rate of successful reperfusion (89.5% vs. 67.5%, respectively, P = 0.11), favourable functional outcome (47.4% vs. 45.0%, respectively, P = 1.00) and mortality (21.1% vs. 27.5%, respectively, P = 1.00). On multiple regression analysis, successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were independent predictors of favourable outcome (P = 0.0003, 0.015 and 0.028, respectively). Conclusions: Successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were clinical predictors of favourable outcome. However, we did not observe an age-dependent effect of clinical outcome after endovascular therapy.

Postoperative ischemic events in patients undergoing carotid artery stenting using algorithmic selection for embolic protection.

PURPOSE: Carotid artery stenting (CAS) is a valuable alternative to carotid endarterectomy, especially in high-risk patients. However, the reported incidences of perioperative stroke and death remain higher than for carotid endarterectomy, even when using embolic protection devices (EPDs) during CAS. Our purpose was to evaluate 30-day major adverse events after CAS when selecting the most appropriate EPD. METHODS: We reviewed the clinical outcomes of 61 patients with 64 lesions who underwent CAS with EPDs. Patients who underwent CAS associated with thrombectomy and who had a preoperative modified Rankin scale score >3 were excluded from the analysis. The EPD was selected based on symptoms, carotid wall magnetic resonance imaging and lesion length, and we analyzed combined 30-day complication rates (transient ischemic attack, minor stroke, major stroke or death). RESULTS: Forty-nine patients were men and 12 were women. The median age was 72 years (range: 59-89 years) and 44 lesions were asymptomatic. A filter-type EPD was selected in 23 procedures, distal-balloon protection in 14 procedures and proximal-occlusive protection in 27 procedures. Two patients (3.1%) experienced a transient ischemic attack and one patient (1.6%) had a minor stroke within 30 days of the procedure. No patients experienced procedure-related morbidities (modified Rankin score >2) or death. CONCLUSIONS: The perioperative stoke rate was low when we selected a proximal-occlusive-type EPD in high-risk patients with vulnerable carotid artery disease. Our algorithm for EPD selection was an effective tool in the perioperative management of carotid artery stenosis.

Skeletal muscle-derived progenitors capable of differentiating into cardiomyocytes proliferate through myostatin-independent TGF-beta family signaling.

The existence of skeletal muscle-derived stem cells (MDSCs) has been suggested in mammals; however, the signaling pathways controlling MDSC proliferation remain largely unknown. Here we report the isolation of myosphere-derived progenitor cells (MDPCs) that can give rise to beating cardiomyocytes from adult skeletal muscle. We identified that follistatin, an antagonist of TGF-beta family members, was predominantly expressed in MDPCs, whereas myostatin was mainly expressed in myogenic cells and mature skeletal muscle. Although follistatin enhanced the replicative growth of MDPCs through Smad2/3 inactivation and cell cycle progression, disruption of myostatin did not increase the MDPC proliferation. By contrast, inhibition of activin A (ActA) or growth differentiation factor 11 (GDF11) signaling dramatically increased MDPC proliferation via down-regulation of p21 and increases in the levels of cdk2/4 and cyclin D1. Thus, follistatin may be an effective progenitor-enhancing agent neutralizing ActA and GDF11 signaling to regulate the growth of MDPCs in skeletal muscle.

Repeated Short-Term Recurrence of Chronic Subdural Hematoma Associated with Metastasis to Hematoma Capsule Originating from Extracranial Malignant Tumor.

BACKGROUND: The recurrence rate of chronic subdural hematoma (CSDH) after trepanation is relatively high and involves various factors. We encountered an extremely rare case in which metastasis of an extracranial malignant tumor to the hematoma capsule was thought to be causing short-term repeated recurrences of CSDH. CASE DESCRIPTION: The patient was a 74-year-old man who had undergone bur hole evacuation of left CSDH 7 months earlier and had been receiving chemotherapy for stage IV gastric cancer for the preceding 6 months. He presented with symptoms of right hemiparesis and was diagnosed with left CSDH. Bur hole evacuation was performed twice, but the hematoma enlarged again both times within a short period. A third bur hole evacuation was performed after middle meningeal artery embolization, but the hematoma again enlarged shortly thereafter. Hematoma enlargement was finally suppressed by extracting the hematoma capsule under craniotomy. In histopathologic examinations, hematoxylin-eosin staining showed poorly differentiated adenocarcinoma primarily along the luminal side of the hematoma capsule and immunohistochemical staining showed results identical to findings from the existing gastric cancer. Pathologic results confirmed metastasis of the gastric cancer to the hematoma capsule, and this was considered to be the cause of short-term repeated recurrence of CSDH. CONCLUSIONS: To the best of our knowledge, this is the first report of metastasis to a hematoma capsule originating from an extracranial malignant tumor. The clinical course in the present case suggests metastasis of extracranial malignant tumor to the CSDH capsule as an extremely rare cause of recurrence.

High-Performance SAW Resonator on New Multilayered Substrate Using LiTaO3 Crystal.

To develop the high-performance filters and duplexers required for recent long-term evolution frequency bands in mobile handsets, a surface acoustic wave (SAW) resonator is needed that has a higher quality (Q) and a lower temperature coefficient of frequency (TCF). To achieve this, the authors focused on acoustic energy confinement in the depth direction for a rotated Y-X LiTaO3 (LT) substrate. Characteristics of multilayered substrates with low-impedance and high-impedance layers under LT layer were studied numerically in terms of acoustic energy distribution, phase velocity, coupling coefficient, and temperature characteristics employing a finite-element method simulation. After several calculations, a novel multilayered structure was developed that uses SiO2 for a low-impedance layer and AlN for a high-impedance layer under the thin LT layer. A one-port resonator using the new substrate was fabricated, and its experimental results showed that the developed resonator had a Bode-Q over 4000 and TCF of -8 ppm/°C, which are four times higher than and one-fifth as small as those of a conventional 4° YX-LT SAW resonator, respectively. By applying this technology, a band 25 duplexer with very narrow duplex gap was successfully developed, which shows extremely low insertion loss, steep cutoff characteristics, and stable temperature characteristics.

Long-Term Volume Reduction Effects of Endovascular Embolization for Intracranial Meningioma: Preliminary Experience of 5 Cases.

BACKGROUND: Preoperative endovascular embolization of intracranial meningiomas denatures the tumor tissue, reduces intraoperative blood loss, and facilitates surgical removal. However, as most meningiomas are surgically removed within a few days after embolization, the effect of long-term volume reduction of the tumor due to the endovascular embolization remains unknown. METHODS: Five patients with intracranial meningioma underwent endovascular embolization between January 2006 and December 2014 and were followed without surgical resection for >14 days. The reduction in tumor and peritumoral edema volumes on sequential head magnetic resonance imaging, along with the clinical symptoms, were retrospectively reviewed. RESULTS: All the tumors indicated a 10%-30% volume reduction 30 days after embolization, which continued thereafter; no meningioma regrowth was observed for >90 days in 2 of 5 cases. Moreover, the peritumoral edema volume was reduced by 30%-70% at 30 days after embolization, and no subsequent increase was observed for >60 days in 4 of 5 cases. The neurologic symptoms related to the tumor mass effect improved after embolization. CONCLUSIONS: Endovascular embolization of intracranial meningiomas with n-butyl cyanoacrylate reduced the tumor and peritumoral edema volumes by 10%-30% and 30%-70%, respectively, within 30 days. Volume and edema reduction effect of embolization may last longer than expected, beyond the timing when most meningiomas are resected after embolization. In this study, we described our preliminary results of the volume reduction of intracranial meningiomas that were embolized using n-butyl cyanoacrylate and monitored without any surgical resection for >14 days. We believe that our study makes a significant contribution to the literature because we showed that volume and edema reduction effect of embolization may last longer than expected, beyond the timing when most meningiomas are resected after embolization.

Carbon dioxide-rich water bathing enhances collateral blood flow in ischemic hindlimb via mobilization of endothelial progenitor cells and activation of NO-cGMP system.

BACKGROUND: Carbon dioxide-rich water bathing has the effect of vasodilatation, whereas it remains undetermined whether this therapy exerts an angiogenic action associated with new vessel formation. METHODS AND RESULTS: Unilateral hindlimb ischemia was induced by resecting the femoral arteries of C57BL/J mice. Lower limbs were immersed in CO2-enriched water (CO2 concentration, 1000 to 1200 mg/L) or freshwater (control) at 37 degrees C for 10 minutes once a day. Laser Doppler imaging revealed increased blood perfusion in ischemic limbs of CO2 bathing (38% increase at day 28, P<0.001), whereas N(G)-nitro-L-arginine methyl ester treatment abolished this effect. Angiography or immunohistochemistry revealed that collateral vessel formation and capillary densities were increased (4.1-fold and 3.7-fold, P<0.001, respectively). Plasma vascular endothelial growth factor (VEGF) levels were elevated at day 14 (18%, P<0.05). VEGF mRNA levels, phosphorylation of NO synthase, and cGMP accumulation in the CO2-bathed hindlimb muscles were increased (2.7-fold, 2.4-fold, and 3.4-fold, respectively) but not in forelimb muscles. The number of circulating Lin-/Flk-1+/CD34- endothelial-lineage progenitor cells was markedly increased by CO2 bathing (24-fold at day 14, P<0.001). The Lin-/Flk-1+/CD34- cells express other endothelial antigens (endoglin and VE-cadherin) and incorporated acetylated LDL. CONCLUSIONS: Our present study demonstrates that CO2 bathing of ischemic hindlimb causes the induction of local VEGF synthesis, resulting in an NO-dependent neocapillary formation associated with mobilization of endothelial progenitor cells.

[Therapeutic strategy for isolated dissecting aneurysms of the posterior inferior cerebellar artery: report of three cases and review of literature].

Dissecting aneurysm of the posterior inferior cerebellar artery (PICA) is a relatively rare disease and its treatment has not been well established. The authors analyzed the clinical and anatomical features of 38 reported lesions and three of our cases to clarify the "best therapeutic modality". The average age was 45.0 years old and 27 patients were male. Left-sided predominance (26 cases) was noted. As to the mode of onset, 23 cases were subarachnoid hemorrhage, 16 were ischemia, and 6 were Wallenberg's syndrome. Anatomically, the sites of dissection were located in the proximal segment of PICA in 31 lesions (75.6%). Review of the cases show that 30 (75%) patients underwent surgical therapy, and 7 (17.5%) patients underwent endovascular treatment. Twenty six patients who took surgical therapy and 5 patients who took endovascular treatment had excellent or good outcome. The critical point in therapeutic procedure is the preservation of perforating branches arising from PICA, therefore surgical trapping with the revascularization of PICA (usually extracranial-PICA anastomosis), in which these tiny branches are secured under microscopic manipulation, has the advantage in principle.

Efficacy of FLOW 800 with indocyanine green videoangiography for the quantitative assessment of flow dynamics in cerebral arteriovenous malformation surgery.

OBJECTIVE: To evaluate the quantitative assessment of flow dynamics during surgery for arteriovenous malformations (AVMs) with FLOW 800 with indocyanine green videoangiography. METHODS: Changes in flow dynamics in the superficial AVM components (feeder, nidus, and drainer), the adjacent cortical artery, and the cortical vein surrounding AVM were evaluated. Analysis was performed at predissection, postclipping of the feeders, and postresection of the nidus with the use of quantitative values of the maximum fluorescence intensity, time to half-maximum fluorescence intensity (T1/2 FI), and the fluorescence intensity rate at T1/2 FI semiautomatically obtained with the use of FLOW 800 software. RESULTS: FLOW 800 assessments were performed in 7 cases. The time difference between the T1/2 FI, defined as transit time, in the cortical artery and the drainer was prolonged from 0.08 ± 0.65 seconds to 2.63 ± 1.79 seconds (P < 0.0001) at postfeeder clipping phase. The transit time between the cortical artery and the cortical vein was reduced to 3.76 ± 1.37 seconds at post feeder clipping phase (P = 0.024) and 2.63 ± 0.80 seconds at final phase (P = 0.005) compared with 4.56 ± 1.47 seconds at predissection phase. The maximum intensity and the fluorescence intensity rate at T1/2 FI were not significantly different at these phases, excluding the maximum intensity of the drainer decreasing from 533 ± 271 to 399 ± 217 (P = 0.006) at post feeder clipping phase. CONCLUSION: FLOW 800 analysis with indocyanine green videoangiography provides the real-time hemodynamic status of the AVMs and adjacent brain at various stages of resection. This technique is feasible to resect AVMs more safely and convincingly.

Prevention of Retrograde Blood Flow Into Large or Giant Internal Carotid Artery Aneurysms by Endovascular Coil Embolization with High-Flow Bypass: Surgical Technique and Long-Term Results.

BACKGROUND: Recanalization has been reported in large or giant aneurysms of the internal carotid artery (ICA) addressed by high-flow bypass and endovascular treatment. Aneurysmal recanalization may be attributable to retrograde blood flow into the aneurysm through the ICA branches, such as the ophthalmic artery or the meningohypophyseal trunk, or through the surgically created bypass. We modified the endovascular treatment of aneurysms to prevent retrograde flow and evaluated the long-term efficacy of our method. METHODS: We used a hybrid operative/endovascular technique to treat 5 patients with large or giant aneurysms arising from the C2-C4 segment of the ICA who presented with visual symptoms due to the mass effect of the aneurysm. To prevent retrograde flow into the aneurysm our modified endovascular treatment involves coil embolization of the aneurysmal orifice and the ICA, including the origin of the ophthalmic artery and meningohypophyseal trunk, and placement of a high-flow bypass using a radial artery graft. RESULTS: During the 5- to 12-year follow-up period, 4 aneurysms disappeared, and the other decreased in size. There were no subarachnoid hemorrhages. All bypass grafts remained patent. Visual preservation was achieved in 2 patients; 1 patient manifested visual improvement. Although 2 patients experienced transient neurological deficits we encountered no permanent complications in this series. The final modified Rankin scale of the 5 patients was 0 or 1. CONCLUSIONS: Prevention of retrograde flow into the aneurysm by coil embolization with high-flow bypass is a safe and effective method. It prevents the recanalization of large or giant ICA aneurysms.

Ruptured aneurysm arising from a basilar artery fenestration and associated with a persistent primitive hypoglossal artery. Case report and review of the literature.

A 42-year-old woman experienced the sudden onset of a severe headache. Angiograms demonstrated a persistent primitive hypoglossal artery (PHA) originating from the internal carotid artery at the C-2 vertebral level. In addition, a fenestration at the PHA-basilar artery (BA) junction and an aneurysm at the proximal end of this fenestration were revealed. To perform endovascular embolization of the aneurysm, a microcatheter was introduced into the aneurysm sac via the PHA and two Guglielmi Detachable Coils were placed in the aneurysm. The patient's postoperative course was uneventful, and she was able to resume her normal life. Although many clinical cases have been reported in which a ruptured aneurysm was associated with a PHA or a BA fenestration, as far as the authors know there has been no case in the literature in which a ruptured aneurysm associated with both anomalies and no case in which endovascular embolization was used to treat a ruptured aneurysm associated with a PHA. This rare case is discussed and a review of the relevant literature is presented.