Endovascular treatment of an infectious aneurysm using the selective provocative test and transcranial motor evoked potential monitoring under general anesthesia: a case report.

The selective provocative test (SPT) under local anesthesia aids in protecting against ischemic complications during endovascular treatment. However, the use of this test under general anesthesia is not well described. Herein, we present a case of a 51-year-old man with a ruptured fusiform aneurysm in the middle cerebral artery M4 segment, which was thought to possibly supply the motor cortex. Internal trapping of the affected vessel and aneurysm by endovascular intervention was successfully performed after SPT using transcranial motor evoked potential (MEP) monitoring under general anesthesia. Transcranial MEP is suitable for neurological assessment during SPT under general anesthesia.

Unilateral oculomotor nerve palsy caused by arterial compression accompanying subarachnoid hemorrhage: a case report.

Unilateral oculomotor nerve palsy, often caused by aneurysmal compression, is one of the decisive findings for confirming the site of a ruptured aneurysm. However, arterial compression can also cause unilateral oculomotor nerve palsy. Here, we present the case of a 59-year-old woman with a ruptured right internal carotid-posterior communicating artery aneurysm accompanied by contralateral oculomotor nerve palsy. The nerve was found to be compressed by the posterior cerebral artery and was isolated from the ruptured aneurysm. When confirming a ruptured aneurysm based on the evidence of unilateral oculomotor palsy, the arteries surrounding the nerve must be thoroughly assessed.

[Endovascular Revascularization for Acute Ischemic Stroke Related to Blunt Carotid Injury:A Case Report].

Although blunt carotid artery injury is known as an important cause of ischemic stroke, the role of the endovascular treatment for acute ischemic stroke related to blunt carotid injuries remains unclear. We report the case of a patient with acute ischemic stroke secondary to blunt carotid artery injury who was treated with endovascular revascularization. A 46-year-old man suffered from sudden left-sided hemiparesis a day after a strike from a Japanese fencing staff on his right neck. 3D-CT angiography revealed tandem internal carotid artery occlusions of the cervical and C1 portions. We performed endovascular revascularization with carotid artery stenting and direct aspiration of the thrombus and achieved complete recanalization. The patient recovered almost completely. We conclude that endovascular revascularization should not be withheld from patients with acute ischemic stroke related to blunt carotid injury.

Successful Resection of a Growing Distal Medial Lenticulostriate Artery Pseudoaneurysm Presenting with Isolated Intraventricular Hemorrhage.

INTRODUCTION: Distal medial lenticulostriate artery (LSA) aneurysms associated with isolated intraventricular hemorrhage (IVH) are extremely rare. We report a very rare case of the isolated IVH due to the rupture of the distal medial LSA pseudoaneurysm that was not visible at the initial angiography but later emerged and grew. CASE REPORT: A 61-year-old woman with a history of hypertension had sudden onset of severe headache and mild consciousness disturbance. The computed tomography scan revealed the IVH, but the initial angiographies showed no evidence of aneurysm. The follow-up magnetic resonance imaging revealed that an intraventricular mass, arising from the right distal medial LSA, emerged and grew into the right anterior horn. Considering the risk of rebleeding, we resected the mass lesion via the transsulcal transventricular approach. The postoperative imaging showed complete obliteration of the mass lesion. Histopathological analysis indicated the pseudoaneurysm. The patient was discharged without any neurological deficit. CONCLUSIONS: The careful and repetitive follow-up imaging should be done in the cases with isolated IVH even if the initial image evaluations are unrevealing. The transsulcal transventricular approach can be the most minimally invasive surgical option for intraventricular lesion.

[A Case of Fibromuscular Dysplasia in a Patient with Various Main Trunk Dissections in the Head and Neck over a Short Period].

We report a case of subarachnoid hemorrhage(SAH)from an intracranial vertebral artery(VA)dissection in a patient with fibromuscular dysplasia(FMD)who presented with headache. A 54-year-old woman complained of spontaneous occipital headache. The dilatation of the left VA was detected on magnetic resonance angiography(MRA). She was diagnosed with left VA dissection(headache onset type). After sudden onset of headache on the second day of hospitalization, her consciousness level, as defined by the Japan Coma Scale, was 300. Computed tomography(CT)revealed SAH. Cerebral angiography showed the dilatation of the left intracranial VA and contrast material pooling, which was suspected to be a sign of dissection. We performed VA intravascular ligation by coil embolization. The postoperative course was good but postoperative MRA revealed arterial wall irregularities in both the extra cranial internal carotid artery and the right VA. Cerebral angiography showed the presence of the string-of-beads sign at these arteries. She was diagnosed with FMD. SAH might develop during the follow-up period in patients with VA dissection, even those in whom the initial symptom is headache. In addition, cases of FMD might also be complicated by various lesions of the main trunk of the cerebral artery.

[Clinical Study on Cerebellar Contusion:A Report on 9 Cases and Literature Review].

We report 9 cases of cerebellar contusion from April 2011 to September 2014 at our department. Frequency, clinicoradiological findings, mechanism of injury, treatments, and outcomes were retrospectively analyzed. Of 239 head injury cases admitted to our department during the same period, 9(3.8%)were diagnosed as cerebellar contusion. Among these 9 cases, 7 were men, and 2 were women. The patient age ranged from 12 to 83 years with a mean age of 64.7 years. The mechanism of injury was traffic accident in one patient, and fall in 8. All cases were associated with direct head trauma to the occiput, and radiographic studies showed occipital bone fracture in 8 cases. Six cases were managed conservatively. Three cases underwent suboccipital craniectomies and clot evacuations. Glasgow Outcome Scale(GOS)score at discharge were Good Recovery(GR)in 2, Moderate Disability(MD)in 2, Severe Disability(SD)in 3, Vegetative State(VS)in 1, and Dead(D)in 1. GOS scores in surgically treated cases were GR in 1, SD in 1, and VS in 1. Supratentorial severe traumatic lesions were concomitant with poor prognosis. Coup injury was a significant cause of cerebellar contusion. External decompression and clot evacuation were useful in patients who suffered severe cerebellar contusion;however, concomitant supratentorial lesions influenced the prognosis.

Usefulness of silent magnetic resonance angiography for intracranial aneurysms treated with a flow re-direction endoluminal device.

PURPOSE: Flow re-direction endoluminal device (FRED) is a novel dual-layer flow-diverting stent to treat cerebral aneurysms with high obliteration rates, however, it induces inevitable metal-related artifacts. We compared silent magnetic resonance angiography (MRA), a new MRA method using ultra-short time of echo and arterial spin-labeling, with conventional time-of-flight (TOF)-MRA for imaging aneurysms treated using FRED. METHODS: Between May 2020 and September 2022, 16 patients with unruptured internal carotid aneurysms treated using FRED simultaneously underwent silent MRA and TOF-MRA after treatment, with 36 follow-up sessions in total. Two observers independently graded the quality of intra-aneurysmal flow and stented parent arteries under both types of MRA from 1 (not visible) to 4 (nearly equal to digital subtraction angiography [DSA]), with reference to DSA images as a standard criterion. RESULTS: The mean scores for intra-aneurysmal flow and stented parent arteries were significantly better for silent MRA (3.93 ± 0.21 and 3.82 ± 0.32, respectively) than for TOF-MRA (2.08 ± 0.99 and 1.92 ± 0.79, respectively) (P < 0.01). Intermodality agreements for intra-aneurysmal flow and stented parent arteries were 0.87 and 0.90, respectively. CONCLUSION: Silent MRA is superior to TOF-MRA for assessing patients treated with FRED, with potential as an alternative imaging modality to DSA.

Elevated ratio of C-type lectin-like receptor 2 level and platelet count (C2PAC) aids in the diagnosis of post-operative venous thromboembolism in IDH-wildtype gliomas.

INTRODUCTION: Podoplanin (PDPN) is known to induce platelet aggregation via interacting with the C-type lectin-like receptor-2 on platelets and is involved in postoperative venous thromboembolism (VTE) formation. In this study, we investigate the correlation between soluble C-type lectin-like receptor (sCLEC-2) levels and PDPN expression in patients with high grade gliomas and the relationship between sCLEC-2 levels and the occurrence of VTE. MATERIALS AND METHODS: Forty-four patients harboring high grade gliomas, treated surgically at the Department of Neurosurgery, Niigata University from April 2018 to August 2020, were included. Patients with high grade gliomas were divided into isocitrate dehydrogenase (IDH)- wildtype and mutant groups, and the presence or absence of VTE and the intensity of PDPN by immunohistochemistry were confirmed. Platelet counts, as well as plasma sCLEC-2 and PDPN were measured in these patients. Furthermore, the levels of sCLEC-2 concentration were divided by the platelet count (C2PAC index) for comparison. RESULTS: IDH-wildtype glioma patients highly expressed PDPN (P < 0.001) compared to IDH-mutant glioma patients. In total, 9 (20.5 %) patients were diagnosed with VTE during the follow-up period, of which 8 patients harbored IDH-wildtype gliomas, and one patient an IDH-mutant glioma. Mean sCLEC-2 levels and C2PAC index in patients with IDH-wildtype gliomas were significantly higher than that of low or no PDPN expression group, which included patients with IDH-mutant gliomas (P = 0.0004, P = 0.0002). In patients with IDH-wildtype gliomas, the C2PAC index in patients with VTE was significantly higher than in patients without VTE (P = 0.0492). The optimal cutoff point of C2PAC for predicting VTE in IDH-wildtype glioma patients was 3.7 with a sensitivity of 87.5 % and specificity of 51.9 %. CONCLUSION: Platelet activation is strongly involved in the development of VTE in patients with IDH-wildtype high grade gliomas, and C2PAC index is a potential marker to detect VTE formation after surgery.

School-Based Stroke Education Through On-Demand E-learning During Coronavirus Disease 2019 Pandemic: Itoigawa Stroke Awareness Campaign.

Introduction Raising stroke awareness is important to shorten the interval from onset to consultation. We performed a school-based stroke education by on-demand e-learning during the coronavirus disease 2019 pandemic. Methods We performed on-demand e-learning and distributed the online- and paper-based manga about stroke for students and parental guardians in August 2021. We carried out this in a manner similar to the prior effective online stroke awareness initiatives in Japan. An online post-educational survey in October 2021 was conducted to evaluate the awareness effects by asking participants about their knowledge. We also investigated the modified Rankin Scale (mRS) at the discharge of stroke patients who were treated in our hospital during the before- and after-campaign periods, respectively. Results We distributed the paper-based manga and asked to work on this campaign to all 2,429 students (1,545 elementary school and 884 junior high school students) who lived in Itoigawa. We acquired 261 (10.7%) online responses from the students and 211 (8.7%) responses from their parental guardians. The number of students who chose all correct answers in the survey significantly increased after the campaign (205/261, 78.5%) compared to that before the campaign (135/261, 51.7%) and those of parental guardians showed similar trends (before campaign 93/211, 44.1%; after campaign 198/211, 93.8%). We investigated 282 stroke patients (90 patients before and 192 patients after-campaign period), and their mRS at discharge after-campaign seemed to be improved. Conclusion Only 10.7% of students and 8.7% of the parental guardians worked on the online survey. However, the number of those who chose correct answers about stroke increased after the campaign. After this campaign, the mRS of stroke patients at discharge improved although it was unclear if this is a direct result of this activity.

Efficacy of Emergency Room Skip Strategy in Patients Transferred for Mechanical Thrombectomy.

Objective: Time to recanalization is directly linked to cerebral infarction prognosis. However, patients transferred from another hospital take longer to arrive than those transported directly. To minimize time to recanalization, the emergency room (ER) skip strategy for hospital transfers was executed and reviewed. Methods: From April 2019, patients transferred from another hospital for mechanical thrombectomy were carried into the angio-suite using emergency service stretchers. Results for these patients (ER skip group) were compared with those for patients transported directly to our hospital (Direct group). Results: Among 108 cases in 32 months, 99 patients (91.7%) had major cerebral artery occlusion and underwent endovascular treatment. No differences in age, baseline National Institutes of Health Stroke Scale score, effective recanalization rate, or proportion of posterior circulation cases were seen between groups. The ER skip group (26 patients) showed significantly longer median time from onset to arrival (240 vs. 120 min; p = 0.0001) and significantly shorter median time from arrival to groin puncture (11 vs. 69 min; p = 0.0000). No significant differences were evident in time from groin puncture to recanalization (39 vs. 45 min), time from onset to recanalization (298 vs. 244 min), or rate of modified Rankin Scale score 0-2 after 90 days (42.3% vs. 32.9%). Median time from alarm to recanalization (266 vs. 176 min; p = 0.0001) was significantly longer in the ER skip group. Door-to-puncture (DTP) time for the Direct group gradually fell as the number of cases increased, reaching 40 min by the end of study period. In contrast, DTP time for the ER skip group remained extremely short and did not change further. The proportion of patients who underwent both CT and MRI before endovascular treatment was significantly lower in the Direct group (30.1%) than in the ER skip group (57.7%). In the ER skip group, median length of stay in the primary hospital was 119 min, and the median duration of interhospital transfer was 16 min. Conclusion: The ER skip strategy for patients transferred with large vessel occlusion achieved favorable outcomes comparable to that for direct transport cases. Direct transport to a thrombectomy-capable stroke center remains ideal, however, because the time to intervention is improving for direct transport cases each year.

Long-Term Characteristics of De Novo Bleb Formation at the Aneurysm Neck After Coil Embolization in Unruptured Cerebral Aneurysms.

OBJECTIVE: De novo bleb formation at the aneurysm neck after coil embolization of unruptured intracranial aneurysms is a rarely observed type of recurrence. The aim of this study was to elucidate the clinical characteristics of recurrent aneurysms in the long-term period. METHODS: Between January 2002 and December 2015, 290 unruptured intracranial aneurysms were treated with coil embolization at our institution. Patients who underwent retreatment due to aneurysm recurrence were divided into 2 patterns of recanalization: de novo bleb formation at the neck of a coiled sac (type DNV) and an enlarged residual cavity without de novo bleb formation (type non-DNV). RESULTS: Twenty-seven patients with aneurysms (9.3%) underwent retreatment (type DNV, 7; type non-DNV, 20). The initial aneurysm size of type DNV aneurysms was significantly smaller than that of type non-DNV (6.1 ± 2.2 mm vs. 10.1 ± 3.6 mm; P < 0.01), and time to retreatment in type DNV was significantly longer than that in type non-DNV (9.4 ± 5.3 years vs. 2.0 ± 2.0 years; P < 0.01). Two type DNV basilar artery (BA) aneurysms ruptured after a few years; however, the other type DNV aneurysms, including 4 anterior circulation aneurysms (including the internal carotid artery), were observed to grow gradually without rupture for >10 years until retreatment. CONCLUSIONS: De novo bleb formation at the neck of a coiled sac emerges with insidious growth during long-term follow-up. Constant caution should be exercised, even in cases of small- and medium-sized anterior circulation aneurysms. A risk of rupture risk may be anticipated, especially in BA lesions.

Non-contrast-enhanced silent magnetic resonance angiography for assessing cerebral aneurysms after PulseRider treatment.

PURPOSE: Conventional time-of-flight (TOF) magnetic resonance angiography (MRA) failed to depict clear visualization of coiled cerebral aneurysms with PulseRider due to metal-induced susceptibility artifacts. Our aim was to overcome the metal artifact using a novel imaging technique of non-contrast-enhanced ultrashort echo-time magnetic resonance angiography (UTE-MRA). MATERIALS AND METHODS: Five unruptured intracranial aneurysms were treated using PulseRider and the patients underwent silent MRA (UTE-MRA). The images were compared with TOF-MRA and digital subtraction angiography (DSA). RESULTS: Silent MRA can visualize the residual cavity of the coiled aneurysms, which was not well visualized and rather defective when using TOF-MRA. While a segment of the proximal marker composed of stainless steel was poorly visualized, the other parts of the parent artery and the arteries of bifurcation, including the aneurysmal neck, were clearly visualized, equivalent to that of DSA. CONCLUSIONS: UTE-MRA achieves better visualization of cerebral aneurysms after PulseRider treatment than TOF-MRA.

Eye movement during facial affect recognition by patients with schizophrenia, using Japanese pictures of facial affect.

A possible relationship between recognition of facial affect and aberrant eye movement was examined in patients with schizophrenia. A Japanese version of standard pictures of facial affect was prepared. These pictures of basic emotions (surprise, anger, happiness, disgust, fear, sadness) were shown to 19 schizophrenic patients and 20 healthy controls who identified emotions while their eye movements were measured. The proportion of correct identifications of 'disgust' was significantly lower for schizophrenic patients, their eye fixation time was significantly longer for all pictures of facial affect, and their eye movement speed was slower for some facial affects (surprise, fear, and sadness). One index, eye fixation time for "happiness," showed a significant difference between the high- and low-dosage antipsychotic drug groups. Some expected facial affect recognition disorder was seen in schizophrenic patients responding to the Japanese version of affect pictures, but there was no correlation between facial affect recognition disorder and aberrant eye movement.

Development and natural course of lateral posterior choroidal artery aneurysms arising from fragile choroidal collaterals in moyamoya disease: illustrative cases.

BACKGROUND: Choroidal collaterals are a risk factor for hemorrhagic stroke, even in the nonhemorrhagic hemisphere, among patients with moyamoya disease (MMD). Peripheral choroidal aneurysms rupture in fragile collaterals; however, the development and natural course of these aneurysms remain elusive. OBSERVATIONS: A 51-year-old woman, who had experienced a right cerebral hemorrhage 3 years earlier, presented with asymptomatic minor bleeding from a left lateral choroidal artery aneurysm in a predeveloped choroidal anastomosis. Although the aneurysm spontaneously thrombosed within 2 months, the choroidal collaterals persisted. After bypass surgery, the choroidal anastomosis regressed, and neither a de novo aneurysm nor a hemorrhagic stroke occurred. A 75-year-old woman with MMD, who had experienced a left frontal infarction 6 years earlier, experienced recurrent right intraventricular hemorrhage from a ruptured lateral choroidal artery aneurysm that developed in the choroidal anastomosis. The aneurysm spontaneously regressed 3 days after the rebleeding with no recurrence over the following 7 years. LESSONS: Choroidal artery aneurysms may develop in the choroidal anastomosis and rupture in the nonsurgical or contralateral hemispheres. Patients with MMD who have a history of hemorrhagic or ischemic stroke and impaired cerebral blood flow require careful observation. Although aneurysms may rapidly regress spontaneously, bypass surgery can stabilize hemodynamic stress and prevent further hemorrhage.

Retrograde T-Stent Technique for Large, Wide-Necked Internal Carotid-Posterior Communicating Artery Aneurysm.

Objective: We report a case of a wide-necked internal carotid-posterior communicating (IC-Pcom) artery aneurysm treated by the retrograde T-stent technique in which a stent was also placed in the Pcom artery via the posterior circulation. Case Presentation: A 35-year-old woman was diagnosed with an unruptured right IC-Pcom artery aneurysm (maximum diameter: 11 mm, neck diameter: 8.5 mm) during a detailed examination for vertigo. The Pcom artery (2.1 mm) branched from the aneurysmal dome. A microcatheter was guided in retrograde via the Pcom artery from the posterior circulation. A low-profile visualized intraluminal support (LVIS) Jr. 2.5 mm × 17 mm was deployed from the internal carotid artery (ICA) to the Pcom artery, and then, an LVIS 4.5 mm × 23 mm was deployed while pressing the flare of the LVIS Jr. protruding into the ICA. T configuration stenting was completed, and the coil was inserted as tightly as possible. Conclusion: The retrograde T-stent technique, which has the advantage of optimal stent positioning, is useful for preserving a Pcom artery branching from the aneurysmal dome.

Hemodynamic features of an intracranial aneurysm rupture predicted by perianeurysmal edema: A case report.

BACKGROUND: Perianeurysmal edema (PAE) has been suggested as an indicator of potential aneurysm rupture; however, the hemodynamic features of these aneurysms are still unknown. A computational fluid dynamic (CFD) analysis was performed to evaluate the hemodynamic features of a very rare case of a ruptured middle cerebral artery (MCA) aneurysm with PAE. CASE DESCRIPTION: A 65-year-old woman presented with disturbed consciousness. A subarachnoid hemorrhage due to an azygos anterior cerebral artery (ACA) aneurysm rupture was suspected. An unruptured MCA aneurysm with PAE was identified in the left temporal lobe. Although the ACA aneurysm was clipped to prevent re-bleeding, the MCA aneurysm subsequently ruptured 6 days later. Clipping of the MCA aneurysm was performed, and hemosiderin deposits suggestive of sentinel bleeding were found on the surface of the aneurysm dome. CFD analysis revealed unstable hemodynamic stress at the expanded bleb area after rupture, localized to the rupture site. Moreover, this analysis revealed flow impingement with pressure elevation and low wall shear stress, which indicated increased inflammation and aneurysm wall thinning that likely led to rupture. CONCLUSION: Hemosiderin deposits at the aneurysm wall and PAE indicates leakage from a cerebral aneurysm. Hemodynamic stress at the aneurysm may promote an inflammatory response and lead to wall weakening accompanied by PAE. Based on our findings, we recommend that surgical intervention should be considered as the first line of treatment for such aneurysms to prevent rupture.

Delayed Bleeding of Unruptured Intracranial Aneurysms After Coil Embolization: A Retrospective Case Series.

OBJECTIVE: Delayed bleeding of unruptured intracranial aneurysms (UIAs) after coil embolization is rare; this study aimed to analyze the occurrence of delayed bleeding of UIAs after coil embolization. METHODS: We retrospectively analyzed patients with UIAs after coil embolization between January 2002 and December 2018 and assessed the features of UIAs with delayed bleeding after coil embolization. RESULTS: Analysis included 307 patients with 335 UIAs. Mean follow-up was 7.1 ± 4.9 years, and total follow-up was 2365 aneurysm-years. There were 271 (80.9%) aneurysms located in the anterior circulation and 64 (19.1%) aneurysms located in the posterior circulation. Significant differences were observed between the 2 groups in terms of maximum size of the aneurysm (P < 0.01), width of the aneurysm neck (P < 0.01), and number of retreatment cases (P < 0.01). During the follow-up period, delayed bleeding occurred in 4 aneurysms (annual bleeding rate of 0.17%); all were located in the posterior circulation. The original size was not relatively large (mean 8.6 ± 2.4 mm). All aneurysms bled within 5 years (mean 35 ± 9.6 months) after the initial treatment. Two were de novo aneurysms that developed adjacent to the coiled aneurysms and were not detected on follow-up magnetic resonance angiography. CONCLUSIONS: Cautious follow-up of UIAs with digital subtraction angiography is important, articularly within the first 5 years after the procedure. If there are changes in the anatomic outcomes, short-term reassessment or additional treatment should be actively considered, particularly for aneurysms in the posterior circulation.

Possibility of Worsening Flow Diversion Effect Due to Morphological Changes of a Stented Artery With Multiple Overlapping Stents for Partially Thrombosed Vertebral Artery Aneurysms.

Background: Morphological changes of a stented artery can cause a flow diversion effect to reduce intra-aneurysmal flow; however, there is a potential for the negative effect of increased intra-aneurysmal flow. We present cases with multiple overlapping stents for a partially thrombosed vertebral artery aneurysm and characterize the hemodynamic properties of a recurrent case by focusing on the morphological changes of the stented artery. Methods: Between October 2017 and April 2019, four consecutive cases of symptomatic unruptured large and giant partially thrombosed vertebral artery aneurysms were treated with multiple overlapping low-profile visualized intraluminal support stents and no coils. Both angiographic and clinical outcomes were assessed. Computational fluid dynamics analysis was performed to clarify hemodynamic features. The degree of pressure elevation was calculated as the pressure difference (Pd). Wall shear stress (WSS) was also calculated. Results: In three of the four cases, successful flow reduction was achieved with no morphological change of the stented arteries. The patients' symptoms were gradually improved. The remaining case required additional stents after the initial treatment. In the recurrent case, Pd was noticeably elevated at the aneurysm neck after treatment, and WSS was generally increased in the area due to altered blood flow into the aneurysm dome caused by morphological changes of the stented artery. Conclusion: Overlapping stents can be used for the treatment of large and giant thrombosed vertebral artery aneurysms with flow diversion effect; however, morphological changes of the stented artery requires careful attention as it may lead to an increase in the intra-aneurysmal flow, causing negative outcomes.

Safety and feasibility of the distal transradial approach: A novel technique for diagnostic cerebral angiography.

PURPOSE: We aimed to evaluate the safety and feasibility of the distal transradial approach (DTRA) as a novel technique for cerebral angiography based on our institutional initial experience. METHODS: We retrospectively analyzed our institutional database of consecutive diagnostic cerebral angiographies performed with DTRA from December 2018 to August 2019. Patient demographics and clinical and procedural data were recorded. RESULTS: In total, 51 diagnostic cerebral angiographies in 51 patients (age, 15-83 years; mean age, 59.4 years, SD 13.5; 35 (69%) females) were performed or attempted with DTRA. Ultrasound evaluation showed that the mean inner distal radial artery diameter was significantly smaller than the mean inner forearm radial artery diameter (2.19 mm vs. 2.56 mm, P < 0.001). Cannulation via the distal radial artery was successful in 47 (92%) procedures. In the four procedures that failed, operators converted to the ipsilateral transradial approach without repositioning or redraping. Selective catheterization of the intended vessel was achieved in 64 (91%) of 70 vessels. In the remaining six, operators achieved the objective of the examination with angiography injecting from proximal and conversion to another approach was not required. One patient experienced temporary numbness around the puncture site after the procedure. No radial artery occlusion was identified in the patients who underwent ultrasound evaluation. CONCLUSION: Our results demonstrate that DTRA could become a standard approach for diagnostic cerebral angiography owing to the low complication rate and the high cannulation success rate.

Treatment Strategies for Infectious Intracranial Aneurysms: Report of Three Cases and Review of the Literature.

We retrospectively reviewed the cases of three patients with infectious intracranial aneurysms (IIAs), and discuss the indications for surgical and endovascular treatments. We treated two men and one woman with a total of six aneurysms. The mean age was 43.3 years, ranging from 36 to 51 years. One patient presented initially with an intraparenchymal hemorrhage, one with mass effect, and the other one had four aneurysms (one causing subarachnoid hemorrhages and the other causing delayed intraparenchymal hemorrhages). The average size of all aneurysms was 12.2 mm (range, 2-50 mm). They were preferentially located in the distal posterior cerebral artery, and then, in the middle cerebral artery. All cases were caused by infective endocarditis. We selected endovascular treatments for five aneurysms and treated all but one within 24 h from detection. One aneurysm was treated by combined therapy with endovascular intervention and surgery. After treatment, none of the IIAs presented angiographical recurrence or re-bleeding. If feasible, endovascular treatment is probably the first choice, but a combined surgical and endovascular approach should be considered if surgery or endovascular treatment alone are not feasible. The method of treatment should be individualized. For cases with high risk of aneurysm rupture, treatment should be performed as soon as possible.