Superiority of Endovascular Coiling Over Surgical Clipping for Clinical Outcomes at Discharge in Patients With Poor-Grade Subarachnoid Hemorrhage: A Registry Study in Japan.

BACKGROUND AND OBJECTIVES: The differences in clinical outcomes between endovascular coiling (EC) and surgical clipping (SC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) are controversial. Therefore, this study aimed to evaluate whether EC is superior to SC and identify risk factors in patients with poor-grade aSAH. METHODS: We used data from the "Predict for Outcome Study of aneurysmal SubArachnoid Hemorrhage." World Federation of Neurological Societies (WFNS) grade III-V aSAH was defined as poor-grade aSAH, and unfavorable clinical outcomes (modified Rankin Scale scores 3-6) were compared between SC and EC after propensity score matching (PSM). In-hospital mortality was similarly evaluated. Predictors of unfavorable clinical outcomes were identified using multivariable analysis. RESULTS: Ultimately, 1326 (SC: 847, EC: 479) and 632 (SC: 316, EC: 316) patients with poor-grade aSAH were included before and after PSM, respectively. Unfavorable clinical outcomes at discharge were significantly different between SC and EC before (72.0% vs 66.2%, P = .026) and after PSM (70.6% vs 63.3%, P = .025). In-hospital mortality was significantly different between groups before PSM (10.5% vs 16.1%, P = .003) but not after PSM (10.4% vs 12.7%, P = .384). Predictors of unfavorable clinical outcomes in both SC and EC were WFNS grade V, older than 70 years, and Fisher computed tomography (CT) grade 4. Predictors of unfavorable clinical outcomes only in SC were WFNS grade IV (odds ratio: 2.46, 95% CI: 1.22-4.97, P = .012) and Fisher CT grade 3 (4.90, 1.42-16.9, P = .012). Predictors of unfavorable clinical outcome only in EC were ages of 50s (3.35, 1.37-8.20, P = .008) and 60s (3.28, 1.43-7.52, P = .005). CONCLUSION: EC resulted in significantly more favorable clinical outcomes than SC in patients with poor-grade aSAH, without clear differences in in-hospital mortality. The benefit of EC over SC might be particularly remarkable in patients with WFNS grade IV and Fisher CT grade 3.

Association and Implications of Blood and Plaque n-3 Polyunsaturated Fatty Acid Composition in Patients Treated with Oral Eicosapentaenoic Acid before Carotid Endarterectomy.

Long-chain n-3 polyunsaturated fatty acids (PUFA), especially eicosapentaenoic acid (EPA), have been shown to prevent atherosclerosis-related cardiovascular disease, including stroke. Recently, the ratio of serum EPA to arachidonic acid (AA; EPA/AA ratio) has been reported to be a biomarker to prevent cardiovascular disease. In this study, we evaluate whether the serum EPA/AA ratio would be a useful biomarker for determining the efficacy of orally administered EPA in preventing stroke by investigating tissue and serum EPA/AA ratios, serum inflammatory markers, and carotid artery intimamedia thickness (IMT). Patients with dyslipidemia, as the primary illness scheduled for carotid endarterectomy (CEA), were included and randomly assigned to the EPA group (EPA: 1,800 mg/day plus statin; 10 patients) or non-EPA group (statin only; 15 patients). PUFA fraction was evaluated in the tissue (post-CEA) and serum (pre-CEA and 6 months thereafter). As for the tissue PUFA fraction in the plaque, the EPA group had a significantly higher EPA/AA ratio (EPA group, 0.46; non-EPA group, 0.28; p = 0.01). At 6 months postoperatively, the EPA group had a significantly higher serum EPA/AA ratio (baseline, 0.83; follow-up, 1.60; p = 0.05). No significant differences were found for inflammatory markers and IMT. Both serum and tissue EPA/AA ratios were higher in patients treated with oral EPA. Serum EPA/AA ratio might be a useful biomarker for the efficacy of orally administered EPA.

Bilateral symptomatic large cavernous carotid artery aneurysms treated by extracranial-intracranial bypass with parent artery occlusion.

Bilateral large cavernous sinus internal carotid aneurysms (CCAs) occur very rarely. While the choice of treatment method is important, the timing of contralateral side treatment is equally important. We herein report the case of a 72-year-old woman who presented with progressive bilateral visual impairment and was treated by two-stage. First, the left CCAs had been treated, and the aneurysm was thrombosed, but her left visual acuity did not recover; the right CCA was becoming larger 2 years later, and her right visual acuity began worsening. The right CCAs was treated by almost same method. Her right visual acuity improved compared with the second preoperative findings. Our case findings suggest the importance of considering the appropriate timing to avoid symptom aggravation in patients with bilateral CCAs.

Enterprise Treatment for Recurrent Basilar Tip Aneurysm after PulseRider-assisted Coil Embolization: A Case Report.

PulseRider (Cerenovus, Irvine, CA, USA) is a relatively novel device used for the treatment of wide-neck aneurysms with a coil-assisted effect. However, treatment options for recurrent aneurysms after PulseRider-assisted coil embolization remain controversial. Here we report a case of recurrent basilar tip aneurysm (BTA) treated with Enterprise 2 after PulseRider-assisted coil embolization. A woman in her 70s underwent coil embolization for a subarachnoid hemorrhage with ruptured BTA 16 years ago. Recurrence was detected at 6-year follow-up, and an additional coil embolization was performed. Nevertheless, gradual recurrence still occurred, and PulseRider-assisted coil embolization was performed without any complications 9 years after the second treatment. However, recurrence was detected once more at 6-month follow-up. Thus, stent-assisted coil embolization using Enterprise 2 (Cerenovus) through PulseRider was selected for angular remodeling. Enterprise 2 was deployed between the right P2 segment of the posterior cerebral artery (PCA) and basilar artery (BA) after an effective coil embolization, which achieved effective angular remodeling between the right PCA and BA. The patient's postoperative course was uneventful, and no recanalization was detected after half a year. Although PulseRider is effective for wide-neck aneurysm treatment, recurrence remains a possibility. Additional treatment using Enterprise 2 is safe and effective with the expectation of angular remodeling.

Subclavian Artery-Carotid Artery Bypass for Subclavian Artery or Common Carotid Artery Severe Stenosis or Occlusion.

Various surgical treatments are available for occlusive subclavian and common carotid artery diseases. Nevertheless, to date, when cerebral endovascular treatment is utilized, revascularization via direct surgery may be required. This study reported five symptomatic cases of revascularization for CCA and SCA occlusive and stenotic lesions that were expected to be challenging to treat with endovascular treatment. We performed subclavian artery-common carotid artery or internal carotid artery bypass using artificial blood vessels or saphenous vein grafts in five patients with subclavian steal syndrome, symptomatic common carotid artery occlusion, and severe proximal common carotid artery stenosis. In this study, good bypass patency was achieved in all five cases. Although there were no intraoperative complications, one patient had a postoperative lymphatic leak. Moreover, there was no recurrence of stroke during postoperative follow-up for an average of 2 years. Conclusively, subclavian artery-common carotid artery bypass can be an effective surgical treatment for common carotid artery occlusion, proximal common carotid artery stenosis, and subclavian artery occlusion.

Cerebral hyperperfusion syndrome after stenting for revascularization of intracranial internal carotid artery dissection.

Cerebral hyperperfusion syndrome (CHS) is one of the complications of cerebral revascularization. The main pathophysiology of CHS was considered to be cerebral autoregulation impairment due to long-standing cerebral hypoperfusion. Herein, we describe the case of a 40-year-old man with symptomatic intracranial arterial dissection (IAD) related to internal carotid artery stenosis. The patient underwent intracranial stenting 11 days after onset due to severe cerebral hypoperfusion presenting with neurological symptoms, and CHS presenting with intracerebral hemorrhage, post-operatively. The present case indicated not only the potential risk of CHS after intracranial stenting in IAD-related stenosis but also that cerebral hypoperfusion-even in a short period-might lead to CHS.

Using a novel CLEM system to localize lipid droplets and membranes in desiccated embryonic axis cells of soybean seeds.

Lipid droplets and membranes in radicle cells from desiccated embryonic axes of soybean (Glycine max) seeds were examined by a recently developed correlative light and electron microscopy system, which has been designed to facilitate the observation of identical locations using an upright reflected light microscope and compact SEM successively with minimum time lapse. Lipids are major components of membranes and are also stored in numerous lipid droplets lining plasma membranes in many seed cells. Fluorescently stained lipid droplets and membranes in the desiccated radicle cells were mainly located along the surface of shrunk protoplasm and around presumptive protein bodies, which will turn into vacuoles and increase their volume for radicle protrusion. Co-localization of lipid droplets and membranes suggests the presence of a membrane protection mechanism during desiccation and rehydration processes that ensures prompt elongation of radicle cells during germination.

Urgent Carotid Artery Stenting with Intracranial and Carotid Stent for Symptomatic Bilateral Consecutive Internal Carotid Artery Dissection: A Case Report.

Spontaneous internal carotid artery dissection (CAD) is a relatively rare disease, with patients, including those with bilateral CAD, often recovering after conservative therapy. However, patients with symptomatic and progressive disease require urgent carotid artery stenting (CAS). If CAD extends to the petrous portion of the internal carotid artery (ICA), it is difficult to treat with a carotid stent alone. This report describes a rare case of consecutive spontaneous bilateral CAD that required an intracranial stent with an interval of 4 years between the first and second CAS. A 58-year-old man with a history of dyslipidemia was admitted for transient ischemic attacks. He underwent CAS with carotid and intracranial stents on the third day for the left CAD due to exacerbation of symptoms under antithrombotic therapy and new stroke on magnetic resonance imaging (MRI). He recovered well. However, 4 years after the initial treatment, the patient was admitted again because of a sudden headache, photophobia, and transient weakness of the left lower limb. He was diagnosed with CAD on the contralateral side. He underwent CAS with carotid and intracranial stents due to progressive neurological deterioration under antithrombotic therapy. After treatment, he was clinically stable without any new infarctions on a follow-up MRI. He was discharged without neurological deficit. Our case of bilateral internal CAD treatment demonstrated that early revascularization with immediate stenting with carotid and intracranial stents in CAD contributes to the prevention of extensive neurological damage, thereby providing a favorable outcome in some cases.

A Case of Cavernous Malformation of the Midbrain Removed via an Interhemispheric Transcallosal Subchoroidal Approach.

Cavernous malformations of the midbrain have a higher rate of hemorrhage and a poorer prognosis than vascular malformations of other brain areas. Surgical resection of these lesions is often necessary to avoid neurological deficits in affected patients. Herein, the literature surrounding cavernous malformations was examined, and the case of a 48-year-old man with left hemiparesis and diplopia caused by incomplete right oculomotor nerve palsy, who was diagnosed with a hemorrhage from a midbrain cavernous malformation, was discussed. The lesion expanded gradually on magnetic resonance imaging and was symptomatic; radical removal of the lesion before the onset of irreversible symptoms due to recurring bleeding was therefore considered to be beneficial for the patient. Surgical removal of the entire cavernous malformations of the midbrain was performed using an interhemispheric transcallosal subchoroidal approach, with excellent postoperative results and complete recovery from the oculomotor nerve palsy and left hemiparesis. This case shows that this approach is the most appropriate for surgical resections of lesions in the upper midbrain.

Kissing Aneurysms of the Posterior Inferior Cerebellar Artery Treated by Anchor Coil Technique and Stenting from the Contralateral Side: A Case Report.

Kissing aneurysms refer to the condition in which two cerebral aneurysms with separate necks are in contact with each other. At present, there is scarce information on kissing aneurysms occurring near the vertebral artery (VA)-posterior inferior cerebellar artery (PICA). We report the first case of VA-PICA and nonbranched PICA kissing aneurysms, which were successfully treated with contralateral stenting after the anchor coil technique using two microcatheters. A 64-year-old woman was diagnosed with a left VA-PICA aneurysm (5.5 mm) and an adjacent small PICA aneurysm (2.5 mm) with the aneurysmal walls in close contact. For stenting, microcatheters were navigated to the PICA from the contralateral side, and framing coils for the anchor were placed into each aneurysm from the ipsilateral side. Next, a Neuroform Atlas stent was deployed from the PICA to the distal side of the VA, and coiling was completed using the jailing technique. The patient had a good postoperative course, and a left vertebral angiogram revealed complete occlusion of both aneurysms after 6 months. Adequate surgical planning and application of an appropriate stent-assisted coil embolization technique contributed to the success of the procedure in this rare case.

Triple bypass for multisystem smooth muscle dysfunction syndrome due to Arg179His ACTA2 mutation.

Missense mutations in the smooth muscle-specific isoform of the alpha-actin (ACTA2) gene, which encodes smooth muscle actin, congenitally cause systemic smooth muscle dysfunction, leading to multiple systemic smooth muscle dysfunction syndrome. This disease is often diagnosed through the development of congenital mydriasis, patent ductus arteriosus, or thoracic aortic aneurysm at a young age. Some patients develop cerebrovascular lesions, also known as ACTA2 cerebral arteriopathy, which cause ischemic stroke and require surgical revascularization. However, an effective and safe treatment has not yet been established owing to the rarity of the disease. Furthermore, most reports of this disease involve children, with only a few reports on adults and few detailed reports on treatment outcomes published to date. We report a 46-year-old woman with ACTA2 cerebral arteriopathy caused by Arg179His, the most common mutation in this disease; she is the oldest patient reported with this disease to the best of our knowledge. The patient was diagnosed with multiple systemic smooth muscle dysfunction syndrome and ACTA2 cerebral arteriopathy after experiencing a stroke in the right cingulate gyrus. She underwent direct triple bypass with three anastomoses of the right superficial temporal artery to the middle and anterior cerebral arteries. She developed an ischemic stroke as a postoperative complication.The efficacy and safety of this procedure have not been clearly confirmed owing to the frailty of the donor superficial temporal artery and the poor development of collateral circulation; however, direct bypass should be considered a treatment option for patients experiencing progressive multiple strokes.

Prediction of Cross-Clamp-Induced Cerebral Ischemia During Carotid Endarterectomy Using Arterial Blood Flow Assessment.

BACKGROUND: Cross-clamping during carotid endarterectomy (CEA) is associated with the risk of cerebral ischemia. Various studies have evaluated different criteria for detecting cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid artery is cross-clamped and incised. Here, we explored a parameter that can predict cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter. METHODS: The carotid arterial blood flow was measured directly (direct ABF) in the common carotid artery prior to cross-clamping. The anatomical information in preoperative magnetic resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and carotid peak systolic flow velocity by carotid echo from the skin surface were also evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP) during cross-clamping to insert a shunt was assessed, and a decrease in amplitude of ≥ 50% was considered an indicator for cerebral ischemia. Surgery was performed under general anesthesia, and a shunt was inserted in all cases. RESULTS: Of 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during cross-clamping. The baseline characteristics and intra- and postoperative findings were not significantly different between patients with and without a decrease in SSEP. Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) differed significantly between the 2 groups (P = 0.011). The direct-ABF ratio ≤ 0.58 was predictive of cerebral ischemia during CEA. CONCLUSIONS: Direct-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting cerebral ischemia prior to carotid artery cross-clamping during CEA.

Occipital artery to middle cerebral artery bypass in pediatric moyamoya disease: rescue therapy after failed revascularization.

OBJECTIVE: Patients with pediatric moyamoya disease (PMMD) showing recurrent symptoms or decreased cerebral blood flow after initial revascularization therapy may require additional revascularization to improve their clinical condition. The authors evaluated the clinical and hemodynamic benefits of an occipital artery (OA)-middle cerebral artery (MCA) bypass for patients with PMMD who have undergone an initial revascularization procedure. METHODS: The authors retrospectively identified 9 patients with PMMD who had undergone OA-MCA bypass between March 2013 and December 2017, and who had received a previous superficial temporal artery-MCA bypass. The following clinical data were collected: initial revascularization procedure, symptoms (presence or recurrence), pre- and postoperative cerebral blood flow and cerebrovascular reactivity (CVR) changes, posterior cerebral artery (PCA) stenosis, PCA-related and nonrelated symptoms, and latest follow-up. RESULTS: Preoperatively, all patients (n = 9) suffered non-PCA-related recurrent symptoms, and 4 had PCA-related symptoms. At 1-year follow-up, all patients with PCA-related symptoms showed complete recovery. Additionally, 8 (89%) patients with non-PCA symptoms experienced improvement. Only 1 (11%) patient showed no improvement after the surgical procedure. The mean pre- and postoperative CVR values of the MCA territory were 14.8% and 31.3%, respectively, whereas the respective mean CVR values of the PCA territory were 22.8% and 40.0%. CONCLUSIONS: The OA-MCA bypass is an effective rescue therapy to improve the clinical condition and hemodynamic changes caused by PMMD in patients who experience recurrent symptoms after initial revascularization.

Intracranial Mycotic Aneurysm after Left Ventricular Assist Device Implantation Treated with Trans-arterial Embolization via the Brachial Artery: A Case Report.

Implantation of left ventricular assist device (LVAD) is widely performed in patients with end-stage chronic heart failure. Infection and stroke are major complications after LVAD implantation. However, the incidence of intracranial mycotic aneurysm after LVAD implantation is rare, and with no standard of care. In this study, we describe a case of an intracranial mycotic aneurysm after LVAD implantation that was successfully treated with trans-arterial embolization (TAE) with N-butyl 2-cyanoacrylate (NBCA) via the brachial artery. A 49-year-old man with a history of implantation of LVAD for ischemic cardiomyopathy was admitted to our institution. He had infectious endocarditis and was administered systemic antibiotics. At 3 weeks after admission, intracranial mycotic aneurysm of the left posterior parietal artery was detected during a diagnostic examination for asymptomatic intracranial hemorrhage. Anticoagulant therapy was administered to prevent thromboembolic complications of LVAD implantation. Under local anesthesia, TAE with NBCA was performed via the brachial artery because of the tortuous anatomy of the origin of the innominate artery and implant of the aortic arch. The aneurysm was completely obliterated. The patient was discharged without neurological deficits. TAE using NBCA could be an effective modality for the treatment of intracranial mycotic aneurysm after LVAD implantation.

Selection of approach and bypass for fetal-type posterior cerebral artery aneurysm: illustrative cases.

BACKGROUND: Unlike in aneurysms of the adult-type posterior cerebral artery (PCA), in aneurysms of the fetal-type PCA, parent artery occlusion (PAO) results in vascular insufficiency and major ischemic strokes. Preservation or reconstruction of fetal-type PCAs is necessary to prevent these complications. Furthermore, it is necessary to select an appropriate bypass method and approach for revascularization of the PCA. OBSERVATIONS: The authors report 2 cases of aneurysms of fetal-type PCAs that were successfully treated with PAO with revascularization. A 38-year-old man with a large unruptured right PCA aneurysm at the postcommunicating (P2) segment underwent trapping with superficial temporal artery-PCA bypass via the anterior temporal and subtemporal approaches. In addition, a 45-year-old woman with a left PCA aneurysm at the quadrigeminal (P3)-cortical (P4) segments resulting in subarachnoid hemorrhage underwent proximal clipping of the P3 segment via the occipital interhemispheric approach with an occipital artery-PCA bypass. Although she had perforator infarction, major ischemic stroke was prevented, and aneurysm occlusion was accomplished in both cases. LESSONS: Aneurysms of fetal-type PCAs pose a risk of ischemia due to PAO. The combined use of bypass and revascularization should be considered to prevent major ischemic stroke after occlusion of the fetal-type PCA. However, perforator infarction is a concern.

Results of surgical treatment after Gamma Knife radiosurgery for cerebral arteriovenous malformations: patient series.

BACKGROUND: Gamma Knife radiosurgery (GKRS) is a safe and effective treatment, but it has a risk of bleeding. Herein, the authors describe their experience with some patients who required surgical removal of cerebral arteriovenous malformations (AVMs) located mainly in eloquent areas of the brain after GKRS, and they consider the advantages of surgical removal after GKRS. OBSERVATIONS: Twelve patients who had undergone surgical removal of AVMs after GKRS at Tokyo Women's Medical University between April 2013 and July 2019 were selected for analysis. All participants underwent GKRS as first-line therapy for AVMs located in an eloquent region or if requested by the patient. Complete obliteration was achieved in 7 patients, and the size of the nidus decreased in 3 patients during the follow-up period. The Spetzler-Martin grade decreased in 11 patients. Three patients experienced symptomatic intracerebral hemorrhage before and after confirmation of complete obliteration of the nidus via GKRS, and 7 patients experienced some neurological deficits because of an encapsulated expanding hematoma. All patients underwent resection of the nidus without complications. The preoperative neurological deficits improved in 6 patients and remained unchanged in 6 patients. LESSONS: This report indicates that performing GKRS before surgery may be useful for future multimodal therapy.

High-flow bypass using saphenous vein grafts with trapping of ruptured blood blister-like aneurysms of the internal carotid artery: patient series.

BACKGROUND: Trapping an aneurysm after the establishment of an extracranial to intracranial high-flow bypass is considered the optimal surgical strategy for ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA). For high-flow bypass surgeries, a radial artery graft is generally preferred over a saphenous vein graft (SVG). However, SVGs can be advantageous in acute-phase surgeries because of their greater length, easy manipulability, ability to act as high-flow conduits, and reduced risk of vasospasms. In this study, the authors presented five cases of ruptured BBAs treated with high-flow bypass using an SVG followed by BBA trapping, and they reported on surgical outcomes and operative nuances that may help avoid potential pitfalls. OBSERVATIONS: After the surgeries, there were no ischemic or hemorrhagic complications, including symptomatic vasospasms. In three of the five cases, postoperative modified Rankin scale scores were between 0 and 2 at the 3-month follow-up. In one case, the SVG spontaneously occluded after surgery while the protective superficial temporal artery (STA) to middle cerebral artery (MCA) bypass became dominant, and the patient experienced no ischemic symptoms. LESSONS: High-flow bypass using an SVG with a protective STA-MCA bypass followed by BBA trapping is a safe and effective treatment strategy.

Mechanical thrombectomy in acute ischemic stroke patients with left ventricular assist device.

OBJECTIVES: As the number of patients with left ventricular assist device (LVAD) implantation has been increasing, treatment of LVAD-related ischemic stroke is becoming a critical issue. We sought to clarify the features of mechanical thrombectomy in LVAD-related stroke with large vessel occlusion. METHODS: In a multi-center, retrospective case-control study, we compared 20 LVAD-related strokes with 33 non-LVAD strokes, all of which had large vessel occlusion in the anterior circulation treated with mechanical thrombectomy. A comparative histopathological examination of the retrieved thrombi was also performed. RESULTS: Successful reperfusion was achieved in 75% of the LVAD-related strokes. The time from onset to reperfusion was similar to that of non-LVAD strokes, but the total number of device passes required for reperfusion (median, 2.5 versus 1, P = 0.01) and the incidences of post-procedural parenchymal and subarachnoid hemorrhage (25% versus 3%, P = 0.02 and 55% versus 15%, P = 0.01, respectively) were higher in LVAD-related strokes. Symptomatic intracranial hemorrhage occurred in 4 patients (20%) with LVAD-related strokes. The histopathological analysis revealed that the ratio of erythrocyte components was significantly lower in thrombi retrieved from patients with LVAD-related stroke than in those with non-LVAD stroke (19 ± 6% versus 41 ± 17%, P = 0.01). CONCLUSIONS: Mechanical thrombectomy is feasible in patients with LVAD-related stroke. However, repetitive device passes are needed to achieve successful reperfusion mainly because of the structurally organized thrombi, and the higher risk of hemorrhagic complications should be considered, while offering this therapeutic alternative.

Isolated Posterior Spinal Artery Aneurysm Presenting with Spontaneous Thrombosis After Subarachnoid Hemorrhage.

BACKGROUND: The cause of subarachnoid hemorrhage is more likely to be intracranial than spinal. Bleeding, although common with spinal arteriovenous malformations and spinal cord tumors, rarely occurs with ruptured isolated spinal artery aneurysms. Here, we report a case of isolated thoracic posterior spinal artery aneurysm presenting with thrombosis after subarachnoid hemorrhage. CASE DESCRIPTION: A 67-year-old woman presented with sudden-onset nausea and low back and right thigh pain that worsened with movement. Computed tomography (CT) and magnetic resonance imaging (MRI) scans of the head suggested a small subarachnoid hemorrhage in the high-convexity sulcus, and lumbar puncture showed bloody cerebrospinal fluid. There was no apparent intracranial aneurysm on CT angiography; however, spinal MRI showed a lesion on the right side of the spinal cord at Th10. Contrast-enhanced CT showed an enhancing lesion at this site on day 7 that was not present on day 15. Selective right Th10 intercostal artery angiography on day 22 showed no evidence of aneurysm. The lesion was suspected to be a thrombotic spinal artery aneurysm. Given the unclear natural history of this entity, surgery was performed on day 36. After right Th10 hemilaminectomy and opening the dura, the arachnoid and adhesions were found to be thickened. A fusiform-shaped thrombosed aneurysm continuous with the radiculopial artery was removed. The patient was discharged without neurologic deterioration. CONCLUSIONS: Isolated spinal artery aneurysm is a rare cause of subarachnoid hemorrhage. It is expected that additional cases will clarify the natural history and indications for treatment.

Effect of Direct Neurologic Evaluation on Outcomes During Treatment of Unruptured Intracranial Aneurysms Under Local Anesthesia.

OBJECTIVE: The greatest advantage of local anesthesia (LA) in endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is that direct neurologic evaluation can be performed during the procedure, unlike with general anesthesia. However, the usefulness of such direct evaluation has not been established. In this study, we attempted to assess the effects of direct neurologic evaluation by identifying the causes, management, and outcomes of clinical symptoms during the procedure and procedure-related events during EVT under LA. METHODS: We retrospectively evaluated the medical and radiologic data of 1000 patients (1015 UIAs) who had undergone coil embolization under LA from 2008 to 2016. RESULTS: Clinical symptoms were identified in 62 patients (6.2%) during the procedure. The symptoms improved during the procedure in 27 of these patients (44%) and after the procedure in another 28 (45%). One month after the procedure, 55 patients (89%) had good outcomes and 7 (11%) had poor outcomes. Procedure-related events occurred in 67 patients (6.7%); of these 67 events, 39 were symptomatic and 28 were asymptomatic. Thirty-five of the 39 symptomatic events (90%) [13 of 13 (100%) ruptures, 6 of 10 (60%) thrombus formations, and 16 of 16 (100%) thromboembolisms] were detected on the basis of clinical symptoms before angiographic changes were identified, and they were managed promptly. All 28 patients with asymptomatic events were managed safely without further complications before symptoms developed. CONCLUSIONS: We demonstrated that appropriate management of clinical symptoms and procedure-related events under LA led to favorable outcomes of EVT of UIAs.