Patient with Diffuse Midline Glioma, H3 K27-altered, Carrying an FGFR1 Mutation Who Experienced Thalamic Hemorrhage: A Case Report and Literature Review.

Diffuse midline glioma (DMG), H3 K27M-altered, is a tumor with a poor prognosis mainly found in children. An adolescent patient presented with thalamic hemorrhage, which initially could not be diagnosed as DMG by pathological analysis. A neoplasm in the lateral ventricle close to the previous thalamic hemorrhagic lesion was detected 12 months after the hemorrhage. Thus, endoscopic resection was performed, and a diagnosis was made. Gene expression profiling demonstrated mutation in genes, such as H3F3A and FGFR1. FGFR1 mutation was associated with intratumoral hemorrhage in low-grade gliomas and contributed to longer survival than wild-type FGFR1 in DMG H3K27M. Our findings suggest that patients with DMG, H3 K27-altered, with FGFR1 mutation may be predisposed to intratumoral hemorrhaging and/or have a longer survival time than patients without FGFR1 mutation.

Features of postoperative hearing function changes in patients with cerebellopontine angle and intratemporal tumors other than vestibular schwannomas.

OBJECTIVE: Tumors around the cerebellopontine angle (CPA) and temporal bone can potentially affect hearing function. In patients with such tumors other than vestibular schwannomas (VSs), auditory tests were investigated before and after surgery to characterize the auditory effect of each tumor and to determine prognostic factors. METHODS: A total of 378 patients were retrospectively evaluated for hearing functions before and after surgery. These 378 patients included 168 with CPA meningioma, 40 with trigeminal schwannoma (TS), 55 with facial nerve schwannoma (FNS), 64 with jugular foramen schwannoma (JFS), and 51 with CPA epidermoid cyst (EPD). RESULTS: Preoperative hearing loss was observed in 124 (33%) of the 378 patients. Of these 124 patients, 38 (31%) experienced postoperative hearing improvement. Postoperative hearing deterioration occurred in 67 (18%) of the 378 patients. The prognostic factors for postoperative hearing improvement were younger age and the retrocochlear type of preoperative hearing disturbance. Tumor extension into the internal auditory canal was correlated with preoperative hearing loss and postoperative hearing deterioration. Preoperative hearing loss was observed in patients with FNS (51%), JFS (42%), and MGM (37%), and postoperative hearing improvement was observed in patients with JFS (41%), MGM (31%), and FNS (21%). Postoperative hearing deterioration was observed in patients with FNS (27%), MGM (23%), and EPD (16%). CONCLUSIONS: According to the results of this study in patients with CPA and intratemporal tumors other than VS, preoperative retrocochlear hearing disturbance was found to be a prognostic factor for hearing improvement after surgery. Among the tumor types, JFS and MGM had a particularly favorable hearing prognosis. The translabyrinthine approach and cochlear nerve section should be avoided for these tumors, regardless of the patient's preoperative hearing level.

Resection of petroclival clear cell meningioma by the anterior transpetrosal approach: diagnosis of rare pathology and improvement of preoperative hearing disturbance.

Clear cell meningioma is a rare histological variant of meningioma, which often recurs aggressively. This video demonstrates a patient with a petroclival clear cell meningioma, which was resected completely through the anterior transpetrosal approach. The absence of intratumoral spotty signal voids on preoperative susceptibility-weighted imaging (SWI) suggested that the tumor was a meningioma rather than a schwannoma, although typical imaging features of meningioma were not observed. After surgery, the patient's preoperative hearing disturbance improved from class D to class A, which the authors had sometimes experienced in cerebellopontine angle meningioma surgeries. Careful observation over a 2.5-year period revealed no tumor recurrence, without additional treatment. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21219.

Pediatric vestibular schwannoma without evidence of neurofibromatosis: consecutive 18 microsurgical experiences.

PURPOSE: Sporadic vestibular schwannoma (VS) is rare in children in contrast to adults, and detailed investigations of case series of these patients using a single fixed protocol are scarce. This study presents our surgical experience of pediatric VSs without clinical evidence of neurofibromatosis type 2 (NF2) at the initial diagnosis. METHODS: Among 1385 consecutive sporadic VS surgeries, 18 pediatric patients (1.3%; 11-18 years old) were retrospectively investigated. RESULTS: The most common initial symptom was hearing disturbance (72.2%), and 6 patients (33.3%) experienced a delayed diagnosis (over 2 years after initial symptom onset). Preoperative image characteristics of these tumors included a solid tumor, hypervascularity, and significant extension into the internal acoustic meatus, when compared with adults. Preoperative embolization was successfully accomplished for 2 recent hypervascular tumors. The tumor resection rate was 95-100% under sufficient intraoperative neuromonitoring, and no additional surgery was required during the follow-up period (average: 57.9 months). No patients experienced permanent facial nerve palsy, and serviceable hearing function was preserved in 6 of 11 patients. Signs of NF2, such as bilateral VSs, were not identified in any patients during the follow-up. CONCLUSION: Safe and sufficient tumor resection was achieved under detailed neuromonitoring in pediatric patients with sporadic VS, although this tends to be difficult owing to hypervascularity, a small cranium, and significant meatal extension. Preoperative embolization may help safe resection of hypervascular tumors. Subsequent development of NF2 has not been observed up to the most recent follow-up, but careful observation is essential for these younger patients.

Radio-pathological characteristics of malignant transformation of an epidermoid cyst in the cerebellopontine angle: A case report.

Background: Intracranial epidermoid cysts are rare congenital neoplasms that are clinically indolent and histologically benign. They rarely show malignant transformation, and several such cases have been reported. Some radiological features that suggest malignant transformation have been reported. However, histopathological features that indicate a high risk of malignant transformation have not been reported to date. Case Description: We report a 59-year-old woman with a benign epidermoid cyst in the cerebellopontine angle that showed malignant transformation after 6 years. Magnetic resonance imaging (MRI) at the time of initial onset displayed a high-intensity signal on diffusion-weighted imaging (DWI), no peritumoral edema, and no enhancement on contrast-enhanced T1-weighted imaging. On the other hand, MRI at the time of malignant transformation showed a low-intensity signal on DWI, peritumoral edema, and enhancement of the tumor capsule on contrast-enhanced T1-weighted imaging. Pathological findings at the time of the first surgery differed from normal benign epidermoid cysts, in that stratified squamous epithelial metaplasia was observed, and immunohistochemical (IHC) analysis showed positive p53 staining. In addition, IHC analysis at the time of malignant transformation demonstrated positive p16 staining. Conclusion: In benign epidermoid cysts, it is considered to cause malignant transformation when squamous metaplasia or p53 mutation is observed. Therefore, strict follow-up is required while paying attention to the characteristic changes in MRI for early detection and timely treatment of malignant transformation.

Preoperative Facial Nerve Palsy in Patients With Vestibular Schwannoma: Clinical Features and Postoperative Functional Prognosis in a Case Series of 34 Among 1228 Consecutive Patients.

BACKGROUND: Facial nerve palsy is a rare presenting symptom of vestibular schwannomas and has not been investigated in detail. OBJECTIVE: To investigate the incidence, clinical features, and postoperative long-term outcomes of facial nerve function in patients with vestibular schwannomas causing preoperative facial nerve palsy. METHODS: After excluding patients with neurofibromatosis type 2 and those with prior treatment, 1228 consecutive patients who underwent vestibular schwannoma surgery were retrospectively investigated. Patients with and without preoperative facial nerve palsy were compared statistically to clarify their clinical features. RESULTS: Preoperative tumoral facial nerve palsy was seen in 34 patients (2.8%). Their clinical features included older age, having large cystic tumors with significant meatal extension, and showing abnormal electrogustometric responses, compared with patients without preoperative facial nerve palsy. Owing to the frequent insufficient intraoperative responses on facial nerve electromyography, the tumor resection rate was lower in the group with preoperative facial nerve palsy (mean: 95.2%). Among the 33 patients with sufficient follow-up data (mean: 63.9 mo), additional treatment was required only in 1 patient and facial nerve function improved in 25 patients (75.8%) within 2 yr postoperatively. CONCLUSION: Facial nerve palsy is a rare preoperative symptom that occurs in less than 3% of patients with vestibular schwannoma. Tumor resection in such patients tends to be challenging owing to their advanced age, having large cystic tumors with significant meatal extension, and difficulties in intraoperative facial nerve monitoring, but surgical decompression of the facial nerve can assist in the improvement of their long-term functions.

Intraoperative Continuous Neuromonitoring for Vestibular Schwannoma Surgery: Real-Time, Quantitative, and Functional Evaluation.

In vestibular schwannoma surgery, neuromonitoring is essential to accomplish sufficient tumor resection while avoiding neurologic damage.1-3 An ideal neuromonitoring method should include a real-time alert system, quantitative evaluation, and functional (not mechanical) assessment.4Video 1 demonstrates facial and hearing preservation surgery for vestibular schwannoma by the retrosigmoid transmeatal approach, under intraoperative continuous facial nerve monitoring and auditory brainstem response. Using a ball-type stimulating electrode placed on the proximal facial nerve, the evoked facial nerve electromyograms were continuously monitored by direct 1-Hz stimulation throughout the near-total tumor resection. The patient had no postoperative facial or hearing deterioration. The patient consented to the procedure before the surgery.

Importance of appropriate surgical approach selection for radical resection of cerebellopontine angle epidermoid cysts with preservation of cranial nerve functions: our experience of 54 cases.

BACKGROUND: Although many reports state that only the lateral suboccipital retrosigmoid approach (LSO) should be used for removal of cerebellopontine angle (CPA) epidermoid cysts, it is preferable to use various surgical approaches as appropriate for each patient, for radical resection with an optimal operative field under direct visualization, and for the preservation of cranial nerve (CN) functions. In the present study, we hence focused on the importance of surgical approach selection for removal of CPA epidermoid cysts and analyzed the results of CPA epidermoid cysts after surgery in our series. METHODS: Fifty-four patients who underwent surgery for CPA epidermoid cysts were retrospectively analyzed, regarding their surgical approaches, removal rates, preservation rates of CN function 1 year after surgery, and recurrence. Surgical approaches were selected for patients according to the size and extension of the tumor. RESULTS: Surgical approaches consisted of LSO (20 cases), anterior transpetrosal approach (ATP; 3 cases), combined transpetrosal approach (27 cases), and ATP + LSO (4 cases). Mean tumor content removal and capsule removal rates were 97.4% and 78.3%, respectively. Preservation rates of facial nerve function and useful hearing were 94.4% and 90.7%, respectively. The mean postoperative follow-up time was 62.8 months, and there were two cases of recurrence requiring reoperation about 10 years after surgery. CONCLUSIONS: For CPA epidermoid cyst surgeries, selection of the appropriate surgical approach for each patient and radical resection with an optimal operative field under direct visualization enable tumor removal without the need for reoperation for a long time, with preservation of CN functions.

Intraoperative continuous vagus nerve monitoring with repetitive direct stimulation in surgery for jugular foramen tumors.

OBJECTIVE: Surgery for tumors around the jugular foramen has significant risks of dysphagia and vocal cord palsy due to possible damage to the lower cranial nerve functions. For its treatment, long-term tumor control by maximum resection while avoiding permanent neurological damage is required. To accomplish this challenging goal, the authors developed an intraoperative continuous vagus nerve monitoring system and herein report their experience with this novel neuromonitoring method. METHODS: Fifty consecutive patients with tumors around the jugular foramen (34 jugular foramen schwannomas, 11 meningiomas, 3 hypoglossal schwannomas, and 2 others) who underwent microsurgical resection under continuous vagus nerve monitoring within an 11-year period were retrospectively investigated. Evoked vagus nerve electromyograms were continuously monitored by direct 1-Hz stimulation to the nerve throughout the microsurgical procedure. RESULTS: The average resection rate was 96.2%, and no additional surgery was required in any of the patients during the follow-up period (average 65.0 months). Extubation immediately after surgery and oral feeding within 10 days postoperatively were each achieved in 49 patients (98.0%). In 7 patients (14.0%), dysphagia and/or hoarseness were mildly worsened postoperatively at the latest follow-up, but tracheostomy or gastrostomy was not required in any of them. Amplitude preservation ratios on intraoperative vagus nerve electromyograms were significantly smaller in patients with postoperative worsening of dysphagia and/or hoarseness (cutoff value 63%, sensitivity 86%, specificity 79%). CONCLUSIONS: Intraoperative continuous vagus nerve monitoring enables real-time and quantitative assessment of vagus nerve function and is important for avoiding permanent vagus nerve palsy, while helping to achieve sufficient resection of tumors around the jugular foramen.

Long-term prognosis of preserved useful hearing after surgery in patients with vestibular schwannoma: a study of 91 cases.

BACKGROUND: In patients with a vestibular schwannoma, some studies have reported that useful hearing preserved initially after surgery deteriorates gradually in the long term. Studies with more patients are needed to clarify the maintenance rate of postoperative hearing function and to identify prognostic of hearing function. METHOD: Ninety-one patients (mean age, 39.5 years; mean tumor size, 18.9 mm) with preserved useful hearing immediately after surgery were retrospectively analyzed. The useful hearing was defined as the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) classes A and B. Hearing tests, including auditory brainstem responses (ABR) and distortion product otoacoustic emissions (DPOAE), were evaluated preoperatively, immediately after surgery, and at outpatient follow-up. RESULTS: At the final follow-up (mean, 63.0 months), the useful hearing was maintained in 79 patients (87%), and the hearing class remained unchanged during the follow-up period in 40 patients (44%). Significant predictors of useful hearing maintenance were AAO-HNS class A immediately after surgery, improvement of ABR, and the absence of postoperative DPOAE deterioration. Postoperative DPOAE deterioration correlated with hearing class deterioration. CONCLUSIONS: Despite hearing being preserved in vestibular schwannoma patients immediately after surgery, Thirteen percent lost their useful hearing during the long follow-up period, and hearing class worsened in 55% of the patients. This study, which analyzed one of the largest series of vestibular schwannoma patients, demonstrated that retrocochlear condition is a key factor for useful hearing maintenance. In patients with vestibular schwannoma who have preserved hearing function, regular postoperative monitoring of hearing function is as important as regular MRI.

Management of Sigmoid Sinus Injury: Retrospective Study of 450 Consecutive Surgeries in the Cerebellopontine Angle and Intrapetrous Region.

BACKGROUND: The sigmoid sinus is the biggest obstacle when approaching the posterior fossa and temporal bone. Adequate sinus exposure is required to obtain a sufficient operative field, but sinus injury is a potentially life-threatening complication. OBJECTIVE: To present our experience of sigmoid sinus injury and its management during surgeries in the cerebellopontine angle and intrapetrous region, with operative videos. METHODS: A total of 450 consecutive surgeries (385 retrosigmoid and 65 transmastoid approaches) over a 4-yr period were retrospectively investigated, focusing on sigmoid sinus injury, its repair technique, and long-term patency of the sinus. RESULTS: Pinhole-sized bleedings were controlled sufficiently by bipolar coagulation or fibrin glue-soaked hemostatic fabric. For lacerations of smaller than 3 mm, the sinus wall was reconstructed by suturing. For larger or unsuturable holes, patching a Gore-Tex membrane on a fibrin glue sheet (without any suturing) was used for the reconstruction. Hemostatic agents were not used for large lacerations to avoid any potential risks of delayed sinus occlusion. Major sinus injury requiring suturing or Gore-Tex patching occurred in 13 cases (2.9%). The bleeding was immediately controlled without sinus clamping, and surgery was not discontinued owing to the injury in any of them. The patients had no postoperative symptoms associated with sinus injury. In all the reconstructed sinuses, patency was confirmed on magnetic resonance imaging at the final follow-up. CONCLUSION: Sigmoid sinus injury can be well managed with long-term patency by utilizing different repair techniques. Initial safe and adequate exposure around the injury site was essential for all of these repair procedures.

Arterial spin labeling imaging correlates with the angiographic and clinical vascularity of vestibular schwannomas.

PURPOSE: Hypervascular vestibular schwannomas (HVSs) are a type of the vestibular schwannomas (VSs) that are extremely difficult to remove. We examined whether HVSs can be predicted by using arterial spin labeling (ASL) imaging. METHODS: A total of 103 patients with VSs underwent ASL imaging and digital subtraction angiography (DSA) before surgery. Regional cerebral blood flow (CBF) of gray matter and regional tumor blood flow (TBF) were calculated from ASL imaging, and we defined the ratio of TBF to CBF as the relative TBF (rTBF = TBF/CBF). Angiographic vascularity was evaluated by DSA, and clinical vascularity was evaluated by the degree of intraoperative tumor bleeding. Based on the angiographic and clinical vascularity, the VSs were divided into two categories: HVS and non-HVS. We compared rTBF with angiographic and clinical vascularities, retrospectively. RESULTS: The mean rTBFs of angiographic non-HVSs and HVSs were 1.29 and 2.58, respectively (p < 0.0001). At a cutoff value of 1.55, the sensitivity and specificity were 93.9% and 72.9%, respectively. The mean rTBFs of clinical non-HVS and HVSs were 1.45 and 2.22, respectively (p = 0.0002). At a cutoff value of 1.55, the sensitivity and specificity were 79.4% and 66.7%, respectively. CONCLUSION: The rTBF calculated from ASL imaging correlates well with tumor vascularity and may be useful for predicting HVSs before surgery.

Microvascular decompression for trigeminal neuralgia caused by trigeminocerebellar artery.

In this operative video, the authors demonstrate the case of a 53-year-old woman who presented with typical right trigeminal neuralgia by a trigeminocerebellar artery (TCA). The TCA was first defined by Marinkovic as a unique branch of the basilar artery supplying both the trigeminal nerve root and the cerebellar hemisphere. As a result of the close relationship between this vessel and the nerve root, the TCA might compress the nerve root, thereby causing trigeminal neuralgia. However, few cases of trigeminal neuralgia caused by TCA have been reported. This video shows the microvascular decompression for trigeminal neuralgia by the TCA. The video can be found here: https://youtu.be/UnGsCQRK6aY.

Retrosigmoid Intradural Suprajugular Approach to Jugular Foramen Tumors with Intraforaminal Extension: Surgical Series of 19 Cases.

OBJECTIVE: The intraforaminal component of jugular foramen tumors is difficult to access surgically, as it requires complex approaches for radical removal and leads to a high recurrence due to residual tumor. The retrosigmoid suprajugular approach, intradural drilling of the roof of the jugular foramen, has been recently proposed for removal of such intraforaminal component without sacrificing the sigmoid-jugular venous system or requiring additional approaches. This study presents our experience with this approach and introduces the use of intraoperative continuous vagus nerve monitoring. METHODS: Nineteen patients (14 with neuromas and 5 with meningiomas) were operated using this approach over a 12.5-year period. In the more recent 14 cases, continuous vagus nerve monitoring was performed with a ball-type electrode placed on the proximal vagus nerve. RESULTS: More than 95% of the tumor removal was achieved in all but the first neuroma case. Extubation immediately after surgery and oral feeding within a week postoperatively was achieved in all patients. Seven of 9 patients with preoperative hearing disturbance symptomatically improved after surgery. All but the first case had no signs of recurrence during the follow-up period (average of 58 months). CONCLUSIONS: The retrosigmoid suprajugular approach is safe and effective for removal of tumors extending into the jugular foramen, maintaining a chance of hearing improvement. Intraoperative continuous vagus nerve monitoring is useful to avoid postoperative complications in such surgeries.

Combined Transpetrosal Approach With Preservation of Superior Petrosal Vein Drainage for a Cerebellopontine Angle Epidermoid Cyst Extending Into Meckel's Cave: 3-Dimensional Operative Video.

The combined transpetrosal approach enables wide exposure around the petroclival region by cutting the tentorium and superior petrosal sinus. We often choose this approach for removal of tumors ventral to the facial and vestibulocochlear nerves, such as petroclival meningioma and epidermoid cyst, because complete removal of the tumor under direct visualization is required to prevent its later recurrence, especially in young patients. Recent reports revealed anatomical variations of the drainage of the superior petrosal sinus, and dural incision considering preservation of the superior petrosal vein was proposed.1-3 This 3-dimensional video shows a patient with an epidermoid cyst, which was surgically treated using the combined transpetrosal approach, with consideration of the variation of the superior petrosal sinus and preservation of the drainage route of the superior petrosal vein. The video was reproduced after informed consent of the patient. The patient is a 31-yr-old woman who presented with a left cerebellopontine angle epidermoid cyst extending into Meckel's cave. The superior petrosal sinus was of the lateral type, draining only laterally into the transverse-sigmoid junction without medial connection with the cavernous sinus.1 The combined transpetrosal approach was performed with cutting of the superior petrosal sinus medial to the entry point of the superior petrosal vein, in order to preserve its drainage into the transverse-sigmoid junction. Meckel' cave was opened along its lateral margin, and tumor removal was accomplished, leaving only a minute part of the capsule strongly adhering to the neurovascular structures. The patient had no new permanent neurological deficits during follow-up. The figures in the video were modified from Matsushima et al1 by permission of the Congress of Neurological Surgeons.

Dorsally Displaced Facial Nerve in Retrosigmoid Transmeatal Approach for Vestibular Schwannoma: 3-Dimensional Operative Video.

Dorsal displacement of the facial nerve is relatively rare in patients with vestibular schwannoma. Its prediction remains difficult in patients with large tumors, even with the recent advances in preoperative radiologic assessments. Anatomic and functional preservation of the facial nerves combined with maximal tumor removal is particularly challenging in this rare anatomic variant, and surgery may lead to postoperative facial dysfunction, inadequate tumor removal, and/or a high retreatment rate.1 This 3-dimensional video (Video 1) demonstrates a vestibular schwannoma with dorsally displaced facial nerve, which was surgically treated by the retrosigmoid transmeatal approach under continuous facial nerve monitoring. The video was reproduced after informed consent of the patient. A 46-year-old man presented with transient hearing impairment. Neuroimaging displayed a left acoustic tumor extending into the internal acoustic meatus. The retrosigmoid transmeatal approach was performed, and a dorsally displaced facial nerve was predicted by preoperative magnetic resonance images and confirmed during surgery. The facial nerve was accurately dissected under continuous facial nerve monitoring, and gross total removal of the tumor was achieved without postoperative facial dysfunction.2.

Trochlear Nerve Repair during Retrosigmoid Suprameatal Approach for Petrotentorial Meningioma: Operative Video.

When operating on difficult skull base lesions, it is essential to be able to handle unexpected intraoperative findings or troubles, while achieving maximal lesion removal and minimal functional deficit. This video demonstrates a case of trochlear nerve repair that was performed during the retrosigmoid suprameatal approach for treatment of a petrotentorial meningioma, extending into the Meckel's cave. The patient is a 47-year-old woman with a right petrotentorial meningioma, extending into the Meckel's cave. The retrosigmoid suprameatal approach was performed with preservation of the superior petrosal vein. However, a divided trochlear nerve was incidentally found during tumor resection. We hence carefully dissected both nerve ends from the tumor without shortening their lengths, and repaired them by end-to-end anastomosis, using fibrin glue without any graft materials. The tumor was removed completely and the patient's preoperative facial sensory impairment disappeared after the surgery. The patient's facial sensory impairment disappeared completely, but she had transient diplopia after the surgery. However, the newly developed diplopia resolved completely, and she had no neurological deficits or tumor recurrence during the follow-up period of 1-year. The link to the video can be found at: https://youtu.be/g-B-w_zDudg .

A case of unruptured aneurysm of the internal carotid artery presenting as olfactory hallucinations.

BACKGROUND: Olfactory hallucination, a symptom of medial temporal lobe epilepsy, is rarely associated with unruptured intracranial aneurysms. CASE DESCRIPTION: We encountered this situation in a 70-year-old woman with an unruptured aneurysm at the bifurcation of the internal carotid and posterior communicating artery. We were able to achieve epileptic control by craniotomy clipping and medial temporal lesionectomy. CONCLUSION: According to our knowledge, previous reports are limited to cases of large middle cerebral artery aneurysms compressing the lateral orbitofrontal cortex, and this is apparently the first report of a case where olfactory hallucinations occurred from direct stimulation of the entorhinal cortex by an internal carotid and posterior communicating artery bifurcation aneurysm. We examined the pathophysiology underlying the development of olfactory hallucinations. We found craniotomy clipping and focal resection to be useful from the standpoint of seizure control. Whether seizure control can also be obtained with intracranial aneurysm coiling should be investigated in the future.

Endovascular treatment of ruptured intracranial aneurysms in patients 70 years of age and older.

BACKGROUND: An increasing number of elderly patients present with intracranial aneurysms. In addition to female gender, an older age is associated with a higher risk of developing a subarachnoid hemorrhage (SAH), and these patients often fare poorly in terms of long-term outcome. It is often thought that elderly patients would especially benefit from endovascular aneurysm treatment. We assessed the clinical outcomes in elderly patients with ruptured intracranial aneurysms (RIAs) who were treated by endovascular procedures. METHODS: We performed a retrospective review of a prospective database of elderly patients treated with coil embolization for RIAs. The clinical outcomes were assessed using the modified Glasgow Outcome Scale. The rates of procedural complications and adverse events were also recorded. RESULTS: During a period of 5 years, 162 patients with 183 intracranial aneurysms were treated in our hospital by means of an endovascular approach. Among them, 51 patients (31.5%) with a ruptured aneurysm were aged 70 years or older. These patients aged 70-91 years (mean age, 74 years) were treated by coil embolization for RIAs. Among them, seven had a Hunt and Hess (HH) grade of I or II, 42 had an HH grade of III or IV, and 2 had an HH grade of V. Endovascular treatment resulted in 32 complete occlusions (62.7%), 15 neck remnants (22%), and 4 body fillings (7.9%). Procedural complications occurred in five patients (9.8%). The outcomes were good or excellent in 17 patients (33.3%). Three patients (5.8%) who died had an HH grade of IV or V. Rebleeding occurred during follow-up in one patient (1.9%). CONCLUSIONS: Coil embolization of intracranial aneurysms is safe and effective in the elderly. However, the morbidity and mortality rates are higher in patients with high HH grades. This finding suggests that the timing of treatment should be based on the patient's initial clinical status.

Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas.

BACKGROUND: Chronic subdural hematoma (CSDH) is generally treated by burr hole irrigation. However, sometimes repeated recurrence is observed, and treatment may consequently become difficult. We examined the efficacy of embolization of the middle meningeal artery (MMA) for such cases. METHODS: We considered embolization of the MMA for three patients who had refractory CSDH with repeated recurrence and two CSDH patients who were at risk of recurrence and showed signs of recurrence after surgery. A microcatheter was advanced through the MMA as peripherally as possible, and embolization was performed with 15-20% n-butyl-2-cyanoacrylate or 200 µm polyvinyl alcohol particles. RESULTS: EMBOLIZATION WAS PERFORMED IN THE THREE PATIENTS WHO HAD REFRACTORY CSDH WITH REPEATED RECURRENCE: The procedure was performed after burr hole irrigation of the hematoma in two patients and before the irrigation in one patient. In the two CSDH patients at risk of recurrence, embolization was performed when signs of recurrence appeared. The timing of embolization differed for each patient. However, in all the patients, the hematoma tended to decrease in size, and no recurrence was observed. CONCLUSION: Embolization of the MMA is effective for refractory CSDH or CSDH patients with a risk of recurrence, and is considered an effective therapeutic method to stop hematoma enlargement and promote resolution.