Some technical options for successful PulseRider procedures.

Background: Unlike other conventional neck bridge stents, when using the PulseRider (PR), it is not necessary to introduce a microcatheter for stent delivery into the daughter branches from the neck, and it has less intraluminal metal. However, in some cases, securely introducing both leaflets into daughter vessels may be difficult, leading to coil herniation. This study aimed to present some technical issues in PR deployment. Methods: Fourteen PR procedures were performed in our institution between August 2021 and June 2023, and T-type PRs were used in all procedures. Four technical points during PR procedures are presented from our experience, as "technical options (Options 1-4)". All procedures were carried out with T-type PR implants. Results: The PR was successfully placed in all interventions; however, in seven cases (50%), some technique trials were necessary because the leaflets did not unfold in the optimal directions. In Option 1, an introduction procedure with transposition of the daughter artery using a microcatheter is presented. In Option 2, the method for correction of the unfolded leaflet angle is demonstrated. In Option 3, another method for correction of the leaflets is shown. In Option 4, an effective method for neck protection during PR procedures is shown. Conclusion: Various options should be considered to achieve appropriate apposition of PR leaflets. These technical options may be safe and effective for successful PR deployment.

Thromboembolic complications during and after embolization of unruptured aneurysms: A chronological outcome in periprocedural thromboembolic events.

Background: Ischemic complications develop after elective coil embolization procedures at a certain rate. The prevention of these events has been a longstanding issue for many interventional neuroradiologists. This study aimed to clarify whether procedural ischemic events after unruptured aneurysm embolization decrease over time with perioperative anti-thromboembolic treatment or surgical experience. Methods: This study included patients with cerebral aneurysms in our institution between July 2012 and June 2020. Dual-antiplatelet therapy (DAPT) was performed (Phase 1). Thromboembolic events developed at a certain rate; thus, rivaroxaban was administered with single-antiplatelet therapy (SAPT) to improve thromboembolic results (Phase 2), showing better outcomes than in Phase 1. Subsequently, DAPT was administered again (Phase 3). Ischemic complications were evaluated in each phase or compared between the DAPT group and the direct oral anticoagulant (DOAC) with the clopidogrel (DOAC+SAPT) group. Results: Relatively, fewer symptomatic ischemic events were noted in Phase 2 or the DOAC+SAPT group, but the outcome was not better in Phase 3 than in Phase 2. Symptomatic complications were more common in Phase 3 than in Phases 1 and 2. Conclusion: Ischemic complications occurred at a certain rate after endovascular procedures for unruptured aneurysms. The incidence did not decrease over time; particularly, standard DAPT plus postoperative anti-thromboembolic medication did not adequately decrease complications in Phase 3 compared to Phases 1 and 2. Therefore, accumulated experience or a learning curve could not explain the results. DOAC administration might decrease the risk of these events, but further accumulation of evidence or prospective investigation is warranted.

Importance of preoperative coronary artery examination before performing procedures for carotid artery stenosis.

Background: Carotid artery stenosis and coronary artery disease (CAD) often occur simultaneously, with one being an important risk factor in the treatment of the other. This study aimed to perform coronary computed tomography angiography (CTA) as a preoperative evaluation for carotid artery stenosis treatment. Methods: We retrospectively reviewed cases of carotid endarterectomy (CEA) and carotid artery stenting (CAS) performed at our hospital as well as CAD complications. Results: Among the 54 and 166 CEA and CAS cases from May 2014 to February 2022, 53 and 148 cases were analyzed for atherosclerotic stenosis, respectively. Among those who underwent CEA and CAS, 7 (13.2%) and 17 (11.5%) received percutaneous coronary intervention (PCI), 44 (83%) and 97 (65.5%) received symptomatic carotid stenosis treatment and 43 (81.1%) and 110 (74.3%) received preoperative coronary CTA, respectively. Coronary artery stenosis was noted in 14 (32.6%) and 46 (41.8%) patients who had undergone CTA in the CEA and CAS groups, respectively. PCI before carotid treatment was performed in two cases in the CEA group (3.8% of all patients who had undergone CEA) and eight cases in the CAS group (5.4% of all patients who had undergone CAS). Conclusion: Screening may detect asymptomatic coronary artery lesions in carotid artery stenosis even in patients without chest symptoms and suspicion of ischemic heart disease. Preoperative coronary artery screening is important considering that pre and postoperative coronary artery treatment may improve long-term prognosis.

Endovascular Embolization of Femoral Pseudoaneurysm Associated with Therapeutic and Diagnostic Neuroendovascular Procedures.

Objective: We aimed to evaluate the usefulness of endovascular embolization for femoral iatrogenic pseudoaneurysms (PAs) following therapeutic and diagnostic neuroendovascular procedures. Methods: This study included 12 patients with femoral PA due to femoral puncture at our department between May 2014 and April 2021. We performed an analysis of baseline characteristics, treatment, and outcome of these cases. Results: Endovascular embolization was performed in 10 of the 12 PAs using coils and/or N-butyl-2-cyanoacrylate. Of these, 10 PAs were treated with endovascular embolization and 9 were successfully occluded, whereas complete occlusion was not achieved in 1 case of PA (success rate: 90%). No new intraoperative or postoperative complications or postoperative recurrences occurred. Conclusion: Endovascular embolization for PA can be immediately performed under local anesthesia without discontinuation of antithrombotic therapy and may be a safe and effective option for access site complication treatment.

Carotid endarterectomy with stent removal for recurring in-stent restenosis: A case report and literature review.

Background: Percutaneous transcatheter angioplasty (PTA) and carotid artery stenting (CAS) are often performed repeatedly for in-stent restenosis (ISR) after CAS. Only a few reports describe the treatment for repeated ISR. Furthermore, only a few reports describe carotid endarterectomy (CEA) after CAS; thus, the evidence for this procedure is insufficient. Case Description: Herein, we describe a case in which CEA with stent removal was performed in a patient with repeated ISR after CAS. A 78-year-old man presented with dysarthria and slight left limb weakness. CAS was performed for the right internal carotid artery stenosis. ISR occurred again and PTA and stenting were performed. After the second CAS, ISR occurred again. CEA with stent removal was performed. After the CEA with stent removal, the patient experienced no restenosis or other complications. Conclusion: CEA with stent removal can be a good option for treating repeated ISR after CAS.

Use of n-butyl-2-cyanoacrylate for microvascular decompression in a Jehovah's witness patient.

OBJECTIVE: We report the application of n-butyl-2-cyanoacrylate (n-BCA) in microvascular decompression (MVD) surgery for a Jehovah's Witness patient. To our best knowledge, this is the first case wherein n-BCA has been employed as an adhesive to the offending artery. CASE PRESENTATION: A 55-year-old female Jehovah's Witness patient was suffering from serious right hemifacial spasm. Although MVD surgery was needed, the patient resisted any curative medical treatment involving the application of whole blood products, including fibrin glue. Thus, we proposed several choices using artificial materials, including n-BCA as an adhesive, and received informed consent from the patient. RESULT: MVD was performed on the dolichoectatic right vertebral artery and right posterior inferior cerebellar artery. The abnormal vessel response disappeared during the procedure and transposition using n-BCA of the concerned vessels was successful. The patient experienced a favorable postoperative clinical course and has been free from the spasm for a year. No abnormal findings were detected in the radiological examination during the follow-up period. CONCLUSION: Although careful follow-up is mandatory, n-BCA is a possible alternative option in MVD surgery.

Short-Vessel Occlusion Might Indicate Higher Possibility of Success in Reperfusion following Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion.

BACKGROUND: The impact of the length of the occluded vessel in acute large-vessel occlusion on successful reperfusion by mechanical thrombectomy remains unclear. This study evaluated whether diameter and length of the occluded vessel in acute middle cerebral artery (MCA) occlusion might relate to successful reperfusion following mechanical thrombectomy. METHODS: This retrospective study included patients with acute MCA occlusion who underwent intra-aortic injection of contrast medium to obtain maximum intensity projection (MIP) images acquired by flat-panel detector computed tomography (FD-CT) equipped with an angiographic system. All patients received mechanical thrombectomy and were divided into two groups: those with successful reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b/3) and those without. We compared the diameter and length of the occluded vessel between the groups. In the sub-analysis of patients with stent retriever use, ratio of length of occluded vessel to length of the active zone was compared. RESULTS: We enrolled 29 patients (median age: 73, M1 occlusion: 51%, stent retriever use: 72%). Eighteen patients achieved TICI 2b/3 with significantly larger distal end diameter (1.7 [interquartile range: 1.5-1.9] vs. 1.2 [1.2-1.5] mm, p = 0.007) and shorter length (7.1 [4.9-9.7] vs. 12.3 [7.2-15.8] mm, p = 0.043) of the occluded vessel. Sub-analysis of 21 patients showed that the cut-off value for TICI 2b/3 reperfusion was 0.32 as the ratio between the occluded vessel and stent retriever active zone (receiver operating characteristic area under the curve: 0.90). CONCLUSION: In acute MCA occlusion, larger diameter of the distal end and shorter length of the occluded vessel on FD-CT MIP images might indicate a higher possibility of achieving TICI 2b/3 following mechanical thrombectomy.

Difference of Thrombus Location between Initial Noninvasive Vascular Image and First DSA Findings in Mechanical Thrombectomy for Intracranial Large Vessel Occlusion: Post Hoc Analysis of the SKIP Study.

In patients who undergo mechanical thrombectomy for intracranial large vessel occlusion, the occluded site is sometimes distal to the site shown in the initial vascular imaging. We investigated the factors related to the change in the occluded site between the sequential imagings. The 203 patients in the SKIP study were reviewed retrospectively. Magnetic resonance angiography (MRA) or computed tomography angiography (CTA) was used to assess the occluded site. The occluded site shown in the cerebral angiography appeared to be distal to the occluded site shown in the initial vascular imaging in 55 patients (group A). The location of the occluded site in the remaining 148 patients did not change between the sequential imagings (group B). MRA was used more often than CTA in group A (54 MRA, 1 CTA; P <0.01). Patients with middle cerebral artery (M1) occlusion were more likely to show change of the occluded site than patients with internal carotid artery (ICA) occlusion (M1: 38%, ICA: 9%; P <0.01). The number of patients who received intravenous recombinant tissue plasminogen activator did not differ between the two groups (group A: 54%, group B: 49%; P = 0.5). In patients with acute intracranial large vessel occlusion who require mechanical thrombectomy, physicians should be aware that the location of the thrombus may be distal to the occluded site shown in the initial vascular imaging, particularly in patients with M1 occlusion shown by MRA.

Improvement of Cerebrovascular Reserve by Percutaneous Transluminal Angioplasty for Symptomatic Middle Cerebral Artery Stenosis.

Objective: The purpose of this study was to investigate the efficacy of percutaneous transluminal angioplasty (PTA) for symptomatic middle cerebral artery stenosis by analyzing cerebral blood flow (CBF). Methods: Between January 2016 and December 2018, six patients with symptomatic middle cerebral artery stenosis underwent CBF analysis by single-photon emission computed tomography (SPECT) with acetazolamide challenge before and after PTA for stenosis. They were retrospectively reviewed, and the blood flow in the area of the affected middle cerebral artery before and after angioplasty was compared. Results: The mean stenosis rate and length of lesion before angioplasty were 76.4 ± 5.4% and 6.5 ± 2.1 mm, respectively. Balloon angioplasty without stenting was performed on all patients. The mean residual stenosis rate just after angioplasty was 45.4 ± 9.3%. No periprocedual complications developed, and there were no notable cerebral ischemic events during the postprocedural follow-up period. One patient underwent repeat angioplasty for restenosis. Although there was only a mild decrease in blood flow at rest, the cerebrovascular reserve (CVR) in the area of the affected middle cerebral artery was markedly decreased before angioplasty (mean, 3.6 ± 4.3%). After angioplasty, the CVR was significantly improved (mean, 18.0 ± 4.7%, p <0.01). Conclusions: PTA for symptomatic middle cerebral artery stenosis can be safely performed using appropriate interventional techniques for select patients. Reduced CVR due to stenosis can be improved after angioplasty, which may reduce the risk of cerebral ischemic events.

Long-Term Patency and Final Structure After Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery: A Retrospective Study.

OBJECTIVE: To investigate long-term bypass patency and final structure for patients who underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass. METHODS: This study retrospectively evaluated 20 patients who underwent STA-MCA bypass and had 2-year follow-up with cerebral angiography. Patients were divided into internal carotid artery occlusion (n = 11) and MCA occlusion or stenosis (n = 9) groups, and diagnosis was either arteriosclerotic (n = 14) or nonarteriosclerotic (n = 6) disease. Final bypass formation was examined with cerebral angiography at 2 years postoperatively. Diameters of the STA, middle meningeal artery (MMA), and deep temporal artery (DTA) were measured at preoperative angiography and at 2-year follow-up. RESULTS: No significant differences in STA, MMA, and DTA diameters were reported between the internal carotid artery versus MCA group. For patients with arteriosclerotic disease, thicker STA diameters were noted on preoperative angiography. For patients with nonarteriosclerotic disease, MMA and DTA dilatation was noted on 2-year follow-up imaging. For patients with arteriosclerotic disease, all direct bypasses were patent at 2 years. For patients with nonarteriosclerotic disease, remarkable angiogenesis was demonstrated. CONCLUSIONS: Long-term patency of a direct bypass may be correlated with arteriosclerotic or nonarteriosclerotic etiology. An indirect bypass route may develop in patients with nonarteriosclerotic disease; therefore, it is important to create a foundation for an indirect bypass with MMA and DTA preservation during craniotomy. In 2 patients with nonarteriosclerotic disease, STA remained the primary bypass foundation; however, the technique resembled novel angiogenesis after encephaloduroarteriosynangiosis and not direct STA-MCA bypass. Therefore, final bypass structure might be affected by disease etiology.

Efficacy of a 14-coil for Framing in Coil Embolization of Small Cerebral Aneurysms.

Objective: The purpose of this study was to demonstrate the efficacy of a 14-coil (Target XL) for framing in coil embolization of small cerebral aneurysms. Methods: Between January 2017 and December 2018, 46 patients underwent coil embolization of a small cerebral aneurysm that was less than 5 mm in maximum diameter. They were categorized into 26 patients in whom only 10-coils were used and 20 in whom Target XL was used for framing. The volume embolization rate (VER) and recanalization rate were compared between the two groups. Results: Although there were two patients in whom Target XL was replaced with a 10-coil for framing, no adverse events associated with the use of Target XL were noted. The mean VER of the first framing coil was significantly higher in aneurysms that were framed with Target XL than in those framed with a 10-coil (Target XL 22.6 ± 4.5%, 10-coil 17.9 ± 8.4%; p = 0.03). Furthermore, the mean VER at the end of the procedure was significantly higher in aneurysms with Target XL used for framing than in those embolized using only 10-coils (14-coil: 36.8 ± 7.8%, 10-coil: 32.0 ± 6.5%; p = 0.03). No recanalization was observed in aneurysms for which Target XL was used for framing, whereas five aneurysms embolized using only 10-coils were recanalized. Conclusion: Target XL may be safe and feasible as a framing coil in coil embolization of small cerebral aneurysms, which may result in a high VER, low recanalization rate, and good outcome.

Strategies to Prevent Ischemic Complications after Stent-assisted Coil Embolization of Cerebral Aneurysms.

Objective: There have been no delayed ischemic complications related to stent-assisted coil embolization (SACE) of cerebral aneurysms at our institution. We demonstrate our strategies for stent placement and postoperative management of antiplatelet therapy to reduce the risk of ischemic complications. Methods: We analyzed 57 cases of SACE retrospectively. In the procedure, an appropriate stent was selected and placed to fit the arterial wall without impeding on small arterial branches. Two different antiplatelet drugs, including clopidogrel, were used. Six to twelve months after surgery, follow-up angiography was performed to assess the safety of terminating antiplatelet therapy. In cases in which antiplatelet therapy was tapered, the two antiplatelet drugs were switched to clopidogrel alone, and it was subsequently tapered and finally discontinued. Results: There were 49 cases of SACE in which postoperative antiplatelet therapy was tapered. Among these cases, antiplatelet therapy was discontinued in 35 cases. The mean duration of dual antiplatelet therapy was 10.6 ± 2.8 months, and the mean duration of total antiplatelet therapy was 15.0 ± 2.1 months. Three patients developed SACE-related ischemic stroke, which developed in the early phase after surgery in all. Conclusion: Antiplatelet therapy can safely be terminated in most cases of SACE. In order to reduce the risk of ischemic complications, stent selection, stent placement, and management of antiplatelet therapy should be performed appropriately. Furthermore, careful follow-up should be continued even after the termination of antiplatelet therapy.

Intracerebral hemorrhage in patients with chronic liver disease.

The characteristics of intracerebral hemorrhage (ICH) accompanying chronic liver disease (CLD) were investigated in ICH patients hospitalized between 1998 and 2008 divided into the CLD group (55 ICHs in 49 patients) and the idiopathic group without CLD (668 ICHs in 648 patients). The CLD group included a subgroup with liver cirrhosis (LC). Age, sex, history of hypertension, Glasgow Coma Scale (GCS) score on admission, and hematoma locations were reviewed. Outcomes on discharge and causes of in-hospital death were also studied. Factors associated with life prognosis in CLD patients were investigated using uni- and multivariate analyses. History of hypertension and deep cerebral hemorrhage were less frequent in the LC subgroup compared to the idiopathic group. Distributions of GCS scores on admission were not significantly different, but incidence of in-hospital death was significantly higher in the CLD group than in the idiopathic group. LC was an independent prognostic factor for CLD patients, but hematoma enlargement was not. Death primarily due to ICH was less frequent in the CLD group than in the idiopathic group. In conclusion, hemostatic disorders seemed to be related to site of hemorrhage, but not to life prognosis in the CLD group. Prognosis was mainly worsened by non-neurological complications.

Treatment of traumatic acute subdural hematoma in adult hydrocephalus patients with cerebrospinal fluid shunt.

OBJECTIVE: The presence of a cerebrospinal fluid (CSF) shunt is a predisposing factor for the development of subdural hematoma (SDH) in patients with hydrocephalus. However, few reports have addressed how patients with a CSF shunt should be treated in the event of traumatic acute SDH. The purpose of this study was to show how post-traumatic management of CSF shunt affects acute SDH in adult patients with hydrocephalus. METHODS: Twelve patients were studied retrospectively. Pressure settings of shunt valve prior to head injury (HI), severity of HI, treatment on admission, changes in SDH thickness and subsequent hydrocephalus were mainly analyzed. RESULTS: Ten patients experienced mild HI, with nine showing neurological deterioration until admission. Five patients needed surgical hematoma removal soon after admission. SDH recurred in four cases where shunt pressure levels were kept relatively low. Shunt ligation or raising the pressure level in the programmable valve proved effective for controlling postoperative SDH in such cases. Six of the remaining seven patients underwent only shunt ligation or readjustment of pressure level in the programmable valve on admission. SDH thickness was reduced as ventricles dilated without major neurological complications. Four patients showed delayed development of SDH even though shunts were kept ligated. CONCLUSIONS: Hematoma removal alone may result in hematoma recurrence and require a second treatment comprising shunt management to effectively control hematoma. Using shunt management as the only initial treatment can reduce hematoma volume, but some patients may suffer delayed SDH development and require surgery.

Treatment of ruptured internal carotid artery trunk aneurysms: feasibility of endovascular trapping or proximal obliteration of the ICA.

OBJECTIVE: Ruptured aneurysms arising from non-branching sites of the internal carotid artery (ICA) are often difficult to treat by neck clipping or endosaccular coiling. We discuss the feasibility of simple endovascular ICA ligation or trapping to treat aneurysms. METHODS: Data from eleven patients were retrospectively analyzed regarding Hunt and Hess grade on admission, angiographic collateral capacities during digital carotid compression, results of balloon test occlusion of the ipsilateral ICA, type of treatment, and Glasgow outcome scale at discharge. RESULTS: First endovascular treatments were performed by day 5 in four cases. Two patients with good clinical grade and good collateral capacity underwent endovascular ICA trapping in the acute stage and showed good outcomes. Two patients displaying poor clinical grade but good collaterals underwent endosaccular embolization. These aneurysms recurred later and the ICAs were trapped by coils in the chronic stage. Four cases underwent first endovascular treatments in the chronic stage. Three patients with good collaterals underwent endovascular ICA trapping or ligation and showed favorable outcomes. CONCLUSIONS: Seven of eleven patients could be treated by endovascular ICA trapping or ligation, which offers a simple, safe method for ruptured ICA trunk aneurysms, if collateral capacity is good and neurological condition is not serious.

Improvement of the tissue-adhesive and sealing effect of fibrin sealant using polyglycolic acid felt.

Although fibrin sealant (FS) has an advantage of high biocompatibility, its adhesive force and sealing effect have been generally considered to be inadequate. In the present study, a high adhesive force and sealing effect were obtained by first rubbing fibrinogen solution into the target tissue, attaching polyglycolic acid (PGA) felt to the treated area, and finally spraying it with FS. This method was compared with three conventional FS application methods and a method using fibrin glue-coated collagen fleece. The adhesive force resulting from the present method was 12 times higher than that for the sequential application method, 4.5 times higher than the spray method, 2.5 times higher than the rubbing and spray method, and 2.2 times higher than the use of fibrin glue-coated collagen fleece. The high adhesive force of FS with PGA felt seemed to be due the high fibrin content of the fibrin gel (FG). Light and electron microscopic observations suggested that the formation of FG in closer contact with the muscle fibers was a factor contributing to this superior adhesive force. Comparison of the sealing effect of the present method with other methods using various biomaterials in combination with FS showed that the sealing effect of FS with PGA felt was 1.4 times higher that of polyglactin 910, 1.8 times that of polytetrafluoroethylene, and 6.7 times that of oxidized regenerated cellulose.

[A novel method of dural repair using polyglycolic acid non-woven fabric and fibrin glue: clinical results of 140 cases].

This paper presents a report based on the results obtained from clinical applications of a biocompatible dural substitute made of polyglycolic acid non-woven fabric and fibrin glue. The cases subjected to this study were the ones needing reconstruction of dura mater which had become defective due to injury or brain tumor and the ones in which primary suture of the dura mater was considered to be too difficult or inadequate with ordinary methods. The dural substitute was used in 140 cases during the period between June, 2001 and July, 2005. The operations were performed using the supratentorial approach in 66 cases and infratentorial approach in 74 cases. Among these procedures, 39 cases were indicated for microvascular decompression, the commonest operation performed, then cranial base surgery in 27 cases and tumor resection in 24 cases, and so on. Lumber spinal fluid drainage or re-operation was required in 3 cases (2.1%) due to formation of post-operative cerebrospinal fluid leakage or subcutaneous accumulation of cerebrospinal fluid. With the dural substitute no infection was observed as a complication in any of the cases. Among the 140 cases presented this time, 27 cases were cranial base surgery and 74 cases were performed, using the infratentorial approach. Nevertheless, the study showed that the closing ability of the dural substitute was adequate even in actual clinical settings it is reported above that the incidence rate of post-operative cerebrospinal fluid leakage or subcutaneous accumulation of cerebrospinal fluid which require additional intervention was only 2.1%.

Fibrin glue and polyglycolic Acid nonwoven fabric as a biocompatible dural substitute.

OBJECTIVE: A novel biocompatible dural substitute created using fibrin glue and polyglycolic acid nonwoven fabric was examined for closing ability and histology. METHODS: A rabbit skin model of dural defect was repaired using fibrin glue-covered polyglycolic acid fabric without suture and subjected to a water leakage test to investigate closing ability. In addition, the dural defects created on 12 hemispheres in 6 beagle dogs were repaired with the dural substitute and subjected to macroscopic and histological examination of the dural substitute and adjacent tissue 1 and 2 months later. RESULTS: The dural substitute showed a breaking pressure of 109.9 +/- 37.1 mmHg. Macroscopically, no cases of excessive granulation, infection, or liquorrhea, either on the dural substitute or surrounding tissue, were observed. Histology indicated favorable tissue replacement of the dural substitute with collagenous fiber, although slight foreign body reaction was associated with its absorption. There was no evidence for adhesion to the brain surface or influence on nerve cells. CONCLUSION: Dural substitute created using fibrin glue and polyglycolic acid fabric is advantageous in that it exerts excellent closing ability without requiring suture and can replace biological tissue without causing incompatibility.

Nonsuture dural repair using polyglycolic acid mesh and fibrin glue: clinical application to spinal surgery.

BACKGROUND: In spinal surgery, repair of the dura is difficult when it is torn or fragile or is ossified as in cases with ossification of posterior longitudinal ligament. We report our experience with a nonsuture dural repair technique in patients undergoing spinal surgery; it uses a dura substitute composed of polyglycolic acid (PGA) mesh and fibrin glue. Here, we report the efficacy and safety of nonsuture duroplasty using PGA mesh and fibrin glue (PGA-fibrin sheet). METHODS: The artificial dura mater is composed of a PGA-fibrin sheet. The dural defect is covered with a patch sprayed with fibrin glue without suturing to the dura mater. We first evaluated this technique in an experimental study by performing water leakage tests. Between May 2001 and January 2005, we used it in 160 spinal surgeries that required intraoperative dura repair. RESULTS: Our preliminary tests showed that the threshold for water pressure without leakage was 161 +/- 42 and 96.5 +/- 32 mm Hg when the unsprayed margin around the perimeter of the patch was 5 and 2 mm, respectively. Of the 160 operated patients, 10 (6.3%) experienced subcutaneous cerebrospinal fluid (CSF) leakage. Of these, 6 required a second operation; in the other 4, the CSF collection diminished spontaneously. There were no other complications such as allergic reaction, adhesion, or infection. CONCLUSION: In combination with CSF diversion, the PGA-fibrin sheet is a viable alternative method for dural repair in spinal surgery.

Basilar artery dissection.

OBJECT: Little is understood about the clinical manifestations of basilar artery (BA) dissections, which can present with subarachnoid hemorrhage (SAH), brainstem compression, or ischemia. In any instance, the prognosis seems poorer than that for vertebral artery (VA) dissection. The authors analyzed clinical presentations and radiological features of BA dissection with and without rupture. METHODS: Between 1998 and 2003, the authors treated 10 patients (eight men and two women, ranging in age from 32-78 years; mean age 54 years) with BA dissection. Diagnosis was based on clinical and radiological findings, including those from magnetic resonance imaging and cerebral angiography studies. Of the 10 patients, five had impaired consciousness at disease onset. Among four patients presenting with SAH, two were treated conservatively and had fair outcomes without recurrent hemorrhage. The other two patients with SAH were treated using unilateral endovascular VA occlusion, but one of them subsequently suffered fatal rebleeding. A fifth patient presented with progressive signs of a mass involving the brainstem, whereas the remaining five patients showed brainstem ischemia; all were treated conservatively. Four patients could not return to their previous daily activities. CONCLUSIONS: Basilar artery dissections are rare lesions associated with significant morbidity and death. The natural course of and the treatment options for BA dissection differ considerably from those for VA dissections. Management of these lesions is controversial and difficult, and requires particular care.