Outflow angle: a risk factor for thromboembolic complications in coil embolisation for treating unruptured middle cerebral artery bifurcation aneurysms.

BACKGROUND: Thromboembolic complications are a relevant risk in coil embolisation of cerebral aneurysms. This retrospective study aimed to assess the treatment outcomes of unruptured middle cerebral artery (MCA) bifurcation aneurysms and the predictors for thromboembolic complications based on the aneurysm morphological characteristics. We examined the following three features: inflow angle, outflow angle (OA), and bifurcation angle, formed by the aneurysm and neighbouring blood vessels. METHODS: A total of 32 MCA bifurcation aneurysms were retrospectively investigated in 32 patients treated consecutively at our institute between April 2008 and March 2019. The predictors for thromboembolic complications were analysed in two groups: patients with and without thromboembolic complications. RESULTS: Perioperative thromboembolic complications were detected in six patients (18.8%), including two and six intra- and post-procedural thromboembolic complications, respectively; all cases were resolved. Regarding the aneurysms' morphological characteristics, the group with thromboembolic complications showed a significantly smaller OA (55.58° ± 14.05° vs. 86.04° ± 28.58°, P = 0.01) than the group without complications. Multivariate analysis revealed that smoking habits and OA < 70° were significant predictors of thromboembolic complications (smoking habits: P = 0.01, odds ratio [OR]: 6.89, 95% confidence interval [CI]: 3.78-12.62; OA < 70°: P = 0.04, OR: 3.19, 95% CI: 1.52-6.56). CONCLUSIONS: Our findings indicate significant pre-procedural predictors of thromboembolic complications to consider for safe treatment; clipping should be preferred to coil embolisation in high-risk patients. The method of choice should be considered in each case to allow the safe treatment of unruptured MCA aneurysms.

Predictors of Clopidogrel Hyper-Responsiveness in Neuro-Interventional Procedures.

BACKGROUND: Hyper-responsiveness to clopidogrel abnormally inhibits platelet aggregation and increases hemorrhagic complications. The present study investigated clinical factors related to clopidogrel hyper-responsiveness in neuro-interventional procedures. METHODS: Two hundred twenty-four patients receiving clopidogrel for coil embolization to treat unruptured cerebral aneurysm or carotid artery stenting to treat carotid artery stenosis at the internal carotid artery origin were retrospectively reviewed for their P2Y12 reactivity unit (PRU) values and clinical characteristics. Hyper-responsiveness to clopidogrel was defined as a PRU of <95. RESULTS: The mean PRU was 218.2 ± 77.8. Hyper-responsiveness to clopidogrel was observed in 12 patients (5.4%). Hyper-responsiveness was observed in younger patients, patients with a lower concentration of hemoglobin A1c, and patients with a higher low-density lipoprotein cholesterol (LDL-C) concentration compared with non-hyper-responsive patients (P = 0.01, P < 0.01, P < 0.01, respectively). On analysis of concomitant drugs, the patients in the hyper-responsive group were less frequently administered calcium channel blockers (CCBs) compared with the non-hyper-responsive group (P = 0.01). No significant differences in the usage of proton pump inhibitors or statins were observed. A LDL-C concentration of >120 mg/dL and no usage of CCBs were significant independent predictors of hyper-responsiveness to clopidogrel with a multivariate analysis (OR; 6.16, 95% CI, 1.57-26.64, P = 0.01, OR; 0.09, 95% CI, 0.01-0.82, P = 0.03, respectively). CONCLUSION: The present study shows that a higher LDL-C concentration and no usage of CCBs are independent predictors of clopidogrel hyper-responsiveness. These results are useful to predict perioperative hemorrhagic complications. Considering dose reduction of clopidogrel or alternative drugs in high risk cases is necessary to prevent perioperative hemorrhagic complications.

[Spontaneous Retroclival Subdural Hematoma Diagnosed Using Magnetic Resonance Imaging in an Adult Patient:A Case Report].

Spontaneous retroclival subdural hematoma is rare among adults. To the best of our knowledge, only six cases have been reported. A 73-year-old man presented with sudden severe headache, diplopia, and dysarthria, with no history of trauma. Head CT revealed a retrociliary hematoma. No obvious causes of bleeding, such as cerebral aneurysms or malformations, were detected. Conservative treatment was provided to the patient. MRI showed an intraventricular hemorrhage and a space between the basilar artery and hematoma three days after onset. The hematoma almost disappeared on day 7. MRI, particularly T2-weighted sagittal MRI, is effective in localizing hematomas and confirming intraventricular hemorrhages.

Localized overexpression of alpha-internexin within nodules in multinodular and vacuolating neuronal tumors.

Multinodular and vacuolating neuronal tumors (MVNT) have been recently referred to as a distinctive neuronal tumor entity based on histopathological findings. They are characterized by multiple tumor nodules, vacuolar alteration and widespread immunolabeling for human neuronal protein HuC/HuD. Only 13 cases have been reported in the literature to date and little is known about the histopathology of these tumors. Herein, we report a case of MVNT with additional confirmation of immunohistochemical features. A 22-year-old woman presented with a continuous headache. MRI showed a subcortical white matter lesion with multiple satellite nodules in the frontal lobe appearing as T2/fluid-attenuated inversion recovery (FLAIR) hyperintensities. Histological examination of the resected lesion revealed well-defined multiple nodules composed of predominant vacuolating tumor cells. The tumor cells exhibited consistent immunolabeling for doublecortin, as well as HuC/HuD, both representative neuronal biomarkers associated with earlier stages of neuronal development. Immunopositivity for oligodendrocyte transcription factor 2 (Olig2) and S100 was also detected in tumor cells. Additionally, significant overexpression of alpha-internexin was observed in the background neuropil limited to tumor nodules. Neuronal nuclear antigen (NeuN), synaptophysin and neurofilament, markers for mature neurons, were either negative or weakly positive. The expression profile of neuronal biomarkers can be distinguished from that of classic neuronal tumors and is the immunohistochemical hallmark of MVNT. In summary, we identified the characteristic tumoral expression of HuC/HuD and doublecortin and the presence of abundant neuropil localized in MVNT tumor nodules, which exhibited widespread alpha-internexin expression. These results supported the presumption that MVNT is a distinct histopathological entity.

[A Case of Subgaleal Hematoma with Exophthalmos and Diplopia].

A 9-year-old girl struck the left side of her head on a doorknob, after which she gradually developed swelling. She was treated conservatively at another hospital before being referred and admitted to our hospital 9 days after injury, with complaints of exophthalmos and diplopia. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) revealed a subgaleal hematoma (SGH). We therefore attempted to treat the patient by aspiration of the hematoma via needle puncture through the skin, for which we wrapped an elastic band around the head while infusing a hemostatic agent. No vascular anomalies and no abnormal shunts were identified by angiography under general anesthesia 13 days after injury. The patient was treated surgically due to increased head swelling and deteriorated exophthalmos. The liquefied, dark-red SGH was aspirated via a few cm of skin and a galeal incision on the left side of her head. A multiperforated drainage catheter was introduced into the hematoma cavity and the drainage catheter was connected to the vacuum-drain pump. After the surgery, the left exophthalmos disappeared. Twenty-three days after injury, she was discharged from our hospital without any neurological deficits.

Thromboembolic events associated with single balloon-, double balloon-, and stent-assisted coil embolization of asymptomatic unruptured cerebral aneurysms: evaluation with diffusion-weighted MR imaging.

INTRODUCTION: The introduction of the balloon remodeling and stent-assisted technique has revolutionized the approach to coil embolization for wide-neck aneurysms. The purpose of this study was to determine the frequency of thromboembolic events associated with single balloon-assisted, double balloon-assisted, and stent-assisted coil embolization for asymptomatic unruptured aneurysms. METHODS: A retrospective review was undertaken by 119 patients undergoing coiling with an adjunctive technique for unruptured saccular aneurysms (64 single balloon, 12 double balloon, 43 stent assisted). All underwent diffusion-weighted imaging (DWI) within 24 h after the procedure. RESULTS: DWI showed hyperintense lesions in 48 (40%) patients, and ten (21%) of these patients incurred neurological deterioration (permanent, two; transient, eight). Hyperintense lesions were detected significantly more often in procedures with the double balloon-assisted technique (7/12, 58%) than with the single balloon-assisted technique (16/64, 25%, p = 0.05). Occurrence of new lesions was significantly higher with the use of stent-assisted technique (25/43, 58%) than with the single balloon-assisted technique (p = 0.001). Symptomatic ischemic rates were similar between the three groups. The increased number of microcatheters was significantly related to the DWI abnormalities (two microcatheters, 15/63 (23.8%); three microcatheters, 20/41 (48.8%) (p = 0.008); four microcatheters, 12/15 (80%) (p = 0.001)). CONCLUSION: Thromboembolic events detected on DWI related to coil embolization for unruptured aneurysms are relatively common, especially in association with the double balloon-assisted and stent-assisted techniques. Furthermore, the number of microcatheters is highly correlated with DWI abnormalities. The high rate of thromboembolic events suggests the need for evaluation of platelet reactivity and the addition or change of antiplatelet agents.

[A case of glioblastoma multiforme in the pineal region with intraventricular hemorrhage].

INTRODUCTION: Glioblastoma multiforme (GBM) is a very rare type of tumor involving the pineal region. No case of pineal region GBM with tumoral hemorrhage has ever been reported. Here, we present the first such case report. CASE REPORT: A 65-year-old man presented with sudden-onset disturbance of consciousness. CT revealed intraventricular hemorrhage and acute hydrocephalus. The patient was treated by an emergent operation for ventricular drainage. MRI with contrast media showed a heterogeneous enhanced area in the pineal region. The patient underwent endoscopic biopsy surgery and a third ventriculostomy for non-communicating hydrocephalus. The pathological diagnosis was high-grade glioma, indicating the need for tumor removal via the occipital transtentorial approach. The tumor was removed subtotally and radiation and chemotherapy courses were then started. CONCLUSION: Pineal GBM with tumoral hemorrhage has never been reported before. Endoscopic operations are useful for rapid decision making prior to radical surgery.

Cytotoxic Lesions of the Corpus Callosum Associated with Aneurysmal Subarachnoid Hemorrhage May Influence Shunt-Dependent Chronic Hydrocephalus.

BACKGROUND: Cytotoxic lesions of the corpus callosum (CLOCCs) are occasionally associated with aneurysmal subarachnoid hemorrhage (aSAH). The effects of aSAH on clinical outcomes in such cases are unclear. The present study aimed to investigate the frequency and characteristics of CLOCCs associated with aSAH to ascertain the predictors of shunt-dependent chronic hydrocephalus (SDCH) after aSAH. METHODS: We retrospectively investigated cases of aSAH treated by coil embolization. Patients were divided into those with and without CLOCCs. Between-group differences were evaluated, including clinical outcomes and the characteristics of both the patients and the aneurysms. Patients were divided into those with and without SDCH to identify predictive factors of SDCH after aSAH focusing on CLOCCs. RESULTS: This single-center study included 196 patients with aSAH. All patients received coil embolization between April 2013 and March 2020. CLOCCs were detected in 38 (19.4%) patients. In the group with CLOCCs, male sex, poor severity grade at onset, acute hydrocephalus, SDCH (all P < 0.01), and Fisher group 3 or 4 (P = 0.04) were significantly more common than in the group without CLOCCs. Diabetes and CLOCCs were significant predictors of SDCH after aSAH in multivariate analysis (diabetes: P < 0.01, odds ratio: 6.73, 95% confidence interval: 1.61-28.09; CLOCCs: P < 0.01, odds ratio: 6.86, 95% confidence interval: 2.87-16.38). CONCLUSIONS: CLOCCs and SDCH were common in patients with poor-grade aSAH, and CLOCCs were independent predictors of SDCH after aSAH. Meticulous follow-up is necessary to detect SDCH after aSAH, especially in patients with poor-grade aSAH and CLOCCs.

Influence of size ratio on retreatment after coil embolization for unruptured bifurcation aneurysms.

Background: Aneurysm size is considered a risk factor for aneurysm rupture, and even small aneurysms may rupture, especially bifurcation aneurysms (BAs), which are occasionally detected. Therefore, we aimed to investigate the predictors of retreatment after coil embolization for unruptured BAs, with a particular focus on the absolute and relative size of the aneurysm (size ratio [SR]). Methods: To evaluate the predictors of retreatment, patients were divided into two groups: those with and those without retreatment. Patient characteristics and radiographic assessments were compared between the groups. SR was defined as the ratio of the maximum aneurysm diameter and the average diameter of the parent artery. Results: Overall, 181 unruptured BAs in 176 patients were investigated. The mean age of the patients was 63.8 ± 9.6 years. The mean aneurysm size and SR were 7.18 ± 2.94 mm and 2.49 ± 1.32, respectively. Further, 12 aneurysms with retreatment (6.6 %) and 169 aneurysms without retreatment were compared. In univariate analysis, SR was significantly higher in the group with retreatment (P = 0.02), but aneurysm size was not significantly different between the groups (P = 0.09). Multivariable analysis revealed that SR > 2.6 was a significant predictor of retreatment (P = 0.03; odds ratio: 10.41; 95 % confidence interval: 2.1-51.73). Conclusions: This study showed that SR influences retreatment after coil embolization for unruptured BAs. Therefore, if the aneurysm size and parent artery diameter were small, as in cases with a large SR, meticulous follow-up after coil embolization is required to detect recurrence and recanalization.

Hazardous implications of halogenated polycyclic aromatic hydrocarbons in feedstuff: Congener specificity and toxic levels in feed ingredients and feeds.

Studies have shown that halogenated polycyclic aromatic hydrocarbons (HPAHs), including chlorinated (ClPAHs) and brominated PAHs (BrPAHs), could be hazardous pollutants due to their pervasive occurrence in the environment. However, their accumulation properties and toxic potentials in animal feedstuffs remain unclear. This study investigated 75 congeners of parent PAHs, ClPAHs, and BrPAHs in animal-based feed ingredients and fish and swine feeds in Japan using a GC/Orbitrap MS system. The total parent PAHs ranged from below the method detection limit (

Impact of size ratio on thromboembolic events based on diffusion-weighted imaging after coil embolization for unruptured basilar apex aneurysm.

PURPOSE: Coil embolization is one of the main endovascular treatment for basilar apex aneurysms (BAAs), and thromboembolic events are important complications of coil embolization. Even in small aneurysms, there is a risk of rupture, and aggressive treatment should be considered for unruptured BAAs. Using diffusion-weighted imaging (DWI), the study aimed to investigate thromboembolic events after coil embolization for unruptured BAAs by focusing on the absolute aneurysm size and relative aneurysm size (size ratio [SR]). METHODS: To evaluate the predictors of thromboembolic events, patients were divided into those with and without hyperintensity on DWI after coil embolization. Patient and radiographic characteristics were compared between the two groups. SR was defined as the maximum aneurysm diameter divided by the average parent artery diameter. RESULTS: Fifty-six unruptured BAAs in 56 patients were investigated. The mean aneurysm size and SR were 7.61 ± 2.18 mm and 2.74 ± 1.45, respectively. Postprocedural hyperintensity on DWI was detected in 17 patients (30.4%). SR was significantly larger in the group with hyperintensity on DWI (3.75 ± 1.97 vs. 2.3 ± 0.82, P < 0.01) in the univariate analysis. Multivariate analysis revealed that SR> 3.0 was a significant predictor of thromboembolic events after coil embolization for unruptured BAAs (odds ratio: 12.15; 95% confidence interval: 2.95-49.98; P < 0.01). CONCLUSIONS: This study showed that SR is a predictor of thromboembolic events after coil embolization for unruptured BAAs. Therefore, if even in small BAAs, if the BAAs dome height is large compared to the diameter of the posterior cerebral artery (e.g., there is a large SR), preoperative evaluation of the use of antiplatelet therapy is important, particularly to prevent thromboembolic events.

[Granular cell tumor of the neurohypophysis observed with hypoglycemic attack].

Granular cell tumor of the neurohypophysis (GCT) occurs as a solitary, small, nodular tumor and rarely grows to a sufficient size to present symptoms. The authors report a case of a 30-year-old man with GCT presenting with hypoglycemic attack. Hypoglycemic attack could be due to dysfunction of the hypothalamus and one of the important symptoms of GCT.

Global outflow angle influences silent ischemic events in coil embolization for unruptured distal anterior cerebral artery aneurysms.

BACKGROUND: Distal anterior cerebral artery (DACA) aneurysms are rare, and endovascular treatment of these aneurysms is challenging. Thromboembolic events, including silent ischemic events, are one of the most important complications of coil embolization for cerebral aneurysms. The treatment outcomes and predictors of silent ischemic events in coil embolization for unruptured DACA aneurysms were investigated, focusing on the morphological characteristics of aneurysms, especially the inflow angle (IA) and global outflow angle (GOA). METHODS: A total of 12 patients with 12 unruptured DACA aneurysms, treated with coil embolization at our institute, were retrospectively investigated. Predictors for silent ischemic events were evaluated by comparing diffusion-weighted imaging (DWI)-positive and DWI-negative patients. RESULTS: Silent ischemic events detected on DWI were observed in eight aneurysms (66.7%). Comparison of the morphological characteristics of aneurysms between the two groups showed a significantly smaller GOA in the DWI-positive group than in the DWI-negative group (172.6 ± 17.7° vs. 216.8 ± 16.8°, P < 0.01). A multivariate analysis showed that GOA <195° was a significant predictor of silent ischemic events (P = 0.04; odds ratio: 23.62; 95% confidence interval: 1.11-490.39). CONCLUSION: A small GOA was a significant predictor of silent ischemic events after coil embolization for unruptured DACA aneurysms. While some patients can be treated safely with minimally invasive coil embolization, it is necessary to consider surgical clipping in patients at high risk of thromboembolic events with coil embolization.

Comparison of Pipeline Embolization and Coil Embolization for the Treatment of Large Unruptured Paraclinoid Aneurysms.

The efficacy of flow diversion (FD) in the treatment of paraclinoid aneurysms has been established. The pipeline embolization device (PED) is one of the most commonly used FD devices. Coil embolization is also useful for treating paraclinoid aneurysms. This study aimed to compare the efficacy and safety of PED treatment and coil embolization for large unruptured paraclinoid aneurysms. This was a single-center, retrospective study of large unruptured paraclinoid aneurysms treated endovascularly between 2009 and 2019 (coil embolization between 2009 and 2015, and PED between 2015 and 2019). Cases with a follow-up period of less than 1 year and recurrence after coil embolization were excluded. The treatment outcomes between coil embolization and PED were compared. We investigated 45 patients with 45 large unruptured paraclinoid aneurysms treated by endovascular surgery in our institution. Twenty-four patients were treated with coil embolization and 21 with PED. In the PED group, the device cost was significantly lower (2,770.4 ± 699.5 vs. 1941.2 ± 552.8 [1000 yen], P = 0.03), procedure duration was significantly shorter (155.4 ± 66.7 vs. 95.1 ± 35.4 min, P <0.01), and the numbers of re-treatments were lower than those in the coil embolization group (41.7 vs. 14.3%, P = 0.05). Both PED and coil embolization were effective and safe for large unruptured paraclinoid aneurysms, and their treatment results were similar. The PED is more beneficial because of its lower cost, shorter procedure duration, and fewer retreatments, and is therefore more useful for the treatment of large unruptured paraclinoid aneurysms.

A case of cribriform plate dural arteriovenous fistulas with a rare complication after endovascular therapy.

Background: Cribriform plate dural arteriovenous fistulas (dAVFs) are rarely encountered. Here, we report a case of cribriform plate dAVF with a rare complication after endovascular therapy. Case Description: A 60-year-old man presented with severe sudden headache. Head computed tomography showed right subdural hematoma, and magnetic resonance angiography showed dilated bilateral frontal cortical vein. Digital subtraction angiography revealed cribriform plate dAVF fed by the anterior and posterior ethmoidal branches of the bilateral ophthalmic arteries. Transarterial embolization with liquid embolic material was performed and the fistula disappeared. Although magnetic resonance imaging showed the disappearance of the cribriform plate dAVF and subdural hematoma, the patient complained of anosmia after the procedure. Conclusion: Endovascular embolization is an effective treatment option for treating cribriform plate dAVFs. However, anosmia is a possible complication, and endovascular surgeons should take care of this complication, especially in cribriform plate dAVFs supplied with blood bilaterally.

Stent-assisted coil embolization for an unruptured vertebral artery-posterior inferior cerebellar artery aneurysm with retrograde access via type 1 persistent primitive proatlantal artery: A case report.

Vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysms are rare lesions that are difficult to treat with both endovascular and surgical techniques. Tight angulation of the PICA from VA may make access to the PICA difficult from ipsilateral VA if adjunctive techniques are needed. Recently, the safety and efficacy of retrograde access have been reported. We report a case of endovascular treatment for a VA-PICA aneurysm with a stent-assisted technique using retrograde access via contralateral persistent primitive proatlantal artery (PPA).The patient was a 76-year-old woman with an unruptured VA-PICA aneurysm on the dominant VA side. Coil embolization with a stent-assisted technique using retrograde access seemed appropriate. However, the origin of the left VA was not confirmed. Left common carotid artery angiography demonstrated that the PPA (type 1) branching from external carotid artery joined the VA V4 segment.Retrograde access via the PPA for stenting was performed. A microcatheter for stenting was retrogradely advanced to the right PICA at ease. After deploying the stent, coil insertion was completed from the right VA, and the final angiogram showed adequate occlusion of the aneurysm with preservation of the PICA.Thus, PPA may be an approach route in the treatment of VA-PICA aneurysms with unconfirmed contralateral VA orifice and apparent PPA on angiography, when retrograde access is needed.

Target Coil Embolization Using the Combined Transarterial and Transvenous Balloon-assisted Technique for Traumatic Direct Carotid Cavernous Fistula.

Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Cerebral angiography revealed a shunt from the internal carotid artery (ICA) to the cavernous sinus (CS), which indicated DCCF. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique was performed. Angiography was performed 1 week after surgery to confirm the disappearance of DCCF. No recurrence was observed during the 1-year follow-up after treatment. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique is safe and effective for the treatment of traumatic DCCF.

A Patient with a Ruptured Blood Blister-like Aneurysm of the Internal Carotid Artery in Whom Two LVIS Stents Were Inserted.

Objective: We report a case in which multiple overlapping low-profile visualized intraluminal support (LVIS) stents were used as monotherapy for ruptured blood blister-like aneurysm (BBA) of the internal carotid artery (ICA). Case Presentation: A 48-year-old female presented to the emergency room with acute-onset headache. She was alert without neurological deficit with subarachnoid hemorrhage (SAH) Hunt and Kosnik grade I. Emergency angiography revealed a BBA from the supraclinoid ICA. This aneurysm had a small diameter, which makes coil embolization difficult. Therefore, we planned to use multiple overlapping LVIS stents as monotherapy for the ruptured aneurysm. The postoperative course was uneventful without rebleeding. The patient exhibited no neurological deficits on the clinical follow-up at 1 year. Conclusion: Multiple overlapping LVIS stents as monotherapy is useful for ruptured BBAs of the ICA.

A Patient with an Unruptured Aneurysm in the Internal Carotid Artery-duplicated Middle Cerebral Artery on Whom Coil Embolization with Balloon Remodeling Was Performed.

Objective: Treatment of an unruptured aneurysm at the origin of duplicated middle cerebral artery (DMCA) by coil embolization using balloon remodeling has not been reported. We report a case of coil embolization using balloon remodeling for an unruptured aneurysm at the origin of DMCA. Case Presentation: A 71-year-old female was found to have an unruptured aneurysm at the origin of DMCA during an examination for headache. Coil embolization using balloon remodeling for the wide neck aneurysm to preserve both the internal carotid artery (ICA) and DMCA was successful. The perioperative course was uneventful. Conclusion: This treatment enables complete embolization, and preserves both the ICA and DMCA. Thus, it is useful for aneurysms at the origin of DMCA.

Carotid surgical cut-down technique for neuroendovascular therapy.

BACKGROUND: Neuroendovascular therapy is typically performed via the femoral artery, but there are rare cases in which a tortuous upstream angioarchitecture makes it difficult to access the intracranial circulation via this route. METHODS: In this case series, we describe six cases treated by surgical cut-down in the neck, with puncture of the carotid artery. Antiplatelet and anticoagulation agents were used in all cases. The indications for the technique were postsurgical thoracic aortic aneurysm (two cases), postsurgical abdominal aortic aneurysm (one case), major vessel tortuosity of the common carotid artery (two cases) and aortic arch anomaly (one case). RESULTS: The surgical cut-down technique permitted successful neuroendovascular therapy. Although one patient had a small cervical haematoma, he was treated without surgical evacuation. CONCLUSION: Overall, our findings indicate that the surgical cut-down technique is safe and useful for patients in whom the femoral approach is unsuitable.