Search

Objective. Ruptured blood-blister aneurysm (BBA) of the internal carotid artery (ICA) remains a challenging lesion, even in the age of modern neurosurgery and endovascular treatment. This retrospective multicenter study aimed to investigate the real-world treatment choice and treatment results.Methods. We included 182 ruptured BBAs of the ICA treated at 51 neurosurgical centers in Japan between 2013 and 2017. The baseline patient characteristics, radiological features of the aneurysm, treatment modality, details of treatment, complications of treatment, treatment results were retrospectively collected. The treatment strategy was divided into deconstructive and reconstructive procedures. Primary clinical outcomes were evaluated using the modified Rankin Scale (mRS) at final follow-up.Results. Direct surgery was performed in 144 (79%) cases, and the remaining 38 (21%) cases received endovascular treatment. The majority of treatment selections were deconstructive and reconstructive procedures in the direct surgery group and endovascular treatment group, respectively. Overall, favorable clinical outcomes (mRS 0 to 2) were achieved in 66% of cases, and the mortality rate was 15% at the final follow-up (mean 23 months). There was no significant difference in clinical outcome between direct and endovascular treatment groups. Conclusion. Our large nationwide study compared the real-world treatment options for ruptured BBAs and their results. Our findings may offer beneficial information for treatment decision and for future studies investigating ruptured BBAs.

Computed tomography angiography (CTA) immediately after diagnosis of intracerebral hematoma (ICH) on noncontrast CT in the emergency room has benefits, which consist of early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH, but CTA also involves possible risks of acute kidney injury (AKI) and adverse reactions. The purpose of this study was to evaluate the benefits and risks of CTA. A total of 1423 consecutive adult patients diagnosed with ICH who were admitted within 3 days of onset between 2010 and 2017 were retrospectively analyzed. Of 1082 patients undergoing CTA, 162 patients (15.0%) showed secondary ICH, and the sensitivity of CTA for secondary ICH was 95.7%. Of 920 patients with primary ICH, a logistic regression model using the spot sign and four other previously reported risk factors (antiplatelet agents, anticoagulants, interval from onset to arrival, hematoma volume) with an area under the curve (AUC) of 0.787 significantly improved model performance to predict hematoma growth compared with a model using the same four factors without the spot sign (AUC: 0.697) (DeLong's test: P = 0.0002). Rates of AKI occurrence were 9.0% and 9.8% in patients with and without CTA, respectively. The odds ratio of AKI in patients with CTA adjusted by reported risk factors was 1.16 (95% confidence interval: 0.72-1.95, P = 0.5548). Emergency CTA following noncontrast CT in patients with ICH could be useful for early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH with little risk.

The crisis of the coronavirus disease (COVID-19) is causing damage to the social and medical community. However, extreme emergency neuro-interventions such as mechanical thrombectomy still require the healthcare workers to offer the appropriate treatment while preventing further spread of the infection. This article outlines the necessary steps in managing a possible COVID-19 patient starting from patient screening to personnel infection and environmental contamination measures.

Background Recurrent trigeminal neuralgia after successful microvascular decompression is not rare. Case Description A 72-year-old woman who presented with typical right trigeminal neuralgia had been successfully treated by microvascular decompression with transposition of the superior cerebellar artery. However, she complained of trigeminal neuralgia on the ipsilateral side 14 months after the microvascular decompression. Redo microvascular decompression showed that the anterior inferior cerebellar artery, which had not been detected at the initial surgery, compressed the right trigeminal nerve. Conclusions This case is an unusual type of recurrent trigeminal neuralgia because of a subsequently developed offending vessel within a short period.

New-generation tyrosine kinase inhibitors (TKIs), nilotinib and ponatinib, for chronic myelogenous leukemia (CML) have been reported to cause symptomatic cerebral ischemia. Herein, we report two patients with asymptomatic cerebral artery stenosis associated with these TKIs, as a previously unreported finding. Both patients were in their 40 s and administered new-generation TKIs without vascular risk factors. New-generation TKIs for CML can cause major cerebrovascular stenosis without any symptoms. Examining the neck and intracranial arteries using magnetic resonance angiography and carotid ultrasonography may prevent future cerebral infarctions associated with these TKIs.

BACKGROUND: Cerebrospinal fluid (CSF) leakage is a common complication associated with neurosurgical procedures, and eliminating postoperative CSF leaks remains challenging. OBJECTIVE: Unique applications of free or vascularized flaps for watertight dural and skull base reconstruction are presented. METHODS: A total of 512 cases of cranial surgeries were examined focused on the postoperative complications that required revision surgery. These cases were divided into skull base (SB) lesions and non-SB lesions according to the site of dural opening. The postoperative complications were analyzed according to their relationship to the CSF. A free flap, including fascial, myofascial, or pericranial flap, is routinely prepared for later use in dural closure in all cranial surgeries. A pedicled vascularized pericranial flap (VPF) is also used for SB dural reconstruction in extended surgical procedures.RESULTS: There were 434 cases of SB lesions and 78 cases of non-SB lesions. Of the 512 surgical cases, 27 (5.3%) required revision surgery due to patients’ postoperative conditions or complications. There were 9 cases (1.8%) of CSF-related and 18 cases (3.5%) of non-CSF-related complications. Eight of nine cases of CSF-related complications (88.9%) were seen in posterior fossa surgery. Postoperative CSF leaks that required revision surgery were seen in 4 cases (0.8%). SB reconstruction using a VPF was performed in 40 cases of SB surgeries. No postoperative infection was seen in these 40 cases, and only 1 case (2.5%) of pseudomeningocele, which required revision surgery, occurred. CONCLUSION: Dural reconstruction using a fascial flap or VPF plays an important role in achieving successful surgery.

Patients with spontaneous cerebellar hemorrhage present with rapidly deteriorating neurological symptoms due to a hematoma-induced mass effect in the brainstem. We compared the standard surgical approach of a suboccipital craniectomy with neuroendoscopic surgery for treating spontaneous cerebellar hemorrhage. We performed a retrospective analysis of 41 patients indicated for surgery to treat spontaneous cerebellar hemorrhage. At our hospital, craniectomy was performed until 2010, and neuroendoscopic surgery was performed thereafter when a qualified surgeon was available. Duration of surgery and intraoperative blood loss were lower in the neuroendoscopic surgery group. The extent of hematoma removal and the percentage of patients requiring shunting were similar between groups. The mass effect was resolved in all patients in both groups, and no substantial re-bleeding was observed in either group. The outcomes at discharge were comparable between the two groups. Our surgeons used the supine lateral position, which involves fewer burdens to the patient than the prone position. Selection of the site of the burr hole is important to avoid the midline and to avoid the area exactly above the transverse and sigmoid sinus. Our results suggest that minimally invasive neuroendoscopic surgery is safe and superior to craniectomy due to shortened duration of surgery and decreased intraoperative bleeding.

Background The ideal surgery for a blood blister-like aneurysm (BBA) in the internal carotid artery (ICA) involves complete termination of blood flow into the BBA by trapping of the ICA at sites both proximal and distal to the BBA. In the present report, we describe a clipping method with ICA trapping for prevention of anterior choroidal artery ischemia, a major problem in ICA trapping with reconstruction surgery using external carotid artery–middle cerebral artery high-flow bypass (HFB). Methods The data from patients with a ruptured BBA treated by the combination of ICA trapping and blood flow reconstruction from 2008 to 2018 were retrospectively evaluated. Results Fifteen patients had been treated with the combination surgery. Clip placement for ICA trapping depended on the relationship between the distal neck of the BBA and the posterior communicating artery. In the case of the BBA distal neck located at the same level or distal to the posterior communicating artery, oblique placement of a distal clip to the ICA was mandatory to maintain blood flow of the anterior choroidal artery. No patients developed recurrence of the BBA after trapping. The outcomes were assessed using the modified Rankin scale score, with a score of 0 or 1 in 12 of the 15 patients (80%). Conclusions A complete shutdown of blood flow to the BBA by ICA trapping is essential for the permanent prevention of BBA recurrence. In cases of a BBA distal neck located distal to the posterior communicating artery, the oblique clipping technique applied to the ICA is useful to prevent ischemic complications of the anterior choroidal artery.

Many patients with idiopathic normal pressure hydrocephalus (iNPH) have reportedly fallen prior to diagnosis. However, there are no previous reports on the iNPH prevalence among the elderly with history of falls. This study investigated the effectiveness of screening for iNPH in elderly patients presenting after a fall.We retrospectively assessed the Evans' index (EI) of 235 consecutive patients aged 60-89 who presented after falls between May and October 2020. We also assessed the presence of the iNPH triad (gait disturbance, cognitive impairment, and urinary incontinence). Patients with EI 0.3 and with all 3 triad were defined as having possible iNPH; those with clinical improvement after a cerebrospinal fluid (CSF) tap test as having probable iNPH; and those with clinical improvement after a shunt surgery as having definite iNPH. We also examined the 235 patients' EI, and performed a case-control study of EI using sex- and age-matched control patients.Among the included 235 cases presenting after falls, 44 (18.7%) were diagnosed with possible iNPH, 29 (12.3%) with probable iNPH, and 25 (10.6%) with definite iNPH. The mean EI of these 235 patients was significantly larger than that of controls (0.30 ± 0.04 vs 0.26 ± 0.02, p 0.0001). The proportion of possible iNPH in the cases was 44 out of 235 (18.7%), significantly higher than that of the controls (0%, p 0.0001).Screening for iNPH in the elderly presenting after falls can possibly identify iNPH patients in the earlier stage who may benefit more from surgical treatments.

Sex differences in various diseases recently have been recognized as an important factor in the approach to more efficient preventive and therapeutic medicine. We clarified sex differences in the clinical characteristics of chronic subdural hematoma (CSDH) by comparing men and women with CSDH, as there is a well-known male predominance in the prevalence of CSDH.Clinical factors and computed tomography findings were investigated retrospectively in 490 consecutive patients admitted to our hospital between 2006 and 2015 who were diagnosed with CSDH.On univariate analysis, women were significantly older than men (P0.05). In women, premorbid impaired activities of daily living, consciousness disturbance, acute-to-chronic subdural hematoma, and death as outcomes at discharge were significantly more frequent than in men (P 0.05). In contrast, women had less frequent instances of good recovery and less alcohol intake (P0.05). Multivariate analysis demonstrated female sex as an independent predictor of consciousness disturbance at admission. Female sex also was identified as a predictor of death at discharge.We demonstrated sex differences in the clinical characteristics of CSDH. In the future, management of patients with CSDH with regard to sex differences in disease characteristics could be expected to improve the outcomes of women, which have been worse than in men.

Background Loeys-Dietz syndrome (LDS) is a recently recognized autosomal dominant connective tissue disease. The manifestations of LDS include vascular tortuosity, scoliosis, craniosynostosis, aneurysm and aortic dissections. Clinical presentation A 35-year-old woman treated with Stanford type B aortic dissection and breast cancer was referred to us for Borden type II dural arteriovenous fistula (dAVF) draining to the vein of Galen, involving the midline of tentorium cerebelli. The dAVF was treated successfully by combined transarterial and transvenous embolization. Because of tortuosity of vertebral arteries, a genetic test was conducted confirming LDS type 2. Conclusions To our knowledge, this is the first case report of dAVF associated with LDS. The relationship between LDS and dAVF is unknown but this report shows the possibility that mutation of transforming growth factor β receptors 2 ( TGFBR2) related to LDS may be related to shunt diseases. Because intervention in LDS seems to be feasible compared to Ehlers Danlos syndrome and Marfan syndrome, it is important to make the correct diagnosis.

Computed tomography images of patients with chronic subdural hematoma (CSDH) sometimes show obliteration of the basal cistern with high density in an obliterated Sylvian cistern, termed pseudo-subarachnoid hemorrhage (SAH). The present study aimed to clarify the characteristics and outcomes of these conditions.We retrospectively investigated 669 consecutive patients who were surgically treated for CSDH between January 2006 and May 2019.Basal cistern effacement and pseudo-SAH were found in 24 (3.6%) and 11 (1.6%) patients, respectively. Predictors of basal cistern effacement in patients with CSDH were younger age, cerebrospinal fluid leak, and bilateral CSDH (P0.05). In patients with basal and Sylvian cistern effacement, the significantly different main features to differentiate patients with and without pseudo-SAH were younger age, cerebrospinal fluid leak, and thick small hematomas on computed tomography slices of the Sylvian cistern (P0.05). Magnetic resonance imaging showed that high-density areas in the Sylvian cistern of pseudo-SAH on precontrast computed tomography images corresponded to the M1 segment of the middle cerebral artery. The outcomes of patients with basal cistern effacement and of patients with pseudo-SAH did not differ from other patients with CSDH, although rates of surgical complications were significantly higher among patients with basal cistern effacement.Although the outcomes of patients with basal cistern effacement and pseudo-SAH were similar to outcomes of other patients with CSDH, problematic postsurgical complications and cerebrospinal fluid leaks were more likely to arise in such patients.

Prehospital information of patients with intracerebral hematomas (ICHs), including systolic blood pressure (SBP), Glasgow Coma Scale (GCS), and neurological deterioration (ND), defined as GCS score worsening ≥2 points, has been reported, though relationships among the prehospital information and clinical factors, including the spot sign, which was a reported predictor of outcomes, were not clarified. The purpose of this study was to elucidate relationships among prehospital information, the spot sign, and clinical outcomes after admission using multivariate analysis. Consecutive patients with ICHs admitted within 6 h of onset from 2009 to 2017 were investigated. Among 645 eligible patients, prehospital ND was found in 107 (16.6%). Multiple regression analysis showed that predictors of hematoma volume were prehospital GCS (p < 0.0001), prehospital ND (p < 0.0001), anticoagulant use (p = 0.0254), and cortical hematoma (p < 0.0001). Predictors of emergency surgery or death within 24 h were prehospital SBP (p = 0.0005, unit OR: 1.01), prehospital GCS (p < 0.0001, unit OR: 0.82), prehospital ND (p = 0.0002, OR: 3.26), and hematoma volume (p < 0.0001, unit OR: 1.04). Predictors of death at discharge were prehospital GCS (p < 0.0001, unit OR: 0.75), prehospital ND (p = 0.0001, OR: 3.49), and age (p = 0.0008, unit OR: 1.036). On the other hand, none of the 3 items of prehospital information were predictors of the spot sign or hematoma enlargement. The prehospital information and the spot sign could predict post-admission outcomes in a complementary fashion. Prehospital information might be used as a reference for preparing emergency treatment, as well as possible future blood pressure-lowering treatment, before emergency department arrival.

OBJECT The middle meningeal artery (MMA) is suspected to play an important role in the development of chronic subdural hematoma (CSDH). The aim of this study was to clarify whether the MMA was enlarged in patients with CSDHs. METHODS The authors retrospectively assessed 55 patients in whom CSDH was diagnosed between 2010 and 2014 and who underwent MR angiography (MRA) after the onset of CSDH. The authors compared MMA diameters between hemispheres with and without CSDHs on MR angiograms. A case-control study was also performed with 55 sex- and age-matched patients with incidental unruptured aneurysms as controls. RESULTS In 55 patients with CSDHs, the diameters of the 79 MMAs on the CSDH side were significantly larger than the diameters of the 31 MMAs on the non-CSDH side (p < 0.05). In 24 patients with bilateral CSDHs, no significant difference was found between the MMA diameters on the larger hematoma side and those on the smaller hematoma side. In 13 patients who underwent MRA before the onset of the CSDH, the MMAs on MR angiograms acquired after onset of the CSDH were significantly larger than those on MR angiograms acquired before the CSDH onset (p < 0.05). The diameters of the MMAs in 55 patients with CSDHs were significantly larger than those of the MMAs in the 55 control patients (p < 0.05). CONCLUSIONS The MMA is enlarged with development of a CSDH. Information about the MMA observed on MRA in patients with CSDHs may be useful in developing a strategy for future treatment of CSDHs.

Background and Purpose— Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign. Methods— We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates. Results— Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours ( P P =0.004), with positive predictive values decreasing from 53% to 33%. Conclusions— The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.

Cerebrospinal fluid (CSF) plays an essential role in maintaining the homeostasis of the central nervous system. The functions of CSF include: (1) buoyancy of the brain, spinal cord, and nerves; (2) volume adjustment in the cranial cavity; (3) nutrient transport; (4) protein or peptide transport; (5) brain volume regulation through osmoregulation; (6) buffering effect against external forces; (7) signal transduction; (8) drug transport; (9) immune system control; (10) elimination of metabolites and unnecessary substances; and finally (11) cooling of heat generated by neural activity. For CSF to fully mediate these functions, fluid-like movement in the ventricles and subarachnoid space is necessary. Furthermore, the relationship between the behaviors of CSF and interstitial fluid in the brain and spinal cord is important. In this review, we will present classical studies on CSF circulation from its discovery over 2,000 years ago, and will subsequently introduce functions that were recently discovered such as CSF production and absorption, water molecule movement in the interstitial space, exchange between interstitial fluid and CSF, and drainage of CSF and interstitial fluid into both the venous and the lymphatic systems. Finally, we will summarize future challenges in research. This review includes articles published up to February 2016.

While warfarin use and the presence of the spot sign on computed tomography angiography are associated with a high frequency of hematoma enlargement and high mortality among patients with intracerebral hematomas (ICHs), the effects of various combinations of warfarin use and/or the spot sign have never been clarified. The combinations of both or either of warfarin use and/or the spot sign were used to investigate their relationships with hematoma enlargement and mortality before the introduction of prothrombin complex concentrate (PCC) treatment.Consecutive patients with ICHs admitted within 6 h of onset from 2009 to 2017 were investigated.Of 703 eligible patients, the combinations of warfarin use and spot sign-present and of warfarin use and spot sign-absent were seen in 23 (3.3%) and 35 patients (5.0%), respectively. The combination of warfarin use and spot sign-present was a predictor of hematoma enlargement (p 0.05). In regard to mortality (13.5% for all patients), mortality with the combination of warfarin use and spot sign-present was 52.2%, which was significantly higher than in the 3 other groups. Multivariate analysis showed that the combination of warfarin use and spot sign-present was a significant predictor of mortality (p 0.05).Warfarin users with ICHs showing spot signs, who accounted for approximately 40% of ICH patients with warfarin use, showed a high frequency of hematoma enlargement and high mortality. This group was regarded as high-risk patients and should be considered candidates for prompt administration of PCC.

Objective The number of patients with chronic subdural hematoma (CSDH) showing comorbidities and/or impaired activities of daily living (ADL) before the onset of CSDH has increased with the recent aging of society. The purposes of this study were to evaluate ADL worsening by comparing premorbid ADL and ADL at discharge and to investigate the effects of pre-existing comorbidity-related clinical factors on the outcomes. Methods A total of 570 patients with CSDH admitted from 2006 to 2016 were studied retrospectively. Clinical factors, including pre-existing comorbidities, related to outcomes were identified by multivariate analysis. A variation of the modified Rankin Scale (mRS) using 5 united categories of mRS scores 0/1, 2, 3/4, 5, and dead was used for evaluation of ADL. Results Of 570 patients, 390 (68.4%) had pre-existing comorbidities and 120 (21.1%) showed premorbid impaired ADL (mRS scores 2 and worse). Considering pre-existing impaired ADL, ADL deteriorated after CSDH in 92 patients (16.1%), whereas ADL impairment at discharge was found in 173 patients (30.4%). Comorbidities related to ADL deterioration on multivariate analysis were hemodialysis and chronic heart failure. Antithrombotic use for cardiovascular diseases was a predictor of acute-on-chronic subdural hematoma, which was the sole common predictor for ADL deterioration and the occurrence of surgical complications. Conclusions In patients with CSDH, pre-existing comorbidity-linked factors related to outcomes were hemodialysis, chronic heart failure, and antithrombotic use. Patients with acute-on-chronic subdural hematoma with these factors should be regarded as a high-risk group.

The presence of hemiparesis on arrival in patients with subarachnoid hemorrhage (SAH) is presumed to affect prognosis; intracranial hematomas with mass effect responsible for hemiparesis are frequently observed in these patients. The aim of this study was to clarify characteristics and outcomes of patients who presented with hemiparesis on arrival with no responsible hematomas (hemiparesis without hematoma) having mass effect demonstrated on computed tomography.Consecutive patients with SAH treated with surgery for ruptured cerebral aneurysms within 5 days of onset between 2003 and 2015 were retrospectively reviewed.Hemiparesis without hematoma was present in 25 of 858 surgically treated patients (2.9%). Internal carotid artery aneurysms were significantly more common in patients with hemiparesis without hematoma than in the other patients (P0.05). In 19 of 21 surviving patients (90.5%) with hemiparesis without hematoma on arrival, the hemiparesis improved at discharge. Favorable outcomes were achieved in 16 of 25 patients with hemiparesis without hematoma (64%) and in 13 of 59 patients with hemiparesis with hematomas (22.0%); this difference was significant (P0.05).Hemiparesis can be expected to improve in patients with SAH with hemiparesis without hematoma, and such patients appear to have a better prognosis than patients with SAH with hemiparesis and responsible hematomas. A possible major mechanism of hemiparesis without hematoma based on the characteristics identified is a combination of transient ipsilateral hemispheric functional failure caused by the impact of aneurysmal rupture and transient ischemia of the perforators originating from the internal carotid artery.

Detailed features of chronic subdural haematoma (cSDH) associated with disturbance of consciousness and acute-on-chronic subdural haematoma (a/cSDH), in which acute subdural haematoma overlaps cSDH, remain poorly understood. The object of this study was to clarify both characteristics of cSDH associated with disturbance of consciousness and the significance of a/cSDH.Clinical factors and computed tomography (CT) findings were retrospectively investigated in 349 consecutive patients admitted between 2006 and 2013 and diagnosed with cSDH.Glasgow Coma Scale (GCS) was ≤ 8 in 21 patients (6.0%) and 9-14 in 29 patients excluding aphasia and/or dementia (8.3%). Multiple logistic regression analysis indicated that a/cSDH, female sex and haemodialysis were significantly related to severe disturbance of consciousness (GCS ≤ 8). Predictors for a/cSDH observed in 29 patients (8.3%) were trauma history within 7 days before admission, high prothrombin time-international rate, and use of anticoagulants and/or antiplatelets. Unfavourable outcomes were observed in 29 of 299 patients (9.7%) without consciousness disturbance, compared to 27 of 50 patients (54%) with consciousness disturbance. Predictors of unfavourable outcome were consciousness disturbance, increase in age, malignancy, trauma history within 7 days and haemodialysis.Disturbance of consciousness associated with cSDH, often caused by either a/cSDH or concomitant disease, frequently resulted in unfavourable outcomes. As a result, in cSDH patients associated with disturbance of consciousness, underlying conditions, especially a/cSDH, which is often caused by haemostatic abnormality, should be clarified and managed.

A phenomenon of cerebral infarction following acute subdural hematoma (ASDH) in infants and young children, termed cerebral infarction following ASDH (CIASDH), has been well recognized, though both its mechanisms and risk factors have been poorly understood. The purpose of the present study was to investigate the predictors for CIASDH in a population of ASDH, and to evaluate the imaging studies to presume the mechanisms of CIASDH. We retrospectively examined consecutive children 6 years of age or younger, who were diagnosed with ASDH and were admitted to our hospital between 2000 and 2014. In 57 consecutive children with ASDH, 12 (21.1%) developed CIASDH. The multivariate analysis revealed five predictors for CIASDH: presence of seizure, consciousness disturbance at admission, absence of skull fracture, hematoma thickness ≥ 5 mm on computed tomography (CT), and midline shift ≥ 3 mm on CT (p < 0.05). In three of six patients (50%) undergoing magnetic resonance (MR) imaging/fluid-attenuated inversion recovery (FLAIR) within 5 days of admission, serpentine hyperintensities in the subarachnoid space (FLAIR vessel hyperintensities) were demonstrated. MR angiography showed neither occlusion nor stenosis of the cerebral arteries. Single photon emission CT performed at admission in one patient showed a cerebral blood flow reduction in the ASDH side. All the children with CIASDH showed unfavorable outcomes at discharge. Children showing multiple predictors at admission should be carefully observed for development of CIASDH. Evaluation of the imaging studies suggested that a blood flow disturbance in the level of peripheral arteries to microcirculation was one candidate for possible mechanisms to induce the CIASDH.

The authors report a 61-year-old female patient with a giant cavernous aneurysm in the right internal carotid artery (ICA) leading to acute subdural hematoma (ASDH) 7 days after the occurrence of abducens nerve palsy. She underwent ICA occlusion associated with high-flow bypass. In all five reported patients with a cavernous ICA aneurysm causing ASDH, the size of the aneurysm was giant and cranial nerve signs preceded the rupture. When a patient with a symptomatic cavernous ICA giant aneurysm experiences sudden-onset headache and/or consciousness disturbance, rupture of the aneurysm should be differentiated, even though a cavernous ICA aneurysm rarely causes ASDH.

Although arachnoid cysts (ACs) are associated with chronic subdural hematomas (CSDHs), especially in young patients, the detailed features of CSDHs associated with ACs remain poorly understood. The objective of this study was to clarify the relationship between the location of CSDHs and ACs and the significance of ACs in young patients with CSDHs. We retrospectively assessed 605 consecutive patients 7 years of age and older who were diagnosed with a CSDH between 2002 and 2014. Twelve patients (2%) had ACs, and 10 of the 12 patients were 7–40 years of age. Patients with ACs as a complication of CSDHs were significantly younger than those without ACs (p < 0.05). Three different relationships between the location of CSDHs and ACs were found: a CSDH contacting an AC, an ipsilateral CSDH apart from an AC, and a CSDH contralateral to an AC. In 21 patients with CSDHs who were 7–40 years of age, 10 (47.6%) had ACs (AC group) and 7 (33.3%) had no associated illnesses (non-AC group). All 10 young patients with ACs showed ipsilateral CSDHs including a CSDH apart from an AC. All 17 patients in both the AC and non-AC groups showed headache but no paresis at admission. The pathogenesis of CSDHs associated with ACs may be different among the three types of locations. The clinical characteristics of patients with a combination of a CSDH and an AC including headache as a major symptom may be attributed to young age in the majority of patients with ACs.

Background Few studies have examined the risk of computed tomography angiography (CTA) during the acute phase of spontaneous intracerebral hemorrhage (ICH), while the benefits of CTA in ICH have been well-documented. The present study investigated both the benefits of identifying spot signs, which are supposed to indicate hematoma enlargement after admission, and risks of CTA performed during the acute phase of ICH. Methods We retrospectively assessed 323 consecutive patients with spontaneous ICHs admitted to our hospital between April 2009 and March 2012 and who underwent CTA on admission. Results In 80 patients (24.7 %), spot signs were demonstrated on CTA source images. Multivariate analysis revealed two independent factors correlated with presence of the spot sign: age and hematoma volume (p

Numerous studies have identified different predictors for secondary hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH), although predictors regarding timing of the shunt operation have never been reported. Predictors for an early shunt, which was defined as a shunt operation performed ≤30 days after SAH onset, and for a late shunt, performed at 40 days, were investigated.A total of 735 consecutive SAH patients admitted to our hospital between 2003 and 2014 who underwent surgery for ruptured aneurysms within five days of onset were retrospectively assessed.Secondary hydrocephalus developed in 225 patients, including 70 with an early shunt and 96 with a late shunt. Multivariate analysis showed that predictors for secondary hydrocephalus were age ≥70 years, World Federation of Neurosurgical Society (WFNS) grade IV-V, Fisher grade 3-4, intraventricular hemorrhage, anterior cerebral artery aneurysms, and external drainage for acute hydrocephalus (p 0.05). In the early and late shunt groups, multivariate analysis indicated that early shunt was significantly associated with coil embolization, and late shunt was correlated with middle cerebral artery aneurysms and cerebral infarction due to vasospasm (p 0.05).The difference in the predictors between the early and late shunts implied that the mechanisms of secondary hydrocephalus differed between the early and late shunt groups. Knowledge of the associated risk factors might help to predict the timing of the shunt operation for early rehabilitation planning in the future.

The selection of therapeutic modalities, including endovascular coil embolization and surgical clipping, for management of unruptured paraclinoid aneurysms, remains controversial. Detailed long-term outcome data for endovascular coil embolization of unruptured paraclinoid aneurysms are still lacking. Thus, we evaluated the safety and efficacy of coil embolization of unruptured paraclinoid aneurysms.From January 1998 to July 2010, 138 patients underwent endovascular coiling for 140 unruptured paraclinoid aneurysms. Their medical records and radiologic images were reviewed retrospectively.Complications occurred in 5·7% of 140 procedures and the morbidity rate was 0·7%. Of the 140 unruptured paraclinoid aneurysms, a total of 111 aneurysms underwent follow-up imaging evaluation at 2 years or more, or showing reopening on imaging studies within 2 years (65·6±37·2 months). Multivariate analysis revealed two predictors for reopening of the aneurysms: a maximum diameter of aneurysms and a dome/neck ratio of aneurysms (P0·05). Reopening rates of aneurysms with maximum sizes of8, 8-10, and10 mm were 1%, 25%, and 75%, respectively. Reopening rates were significantly different among the three groups (P0·05). In aneurysms with a maximum diameter of 8-10 mm, there was a significant difference of dome/neck ratios between the presence and absence of reopened aneurysms (P0·05).The results indicate that endovascular coil embolization is a safe and effective treatment modality in selected patients with unruptured paraclinoid aneurysms. Consideration of the aneurysm size and the dome/neck ratio could assist in the selection of therapeutic modalities for these aneurysms.

Objective To evaluate quantitatively flow impairment of contrast medium on digital subtraction angiography (DSA) performed before and after filter retrieval following carotid artery stent (CAS) placement with distal filter protection. Methods Retrospective analysis was performed of 55 CAS placement procedures with distal filter protection in 51 patients. From a qualitative analysis, the operators determined if there was flow reduction of contrast medium on digital subtraction angiography (DSA) before filter retrieval. A quantitative analysis was performed of frame-by-frame images before and after filter retrieval to compare the flow state of contrast medium. Results Stop-flow or slow-flow classified by the operators during CAS placement was found in 10 (18%) of 55 procedures. However, the frame-by-frame analysis of DSA images showed flow reduction of contrast medium in 46 (84%) of 55 procedures. Among 45 procedures with normal-flow as classified by the operators, 36 (80%) procedures showed ≥1 frames with delay of contrast medium based on quantitative analysis. Conclusions The frame-by-frame comparison of angiographic images revealed a much higher incidence of blood flow impairment on DSA before filter retrieval compared with the operators' classification during CAS placement procedures. Considering the high incidence of blood flow impairment, the possibility of stagnation of blood flow in the internal carotid artery (ICA) column should be expected during every CAS placement procedure.

A routine aspiration method in filter-protected carotid artery stenting (CAS) has been reported recently in which the proximal internal carotid artery (ICA) blood column was aspirated using an aspiration catheter after postdilatation regardless of flow state on digital subtraction angiography. We examined the debris particles captured by this method.The routine aspiration method was used in 71 CAS procedures. In two procedures, captured debris particles were examined histologically. In the remaining 69 procedures, the size and number of debris particles were measured under a stereoscopic microscope, and then relationships between the amount of debris particles and clinical variables were evaluated using multivariate regression analysis.Histologically, the captured debris contained platelet-precipitating, thrombotic, lipid-rich fibrous and calcified material. The number of debris particles ≥1 mm was 19.6 ± 12.1 (mean ± SD) in 60 procedures with normal flow and 25.9 ± 17.2 (mean ± SD) in 9 procedures with slow/stop flow. Multivariate regression analysis demonstrated that extension of a proximal ICA angulation was an independent predictor of the amount of debris particles with a maximum diameter of either ≥1 mm or1 mm but ≥0.5 mm (p0.05).The captured debris appeared to originate from atheromatous plaques. If the routine aspiration method had not been used in the present series, the debris might have migrated into intracerebral arteries. Restriction of the extension of a proximal ICA angulation might reduce the amount of debris associated with CAS, especially when the proximal ICA angulation is pronounced.

Susceptibility-weighted (SW) magnetic resonance (MR) imaging is a sensitive test to detect intravenous deoxygenated blood. On SW images, dilated appearing draining veins in tissue with perfusion impairment occur due to an increase in intravenous deoxyhemoglobin levels, and could indicate poor perfusion areas in which there is an elevated oxygen extraction fraction. In this study, patients with possible chronic ischemia caused by internal carotid artery stenosis underwent carotid artery stenting (CAS). Changes in cortical vein diameters were evaluated before and after CAS using SW imaging.Twenty-two patients with 25 lesions underwent 3 T SW imaging before and after CAS. The diameters of cortical veins were measured on SW images. Blood flow reduction and cerebrovascular reserve were examined before CAS using a single-photon emission computed tomography (SPECT) study, including an acetazolamide stress test.Two of six patients with both decreased blood flow and reduced cerebrovascular reserve on SPECT showed significantly increased cortical vein diameters on pre-CAS SW images (P0.05). After CAS, these same two patients demonstrated a significant decrease in their cortical vein diameters (P0.05).The present study demonstrates that dilated cortical veins as seen on SW imaging may reflect areas of altered oxygen extraction fraction due to chronic ischemia in patients with carotid artery stenosis, and that cortical venous dilatation is reversed after successful CAS. In the future, estimations of the cortical vein diameters on SW imaging may help to qualitatively evaluate areas of poor perfusion in chronic ischemia.

This study evaluated the effectiveness of intra-aneurysmal coil embolization for large or giant carotid artery aneurysms in the cavernous sinus in seven patients treated by intra-aneurysmal coil embolization from 2001 to 2010. Only one patient showed improved neurological symptoms caused by aneurysmal mass effect during the mean follow-up period of 53.4 ± 27.3 months. Neurological symptoms caused by the aneurysms remained unchanged in two patients, and deteriorated in four. Intra-aneurysmal coil embolization is not considered an effective treatment option for large or giant carotid artery aneurysms in the cavernous sinus.

【目的】摘出術前の直接穿刺による腫瘍塞栓術中に外頸動脈へのNBCA（nbutyl2cyanoacrylate）のmigrationを認めた頚動脈小体腫瘍の１例を報告する．【症例】42歳，女性．徐々に増大し，圧痛を伴う左頚部腫瘤を自覚．頚動脈小体腫瘍と診断し，摘出術に先行して腫瘍塞栓術を行った．経皮的に腫瘍を直接穿刺しロードマップガイド下に20%NBCAによる塞栓術を行い，完全な腫瘍濃染の消失を認めた．塞栓術終了直前にNBCAが外頚動脈の分枝に逆流し，外頚動脈分枝閉塞をきたしたが，症状は出現しなかった．塞栓術翌日に腫瘍摘出術が施行され，約200mlと少ない出血量で全摘出が行われた．【結論】NBCAを用いた直接穿刺による塞栓術は頚動脈小体腫瘍の術前塞栓術として有用であると思われる．しかし，周辺血管への塞栓物質迷入に充分な注意が必要である．

【目的】海綿静脈洞部硬膜動静脈瘻（CS dAVF）に対する経静脈的塞栓術で，マイクロカテーテル（MC）プルアップ法が有用だった1例を報告する．【症例】76歳，女性．CS dAVFによる右眼症状を認めた．通常の方法では右CSへ到達できなかった．ガイドワイヤー（GW）を左下錐体静脈洞（IPS）からposterior intercavernous sinusと右IPSを介し右内頚静脈（IJV）へ誘導，右IJVの近位から誘導したグースネックスネアで捕捉した．GWと共にグースネックスネアとMCを右IPSへ引き上げ，さらに右CS内へ誘導しコイル塞栓を施行，症状は消失した．【結論】MCプルアップ法は，CSへ到達困難な症例に有効な場合がある．

The frequency and causes of neurological change that occurs in patients within 24 hours after the onset of intracerebral hemorrhage (ICH), as well as their relationship to outcome, have seldom been reported. This study evaluated 184 patients with supratentorial ICH and neurological deterioration or improvement; measuring their level of consciousness (LOC) and motor skills the day after admission using the National Institutes of Health Stroke Scale. Nineteen patients (10%) deteriorated and 114 (62%) improved. Patient age, hematoma volume, and change in hematoma volume were independent predictors of early neurological improvement (p < 0.05). Independent predictors of 1-month functional outcome were age, LOC score at admission, motor score at admission, and change in motor score the day after admission (p < 0.05). Approximately 70% of the patients showed early neurological change. Observing early changes in hemiparesis was important for predicting functional outcome.

Sturge-Weber syndrome (SWS) is a neurocutaneous disorder presenting with a facial port-wine stain, along with an occipital leptomeningeal angiomatosis that is typically located ipsilateral to the stain. In this paper, the authors present a rare case of SWS associated with an arteriovenous malformation (AVM) instead of an angiomatosis in the ipsilateral occipital lobe. While the patient was in the care of the authors, the AVM progressively enlarged, and was accompanied by progressive stenoocclusive changes of the venous system. The resulting brain edema finally brought about a serious neurological condition 13 years after the initial diagnosis. Transarterial embolization and medical treatments decreased the edema. Subsequently, however, a large intraparenchymal cyst appeared, aggravating the patient's motor weakness. Aspiration of the cyst ameliorated these symptoms. The analysis of the fluid from the cyst revealed that it contained a very high concentration of protein. Although there is no proven pathogenic mechanism to explain these protein concentrations and the enlargement of the AVM, the authors hypothesize that the progressive edema resulted from a synergic augmentation of the inflow from the AVM and the progressive obstruction of venous drainage that is a hallmark of SWS. The formation of the cyst probably resulted from the blood vessel hyperpermeability that is inherent to SWS.

Three patients developed hemorrhage in the splenium of the corpus callosum 2 weeks after the onset of subarachnoid hemorrhage (SAH) associated with acute hydrocephalus. Computed tomography performed a few days after the onset showed a low density area in the splenium of corpus callosum in all three patients, and preventive measures against symptomatic vasospasm were begun, including vasodilator administration. Computed tomography showed hemorrhage in the splenium of the corpus callosum 17 to 22 days after onset of SAH, manifesting as mental deterioration or headache. Antivasospasm agents were immediately discontinued, and strict blood control measures were instituted. Splenial hematoma is another potential cause of neurological deterioration after surgery for SAH, in addition to vasospasm, hydrocephalus, and rebleeding.

BACKGROUND AND PURPOSE The purpose of this study was to clarify characteristic findings on three-dimensional (3D) digital subtraction angiography (DSA), and to investigate diagnostic usefulness of 3D DSA in vertebro-basilar dissections (VBD). METHODS In 25 consecutive patients with VBD, two-dimensional (2D) DSA, and 3D DSA findings were evaluated by a scoring system. The effects of 3D DSA results on diagnosis were scored in comparison with 2D DSA results. RESULTS A proximal stenosis, a distal stenosis, a bleb, and a relationship between the posterior inferior cerebellar artery and the dissection were significantly better visualized in 3D DSA than those in 2D DSA (P < .05). A characteristic finding of VBD on 3D DSA was a combination of an aneurysmal bulging and its proximal and distal stenoses, which was observed in 92% of the 25 patients. CONCLUSIONS Three-dimensional DSA was more useful for diagnosis in patients with VBD in comparison with 2D DSA.

The authors report a case of a myxoid chondrosarcoma of the pineal region in a 37-year-old woman who presented with an intratumoral hemorrhage. Partial removal of the tumor in an initial surgery resulted in failure to establish a definitive diagnosis. The residual tumor enlarged after a second intratumoral hemorrhage 14 months after the onset of the first symptoms, and gross-total resection of the tumor was achieved in a second surgery. Histological and immunohistochemical findings after the second surgery were consistent with a diagnosis of myxoid chondrosarcoma. Radical excision of a tumor was considered to play an important role in the management of intracranial myxoid chondrosarcoma.

False-negative diffusion-weighted (DW) imaging findings are often encountered during the acute stage of cerebral ischemia. The types of acute ischemia most likely to be missed by conventional DW imaging, and the utility of additional thin-section DW imaging of the infratentorium were investigated in 192 consecutive patients admitted within 24 hours of the onset of ischemic symptoms. If 6-mm section DW imaging at admission showed no obvious lesion, additional 3-mm section DW imaging of the infratentorium was performed. Six-mm section DW imaging failed to demonstrate ischemic lesion in 32 patients; 18 patients with transient ischemic attack (TIA), 13 with infratentorial infarction, and one with supratentorial infarction. Three-mm section DW imaging revealed the ischemic lesions in 12 of these 32 patients. Most patients with negative 6-mm section DW imaging findings at admission suffered from either infratentorial infarction or TIA. If 6-mm section DW imaging shows no ischemic lesion, 3-mm section DW imaging of the infratentorium is considered to be useful for detection of the lesion.

Objective We report a new technique in approaching the cavernous sinus through an occluded inferior petrosal sinus (IPS) using three-dimensional (3D) venography. Case presentation A patient diagnosed with arteriovenous fistula of the right cavernous sinus underwent transvenous embolization. The IPS was not detectable on angiogram. Retrograde injection of contrast with 3D imaging of the internal jugular vein clearly demonstrated the remnant of the IPS. By referring to the images obtained, catheterization of the cavernous sinus by way of the IPS was performed without difficulties. Conclusion Three-dimensional venography for detecting the entrance to the IPS is a useful method and easy to perform. We believe that this technique should be considered whenever the access to an occluded IPS is necessary.

Among patients diagnosed with Grade V subarachnoid hemorrhage (SAH) according to the World Federation of Neurosurgical Societies (WFNS), the identification of those with the possibility of recovery is not feasible, although approximately one-fifth of these patients have favorable outcomes according to a recently published series of surgical papers. We hypothesized that computed tomography angiography (CTA) source images (SIs), which have applied to the detection of acute ischemia, might be useful for selecting Grade V patients with possibilities for favorable outcomes.We retrospectively assessed 170 SAH patients who underwent surgery between January 2009 and February 2012 and quantitatively measured their mean cerebral cortical densities from the initial CTA-SIs.The cortical densities of 123 patients of Grades I-IV were strongly affected by the following two CTA-SI findings that were revealed by multivariate analysis: the density of the internal carotid artery (ICA) just proximal to the petrous portion and the ratio of the subarachnoid (SA) space to intracranial volume (P0.05). Favorable outcomes were obtained in 9 of the 47 Grade V patients (19.1%), and the predictors of the favorable outcomes according to multivariate analysis were increased cortical densities on the CTA-SIs and female patients (P0.05).The outcomes of Grade V patients could be partly predicted based on the estimates of cortical density from the CTA-SIs, and this measure might be useful for the selection of Grade V patients for surgery, provided that both ICA density and SA space ratio are confirmed before the evaluation of cortical density.

Background and Purpose— A spot sign is a bright spot on computed tomography angiography source images, which is predictive of hematoma growth in spontaneous intracerebral hemorrhage, although the cause of the spot sign is unclear. Our aim was to investigate the spot sign seen on computed tomography angiography and a striate artery, which is a presumed site of intracerebral hemorrhage bleeding origin in the putamen. Methods— In consecutive cases of spontaneous intracerebral hemorrhage in the putamen, spot signs and striate arteries were evaluated. Coronal reformat images of computed tomography angiography were created to visualize the striate arteries. Acute deterioration, defined as hematoma enlargement, emergency hematoma removal, or death within the day of admission, was reviewed. Results— Of the 141 patients undergoing computed tomography angiography, 15 of the 30 patients (50%) who had spot signs showed an intrahematoma striate artery (termed spot and tail sign), which was a linear density extending from the middle cerebral artery toward the spot sign. Acute deterioration occurred more frequently in patients who had a spot and tail sign compared with patients who had spot signs without intrahematoma striate arteries ( P P Conclusions— The presence of a spot and tail sign, assumed to indicate active bleeding from the striate artery, could be a more sensitive predictor of acute deterioration than the presence of a simple spot sign.

To determine whether transcranial motor-evoked potential (TCMEP) monitoring is useful for detecting blood flow insufficiency in the anterior choroidal artery (AChA) and reflects motor function during coil embolization of AChA aneurysms.We analysed MEP findings in seven patients who underwent coil embolization for AChA aneurysms. Corkscrew electrodes positioned at C3 and C4 were used to deliver supra-maximal stimuli (230-550 V). TCMEPs were recorded from the brachioradialis, abductor pollicis brevis, anterior tibialis, and abductor hallucis muscles during all endovascular surgery procedures.Three of seven patients showed transient decreases in TCMEP amplitudes obtained from the lower extremities after coil insertion into the aneurysms, although digital subtraction angiography (DSA) showed no blood flow insufficiency in the AChAs. In two of these three patients, extraction of the coils resulted in recovery of TCMEP amplitudes. In the other patient, the amplitude recovered gradually during repeated TCMEP recordings. One of the three patients experienced transient hemiparesis and aphasia 3 hours after treatment. No patients experienced permanent morbidity post-operatively.Decreases in TCMEP amplitude during endovascular treatment for AChA aneurysms are likely to reflect motor dysfunction due to a subtle blood flow insufficiency in the AChA, not detectable by DSA. TCMEP monitoring is a simple and safe monitoring method during coil embolization of AChA aneurysms.

A 35-year-old male presented with basilar artery vasculitis secondary to sphenoid sinusitis manifesting as rapidly deteriorating symptoms including consciousness disturbance and right hemiparesis. Computed tomography (CT) on admission showed sphenoid sinusitis without intracranial lesion. Emergency angiography demonstrated basilar artery stenosis. The neurological deterioration was considered to be caused by ischemia of the perforating arteries branching from the stenotic portion of the basilar artery. The patient was treated with urokinase infusion through a microcatheter just proximal to the stenosis 3 hours after the onset of the symptoms. His consciousness level and right hemiparesis markedly improved immediately after the procedure. Magnetic resonance (MR) imaging on day 5 revealed that extension of the sphenoid sinusitis into the prepontine cistern had formed an abscess which was attached to the clivus. The basilar artery was embedded in the abscess at the angiographic stenosis. Cerebrospinal fluid (CSF) analysis showed white blood cell count of 601/mm3 with 82% neutrophils, 89.2 mg/dl protein, and 31 mg/dl glucose. No causative organism in the CSF could be identified by smear or culture. Early MR imaging and CSF examination are recommended when patients present with both ischemic symptoms involving the basilar artery and opacification of the sphenoid sinus on CT to identify basilar artery vasculitis secondary to sphenoid sinusitis.

BACKGROUND Although elevation of blood pressure in aneurysms induced by injection of contrast medium has been postulated as a major cause of rerupture of ruptured cerebral aneurysms during angiography, no study has proved the elevation of intra-aneurysmal pressure because of difficulty in measuring the intra-aneurysmal pressure during angiography. The present study demonstrated intra-aneurysmal pressure to be raised by injection of contrast medium, using a microcatheter introduced into aneurysms. METHODS To confirm the accuracy of pressure measurement through a microcatheter, we measured intra-aneurysmal pressure in a plastic model of an artery and an aneurysm during and after injection of contrast medium through a microcatheter and a needle inserted into the aneurysm. In a clinical study, intra-aneurysmal pressures were measured through the microcatheter in nine cerebral aneurysms of seven patients. RESULTS In the model experiment, changes in the pressure measured through the microcatheter correlated well with those observed through the needle. In the clinical study, intra-aneurysmal systolic pressures increased by 5-23 mm Hg immediately after injection of contrast medium for 1-3 s in four basilar tip, three internal carotid-ophthalmic, and one middle cerebral artery aneurysm, whereas no pressure change was observed in a posterior cerebral artery aneurysm. Systemic blood pressure during angiography remained unchanged in all cases. CONCLUSIONS This abruptly elevated intra-aneurysmal pressure by injection of contrast medium might cause rerupture of an aneurysm soon after rupture of the aneurysm, especially when the rupture site is fragile.

To study the hemodynamics of arteriovenous malformations and to avoid hemodynamic complications during and after artificial embolization, we measured arterial blood pressures in 21 feeders in 14 patients through a microcatheter system. Before embolization, the pressures were significantly low in feeders with branches terminating in the malformation (terminal divided branches) and comparatively low in arteriovenous malformations with rapid blood flow through the malformation. The pressures in feeders with brain-nutrifying branches distal to the nidus (transient branches) were significantly high. Therefore, transient branches might be distinguishable from terminal divided branches with the use of feeder pressure monitoring. A hemorrhagic complication occurred in one patient. The feeder pressure in this patient was low before embolization and showed the maximum change among the patients after embolization. It seems that the lower the feeder pressure, the more likely complications are to occur, owing to remarkable hemodynamic alterations. Feeder pressure monitoring may be useful for preventing hemodynamic complications, especially when angiographic findings show feeding arteries giving off terminal divided or transient branches or rapid blood flow through the malformation.

Frequent transient ischaemic attacks (TIAs) in the territory fed by the anastomosed superficial temporal artery (STA) after combined therapeutic internal carotid artery (ICA) occlusion and extracranial-intracranial bypass is described in a 52-year-old woman with a giant aneurysm in the supraclinoid portion of the left ICA showing impairment of visual acuity in the left eye and right upper quadrantanopia. After the balloon test occlusion of the left ICA which was tolerated, the left STA-middle cerebral artery anastomosis was performed and occlusion of the left ICA using detachable balloons was carried out a day later. TIAs corresponding to the territory fed by the anastomosed STA occurred nine times two to four days and five times eight to nine days after the ICA occlusion without new infarction on computed tomography (CT) scan. Single-photon emission computed tomography showed no hypoperfusion immediately after the initial TIA. CT scan revealed thrombosis of half of the aneurysm a day after the ICA occlusion. The patient developed the same TIA as previously by compression of the left anastomosed STA at the time of follow-up angiography which was carried out eight days after the occlusion. Although heparin was continuously administered after the ICA occlusion for two days, the initial TIA occurred during heparinization. Anticoagulation seemed to be inadequate judging from activated coagulation time and incomplete thrombosis of the aneurysm occurred during heparinization. It is likely that the TIAs are caused by embolism via the STA, which is a rare ischaemic complication.