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21 cases of 22 ruptured cerebral aneurysms were treated in acute stage with Guglielmi detachable coils and the outcome was assesed. GDCs were placed intra-aneurysm for intra-aneurysmal occlusion. Cases: age 42–80 (mean; 59) y. o., 7 male and 14 female; 4, 6, 8 and 3 patients were categorized (Hunt and Hess) as grades 1, 2, 3 and 4 respectively. GDC embolization was performed within 24 hours of primary hemorrhage in 11 patients, within 2 to 3 days in 4 patients and 5 to 19 days in 6 patients. The occlusion rate was 100% in 7 ANs, more than 75% in 9 ANs and less than 75% in 6 ANs. There were 7 cases of complications, two coil deposits, one embolism and 4 reruptures.

To study the efficacy and long-term outcome of percutaneous transluminal angioplasty (PTA) with/without stent placement for intracranial atherosclerotic stenoses, we reviewed our treated cases retrospectively. Between May 1992 and October 2003, PTA with/without stents was performed in 64 intracranial and skull base vessels in 62 patients, including 24 middle cerebral arteries, 16 internal carotid arteries, 13 vertebral arteries, and 11 basilar arteries. PTA was technically successful in 55 vessels (86%). However, four vessels (6%) failed to achieve satisfactory dilatation. We encountered five periprocedural strokes as symptomatic complications, for a mortality rate of 4.7% and a morbidity rate of 3.1%. All the patients with stent placements survived angioplasty without any complication. In the clinical follow-up available for one week to 11.5 years (mean, 4.7 years), there were three strokes related to the treated vessels. The annual stroke rate in the affected territory was estimated at 1.2% per year. According to these results, PTA for intracranial atherosclerotic stenoses seems to be a beneficial therapy for immediate anatomical results and long-term stroke prevention. Stent-assisted PTA could help patients achieve successful dilatation and avoid complications.

Background Autosomal dominant polycystic kidney disease (PKD) is a hereditary disorder characterized by bilateral multiple renal cysts and early onset chronic renal failure. PKD patients tend to suffer their subarachnoid hemorrhage at a younger age. Unruptured aneurysms in PKD patients are not always innocuous, and proactive treatment has been indicated for these lesions. However, the management of PKD patients undergoing unruptured cerebral aneurysm surgery has been documented on only a few occasions. The purpose of this study was to better define the management of unruptured cerebral aneurysms in patients with PKD. Methods We present a retrospective review of the management of unruptured cerebral aneurysms in 16 patients with PKD. Eight patients were maintained through chronic hemodialysis whereas the remaining 8 patients did not require hemodialysis, at the time of treatment of their cerebral aneurysms. The mean follow-up period was 24 months. Results In the nonhemodialysis patients prophylactic hemodialysis was routinely performed after cerebral angiography to prevent deterioration of the pre-existing renal dysfunction. Microsurgical clipping of the aneurysm was performed in 15 patients (7 nonhemodialysis and 8 hemodialysis patients) and intravascular coil embolization was performed in 1 nonhemodialysis patient. One nonhemodialysis patient who underwent microsurgical clipping required a temporary hemodialysis after surgery, but the patient was not shifted to chronic hemodialysis. No patients developed postprocedural complications, and each showed an excellent recovery. Conclusion PKD patients with unruptured cerebral aneurysms can be safely treated with an appropriate treatment strategy including the use of prophylactic hemodialysis.

¶Background. The role of intraoperative angiography in the surgical treatment of cerebrovascular malformations remains controversial. The authors report on their experiences with intraoperative angiography in a series of 20 cases with cerebrovascular malformation to determine whether the use of intraoperative angiography has a favorable impact on the surgical treatment of cerebrovascular malformations. Methods. Intraoperative angiography was performed in the surgical resection of arteriovenous malformation in 18 patients and in the surgical obliteration of arteriovenous fistula in 2 patients. The incidence of unexpected findings, such as residual nidus, demonstrated by intraoperative angiography was determined. Findings. High-quality subtraction images were obtained by intraoperative angiography in every case and the findings prompted an additional procedure in 1 case that displayed an unexpected residual nidus (5.6%). There were no complications from the intraoperative angiography procedure. Interpretation. Intraoperative assessment of technical results prior to wound closure offers the neurosurgeon the opportunity to resect or obliterate a vascular malformation completely, obviating a second operation.

Adequate exposure of the distal internal carotid artery (ICA) for carotid endarterectomy may be difficult to achieve because of the position of the mandible and associated soft tissues. A simple yet effective use of a head frame is described to gain several centimeters of exposure of the distal ICA. The patient's head and neck are fixed in an extension position using a radiolucent head frame. Nasotracheal intubation and secure taping of the chin are also employed to keep the mouth closed and to prevent the mandible from spontaneously hanging down. The head frame tightly fixes the patient's neck, so the mandible does not disturb the surgical field throughout the operation. This simple method maximizes exposure of the distal ICA. The radiolucent head frame also enables intraoperative angiography to confirm the patency of the ICA and the absence of flap formation. This simple technique is useful for exposing the distal ICA.

Stroke is the third leading cause of death in the adult population. Numerous neuroprotective agents and procedures have been developed and a new wave of therapies is now on the horizon with the potential to minimize ischemic brain damage. On the other hand, surgical treatment has also played an important role in the treatment of stroke. This article highlights recent advances in stroke treatment, including surgical and neurointerventional radiological procedures, as well as potential new therapies. (c) 2001 Prous Science. All rights reserved.

✓ Perimesencephalic nonaneurysmal subarachnoid hemorrhage (SAH) is a distinct type of hemorrhage with a characteristic bleeding pattern and an excellent clinical outcome. The cause of this benign form of SAH remains unknown. The authors report on two cases of perimesencephalic nonaneurysmal SAH in which a small bulge on the basilar artery (BA) was demonstrated on three-dimensional rotational angiography studies. Based on data from these cases, one may infer that the lesion on the BA is responsible for the SAH. The possible pathogenesis is discussed.

A 72-year-old woman was admitted with rapidly progressive paraplegia and sphincter disturbance. T2-weighted images of the thoracic spine showed intramedullary high signal with flow voids suggesting dilated medullary veins. Conventional spinal angiography demonstrated a dural arteriovenous fistula draining into perimedullary veins. Perfusion-weighted MRI demonstrated a prolonged mean transit time and increased blood volume in the high-signal area. The loss of normal perfusion gradient and venous hypertension and were thought to produce these differences. The time-to-peak was almost identical in the high-signal and isointense areas, although the bolus of contrast medium arrived earlier in the former. Arteriovenous shunting was thought to cause faster inflow. These changes may have resulted in increased blood volume in the spinal cord. The high signal has been attributed to oedema due to venous congestion, but there has been no histological confirmation. Perfusion MRI in this case supports this hypothesis.

Intraoperative angiography evaluation of the clippings of cerebral aneurysms was investigated in a series of 38 consecutive patients with unruptured cerebral aneurysms to determine any favorable impact on the outcome. Unexpected findings including major arterial occlusion or residual aneurysm were identified. Specific variables such as the size and site of aneurysm were analyzed to determine the impact on clinical outcome and the incidence of clip modification. There were 11 large and 27 small aneurysms in this series. Mortality and permanent morbidity after microsurgical clipping were 0.0% and 2.6%, respectively. Unexpected angiographic findings necessitating clip repositioning consisted of residual aneurysm in two cases and distal branch occlusion or parent vessel stenosis in four. The need for clip modification was significantly higher for large than for small aneurysms (p = 0.007), and the rate of clip adjustment increased with increasing aneurysm size (p = 0.008). Intraoperative assessment prior to wound closure allows for the recognition and correction of defects and decreases the risk of postoperative complications. Intraoperative angiography may become important in the microsurgical clipping of unruptured cerebral aneurysms, especially large aneurysms.

Between March, 1997 and June, 2000, 104 aneurysms, including 75 ruptured and 29 unruptured aneurysms, were treated with Guglielmi detachable coils by 120 embolizations in our institution. Intraprocedual perforation occurred in four cases, representing 3.3% of the embolizations. Subsequently, two cases deteriorated, and the other two cases recovered completely without any deficit. Aneurysmal perforations mostly occurred in acutely ruptured aneurysms, small aneurysms less than 4 mm, anterior communicating artery aneurysms, or first coil delivery. Rebleedings in the acute period of subarachnoid hemorrhage occurred in four cases of partial occlusion due to aneurysmal morphology, such as a wide neck or an irregular shape. Rebleedings in the chronic period occurred in two cases, one of which rebled two months after partial occlusion, and the other of which rebled 27 months after nearly total occlusion. No subarachnoid hemorrhages documented from previously unruptured aneurysms occurred after embolizations. Insufficient embolization for ruptured aneurysms cannot prevent rebleeding, and partially occluded aneurysms and recurring aneurysms in the follow-up period require immediate re-treatment.

We have treated 93 ruptured aneurysms with Guglielmi Detachable Coils (GDC) in acute period. Seventy-three patients (78%) were independent on discharge. Among the patient of Hunt and Hess Grade I, II and III, 59 patients (88%) were independent. Acute re-rupture occurred in two elderly patients with insufficient embolization and two patients experienced re-rupture in the follow up period. Symptomatic vasospasm was reported in 17.6% of patients. The permanent morbidity rate is 4.4% and one patient died (1.5%). Although the long-term results remain to be determined, embolization with GDC is a safe and promising treatment for acutely ruptured aneurysms.

A 72-year-old woman who presented with a unilateral oculomotor nerve palsy was shown to have a very rare condition: multiple dural arteriovenous fistulae (DAVF) involving the cavernous and sphenoparietal sinuses. The sphenoparietal DAVF was cured completely by transarterial embolisation. Symptomatic relief was accomplished by this procedure. The cavernous sinus DAVF progressed to acquire cortical venous drainage, and was obliterated completely by transvenous embolisation.

Local intra-arterial fibrinolysis may improve the outcome of patients with ischemic cerebrovascular disease. A favorable prognosis is thought to be related to early re-establishment of blood flow into the affected brain. To minimize the time to revascularization during local intraarterial fibrinolysis, we employed an extracorporeal pump to deliver oxygenated blood into the affected brain through a microcatheter. The patient, a 57-year-old man, showed disturbance of consciousness with left hemiparesis and was admitted to our hospital one hour after onset of symptoms. Cerebral angiography demonstrated an acute occlusion of the right middle cerebral artery, and the patient underwent local intra-arterial fibrinolysis with an extracorporeal pump. Oxygenated blood was successfully delivered through a microcatheter into the affected brain before recanalization. Subsequently, recanalization was obtained by intra-arterial fibrinolysis with a tissue plasminogen activator. The outcome of this patient was excellent. Thus, local intra-arterial thrombolysis with extracorporeal pump may be an effective method by which to increase the residual blood flow and widen the therapeutic window for fibrinolysis.

Percutaneous transluminal angioplasty (PTA) was carried out 52 times for 49 lesions in 47 cases of atheroscrelotic stenosis of the intracranial or skull base cerebral arteries. The stenotic lesions involved the middle cerebral artery in 21 cases, the basilar artery in eight cases, the internal carotid artery (petrous-supraclinoid portion) in 15 cases, and the intracranial vertebral artery in five cases. Nearly all cases were symptomatic, such as TIA or stroke, and the degree of stenosis ranged from 70 to 99 percent, with a mean of 80 percent. PTA was performed using a STEALTH balloon angioplasty catheter. In these trials, PTA was successfully performed (as indicated by a residual stenosis under 50%) 41 times. The initial success rate was 79% and stenosis was reduced from 80% to 25%. Clinical follow-up was performed from 7 to 84 months with a mean of 44 months. During this period, death due to myocardial infarction or pneumonia occurred in five cases, stroke related to previous PTA occurred in one case (due to re-stenosis) and stroke unrelated to previous PTA occurred in two cases. Angiographic follow-up was performed in 31 cases after 41 successful PTA procedures. Re-stenosis was seen in 20% of the cases, symptomatic complications occurred in 6%, and asymptomatic complications occurred in 6% of the cases. One case suffered severe subarachnoid hemorrhage just after the PTA due to preexisting aneurysm rupture and he died a week after the PTA. So mortality in this series was 2%. From the results described here, we may conclude that PTA of the intracranial or skull base cerebral artery is technically feasible, and it can be performed with relatively low risk. From our results, it may be a useful method and effective for long-term survival of patients. But results from a larger number of patients and more long-term follow-up data are still necessary in order to evaluate the safety and usefulness of this method.

Instead of the Guglielmi detachable coil (GDC; Target Therapeutics, Fremont, California), the interlocking detachable coil (IDC; Target Therapeutics, Fremont, California) was the only available detachable and retractable coil in Japan until February 1997. From October 1993 to February 1997, endovascular treatment with IDCs were attempted for 25 cases of cerebral aneurysm. Within 25 trials, 15 cases were treated by intra-aneurysmal coil embolization, 9 cases by parent artery or proximal occlusion using IDCs and one case could not be treated due to anatomical problems of the aneurysm. As for 15 cases of intra-aneurysmal coil packing, complete occlusion was performed in 9 cases, subtotal occlusion in 4 cases and partial occlusion in 2 cases. In one of the partial occluded cases, a coil compaction occurred 6 months after embolization. Distal emboli were recognized on CT after embolization in 3 cases, however, only one case was symptomatic. Intraoperative bleeding occurred in one case, but no obvious hemorrhage after coil embolization in any case. From our experiences, treatment for poor-grade ruptured aneurysm is still difficult, but intravascular surgery for cerebral aneurysms using IDC is possible and a useful alternative, especially for surgically difficult aneurysm.

To evaluate the efficacy of preoperative embolization of meningioma, we examined the correlation between the angiographic disappearance of the tumor blush after the embolization and the volume of blood loss and transfusion intraoperatively. Preoperative embolization of meningioma with intravascular neurosurgery was attempted for 42 trials, 41 cases from July 1989 to December 1995. There were no major complications attributed to the embolization procedure. As a subjective assessment in 23 cases the information from the surgeon following the operation was obtained. The angiographic disappearance of the tumor blush and reducing of the bleeding from tumor could be considered to be statiscally significant (p In this study the efficacy of preoperative embolization of meningioma has been especially shown to reduce intraoperative blood transfusion significantly, therefore it is very useful to increase the chance of complete tumor removal with more safely and less invasively.

To the Editor: We read with great interest the article by van der Schaaf and colleagues1 in the July 2004 issue of Stroke in which the authors sought to assess the contribution of venous drainage patterns in the etiology of perimesencephalic hemorrhage (PMH). PMH, defined by a negative 4-vessel angiographic study as bleeding in the cisterns around the midbrain, is associated with an excellent outcome.2 Using computed tomography angiography, van der Schaaf and colleagues found that patients with PMH had primitive venous drainage directly into dural sinuses instead of via the vein of Galen, as with patients having aneurysmal subarachnoid hemorrhage. They also observed that the side of the PMH related to the side of the primitive drainage. They concluded that these results support the venous origin of PMH. Although van der Schaaf and colleagues found differences in the venous drainage of these patients, they neglected to present direct evidence showing that primitive venous drainage led to hemorrhage around the midbrain. They speculated that direct venous pressure from the dural sinus might cause the rupture of the perimesencephalic veins. However, their speculation is not substantiated because other cerebral veins with direct connection to the dural sinus never rupture under normal circumstances. Moreover, if this variation of venous drainage were a cause of bleeding, it …

Corrigendum to “Precise mapping system of entrance skin dose during endovascular embolization for cerebral aneurysm” [Radiat. Meas. 46 (2011), 2103e2106.] Takashi Moritake *, Mikito Hayakawa , Yuji Matsumaru , Tomoji Takigawa , Yasuhiro Koguchi , Yuka Miyamoto , Yusuke Mizuno , Koichi Chida , Keiichi Akahane , Koji Tsuboi , Takeji Sakae , Hidehiko Sakurai a a Proton Medical Research Center, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan Department of Endovascular Neurosurgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan Oarai Research Center, Chiyoda Technol Corporation, 3681 Naritacho, Oarai-machi, Higashiibaraki-gun, Ibaraki 311-1313, Japan Department of Anesthesiology, Yokohama City University, Yokohama, Kanagawa 236-0004, Japan Department of Radiological Technology, Tohoku University, Miyagi, Japan Radiological Protection Section, Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan

To report the usefulness of a side-hole on a guiding catheter for transvenous embolization of transverse-sigmoid sinus (TSS) dural arteriovenous fistulae (DAVF) by a contralateral approach with a reversed Y-shaped confluence.A 66-year-old woman presented after an epileptic seizure. Magnetic resonance imaging revealed venous infarctions of the left temporal area. Angiography showed a DAVF in the left TSS with retrograde drainage toward the superior sagittal sinus and remarkable cortical reflux.A transvenous approach through the right jugular vein was attempted after failure of the approach through the angiographically invisible left jugular vein. Catheterization beyond the confluence failed because the shape of the confluence was a reversed Y. A 5-French catheter with a side-hole was then placed in the superior sagittal sinus from the right TSS, and the microcatheter was successfully navigated into the left TSS through the side-hole. Subsequently, the DAVF was completely occluded by transvenous embolization without any adverse events.A side-hole on a guiding catheter was found to be useful for the navigation of a microcatheter to override a reversed Y-shaped confluence in transvenous embolization of TSS DAVF. This technique could be applicable to difficult configurations for transvenous catheterization, although attention should be paid to disruption of the catheter.

BACKGROUND Autosomal dominant polycystic kidney disease (PKD) is a hereditary disorder characterized by bilateral multiple renal cysts and early onset chronic renal failure. PKD patients tend to suffer their subarachnoid hemorrhage at a younger age. Unruptured aneurysms in PKD patients are not always innocuous, and proactive treatment has been indicated for these lesions. However, the management of PKD patients undergoing unruptured cerebral aneurysm surgery has been documented on only a few occasions. The purpose of this study was to better define the management of unruptured cerebral aneurysms in patients with PKD. METHODS We present a retrospective review of the management of unruptured cerebral aneurysms in 16 patients with PKD. Eight patients were maintained through chronic hemodialysis whereas the remaining 8 patients did not require hemodialysis, at the time of treatment of their cerebral aneurysms. The mean follow-up period was 24 months. RESULTS In the nonhemodialysis patients prophylactic hemodialysis was routinely performed after cerebral angiography to prevent deterioration of the pre-existing renal dysfunction. Microsurgical clipping of the aneurysm was performed in 15 patients (7 nonhemodialysis and 8 hemodialysis patients) and intravascular coil embolization was performed in 1 nonhemodialysis patient. One nonhemodialysis patient who underwent microsurgical clipping required a temporary hemodialysis after surgery, but the patient was not shifted to chronic hemodialysis. No patients developed postprocedural complications, and each showed an excellent recovery. CONCLUSION PKD patients with unruptured cerebral aneurysms can be safely treated with an appropriate treatment strategy including the use of prophylactic hemodialysis.

It has been shown that the physicochemical properties of PbO2 in the positive plate of a lead-acid battery relates to the PbO2 crystal size growth during charge/discharge cycling. It was found that there were two types of PbO2 present in an uncycled positive plate thermally decomposed into tet-PbO: One with, and the other without, forming β-PbOx. The degree of crystallinity was found to be lower in the surface layer of PbO2 crystals than in the interior. The degree of crystallinity of PbO2 crystals increased with cycling, and at the same time the size of PbO2 crystals became larger, causing decrease in the specific surface area and surface roughness. It was also concluded that the electrochemical reactivity of the surface layer of PbO2 was strongly influenced by the properties of the PbO2 crystal lattice characterized by the formula PbO2-δ(xH2O).