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Objective Preoperative embolization of meningioma is commonly performed; however, there is no consensus on the best embolic material to reduce intraoperative blood loss and surgery time. Method We retrospectively assessed the safety and efficacy of 56 cases of preoperative embolization of the middle meningeal artery with N-butyl cyanoacrylate (NBCA) in 105 cases of surgery for meningioma. We also defined a blood loss to tumor volume ratio to compensate for bias caused by tumor volume, and analyzed limited cases (the embolized group n = 52, the non-embolized group n = 21) of the convexity, the parasagittal region, the falx, and the sphenoidal ridge. Result The blood loss to tumor volume ratio was significantly less in the embolized group ( p Conclusion Tumor embolization with NBCA can be safely performed, and the procedure significantly reduces intraoperative blood loss.

Mechanically-induced vasospasm often occurs during guiding catheter insertion, occasionally preventing catheter advancement to the desired location. Delicate manipulation would be impossible without the proper positioning of guiding catheters, and vasospasm-induced cerebral hypoperfusion may cause thrombotic complications. From June 2012 to December 2013, we prospectively analyzed 150 endovascular treatment cases, excluding acute cases, for the frequency of vasospasm, risk factors, and countermeasures. The associated risk factors such as the Japanese-style State-Trait Anxiety Inventory (STAI) score; anatomy and devices; and the efficacies of warm compresses, intra-arterial lidocaine/nicardipine, and tranquilizers were analyzed. Groups 1, 2, and 3 comprised 50 patients each with controls, tranquilizer administration, and prophylactic warm compresses/intra-arterial drug injection, respectively. Moderate or severe vasospasm was seen in approximately 40% patients in each group; however, severe vasospasm was absent in Group 3. Mild vasospasm-induced cerebral infarction occurred in one patient each in Groups 1 and 2. Vasospasm during diagnostic angiography [odds ratio (OR) = 10.63; P = 0.01], many ≥ 30° vessel curves [OR = 4.21; P = 0.01], and the high STAI score [OR = 1.84; P = 0.01] were risk factors for severe vasospasm. Although the relationship between anxiety and sympathetic tone remained unclear, tranquilizer administration relieved vasospasm. Warm compresses and the intra-arterial drug infusion were also useful for relieving vasospasm. Prophylactic measures such as a tranquilizer and warm compresses are expected to alleviate vasospasm; in addition, countermeasures such as the intra-arterial injection of lidocaine/nicardipine are effective.

Cerebral hyperperfusion syndrome(CHS)and cerebral hyperperfusion phenomenon(CHP)induce intracranial hemorrhage and can become critical complications after carotid artery stenting(CAS). The purpose of the present study was to predict and avoid CHS after CAS using bilateral rSOWe retrospectively analyzed 100 consecutive patients who underwent CAS between January 2012 and May 2014 in our institution. We performed continuous bilateral rSOThere were 2 CHS cases(2.2%)and 3 CHP cases(3.3%). In the CHS/CHP group, the ΔrSOWe could promptly detect CHS and CHP in all cases by using continuous bilateral rSO

Background: We report a case in which an effective endovascular treatment cured the worsening of dementia due to a dural arteriovenous fistula (dAVF). Case Report: A 73-year-old woman suffered for 1.5 years from gait disturbance and disorientation that were suspicious of dementia. A brain MRI revealed that her symptoms were likely due to dAVF. An angiography provided a definitive diagnosis of dural transverse-sigmoid sinus fistula. Transvenous embolization completely occluded the fistula and led to a significant improvement of her cognitive function in tandem with a restoration of the cerebral blood flow. Conclusion: Endovascular treatment for dAVF is sometimes effective in treating worsening dementia, which might be due to the drastic change in cerebral blood flow in the area relevant to the cognitive function.

We experienced a very rare case of bleeding from an aneurysm of a branch of the superior cerebellar artery, which feeds a dural arteriovenous fistula (DAVF) of the posterior fossa. The aneurysm was not detected on initial angiography and 2 episodes of rebleeding resulted in deterioration of the patient's condition. Although rare, aneurysms of the pial feeding arteries should be considered as a cause of bleeding in cases of DAVF.

Currently carotid artery stenting (CAS) is a widely used technique for the treatment of carotid artery stenosis. However, some patients with restenosis following CAS have been reported, resulting in potential clinical problems. The purpose of this study was to investigate the hemodynamic changes before and after CAS to find the factors that may influence restenosis. Five patients (two with restenosis, three without restenosis) were included in this study. The geometry and rheological conditions of the carotid arteries were obtained from three-dimensional digital subtraction angiography and ultrasound measurements. Computational fluid dynamics (CFD) modelling was performed to calculate wall shear stress (WSS), wall shear stress gradient (WSSG) and internal carotid artery (ICA) flow ratio. In addition, morphologic analysis was carried out. CFD results indicated that the WSSG of the restenosis group was significantly larger than that of the no-restenosis group. In the restenosis group, the WSS distribution after CAS showed a significant variation at the ICA. The average ICA flow ratio of the restenosis group was 43.5%, while in the no-restenosis group it was 68.6%. Furthermore, there were similar significant differences between the two groups during morphology analysis. CFD technology is useful for physicians in estimating haemodynamic changes during ICA stenosis treatment. These parameters, including ICA flow ratio and WSS distribution, may help to predict carotid restenosis. In future, CFD combined with other medical techniques such as digital subtraction angiography, MRI and pathology technologies will be available for the clinical estimation of ICA restenosis.

A 71-year-old right-handed man was admitted to our hospital with right hemiparesis and sensory impairment associated with mild aphasia. Although aphasia gradually resolved within 2 weeks after stroke onset, his writing ability remained disturbed. A computed tomography (CT) scan at stroke onset revealed a hematoma in the left thalamus, but no cortical lesions were observed. Further, a single-photon emission CT (SPECT) scan showed decreased blood flow in the left thalamus, in the cortical region extending from the left superior temporal gyrus to the parietal lobe, and in the frontal lobe. It is possible that agraphia may have directly resulted from the thalamic lesion, but SPECT findings strongly suggested that a general decrease in left cortical function concomitant with a disruption of the thalamocortical and cortico-thalamocortical projection fibers produced these cognitive deficits.

●Abstract● Objectives: Although use of the small-sized catheters is less invasive for cerebral angiography (CA) difficult manipulability for tortuous vessels is a limitation. We report the clinical feasibility of a newly developed 3.3Fr catheter for CA in terms of manipulability. Methods: The data of 80 consecutive patients who underwent CA via the femoral or radial arteries using the newly developed 3.3Fr catheter were analyzed retrospectively. The duration of the CA procedure and fluoroscopy procedure in patients who underwent CA using a 3.3Fr catheter were compared with those in patients who underwent CA using a 4Fr catheter. We also analyzed the data of 14 patients who underwent CA with the new 3.3Fr catheter and had previously undergone CA with a 4Fr catheter using the same procedures including access routes and selected vessels. Results: CA was completed in all patients without any complications using the 3.3Fr catheter. The differences in the durations of CA and fluoroscopy were not statistically significant between the 3.3Fr and 4Fr catheter groups. There was also no significant difference in CA outcome in the 14 patients who underwent the same procedure using different sized catheters. Conclusions: The newly developed 3.3Fr catheter is useful for CA and its manipulability is the same as that of the 4Fr catheter.

We report two cases in which the vertebral artery (VA) entered the spinal canal via the intervertebral foramen at the C2-C3 disc level, an extremely rare variation regarded as a C3 segmental type of VA, that we diagnosed by magnetic resonance angiography. The C2 segmental type of VA, in which the VA enters the spinal canal via the C1-C2 intervertebral space, is relatively common. It is important to identify these variations before surgery of the craniovertebral junction or interventional procedures to prevent complications.

Objective Advances in vascular reconstruction devices and coil technologies have made coil embolization a popular and effective strategy for treatment of relatively wide-neck cerebral aneurysms. However, coil protrusion occurs occasionally, and little is known about the frequency, the risk factors and the risk of thrombo-embolic complications. Method We assessed the frequency and the risk factors for coil protrusion in 330 unruptured aneurysm embolization cases, and examined the occurrence of cerebral infarction by diffusion-weighted magnetic resonance imaging (DW-MRI). Result Forty-four instances of coil protrusion were encountered during coil embolization (13.3% of cases), but incidence was reduced to 33 (10% of cases) by balloon press or insertion of the next coil. Coil protrusion occurred more frequently during the last phase of the procedure, and both a wide neck (large fundus to neck ratio) (OR = 1.84, P = 0.03) and an inadequately stable neck frame (OR = 5.49, P = 0.0007) increased protrusion risk. Coil protrusions did not increase the incidence of high-intensity lesions (infarcts) on DW-MRI (33.3% vs 29% of cases with no coil protrusion). However, longer operation time did increase infarct risk ( P = 0.0003). Thus, tail or loop type coil protrusion did not increase the risk of thrombo-embolic complications, if adequate blood flow was maintained. Conclusion Coil protrusion tended to occur more frequently in cases of wide-neck aneurysms with loose neck framing. Moderate and less coil protrusion carries no additional thrombo-embolic risk, if blood flow is maintained, which can be aided by additional post-operative antiplatelet therapy.

We retrospectively analyzed the clinical usefulness of lumboperitoneal (LP) shunt placement surgery for chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH).A total of 225 patients underwent endovascular coiling for aneurysmal SAH at our institution between April 2007 and May 2012. Of these, the medical records of 190 consecutive patients were retrospectively analyzed for hydrocephalus incidence, shunt procedure-related complication rate, and hydrocephalus improvement rate. Of the 190 cases included for analysis, 102 were classified as Hunt and Hess (H and H) grades 1–2 (low H and H grade) and 88 as grades 3–5 (high H and H grade). Forty-nine cases were classified as Fisher group 1–2 (low Fisher group) and 141 as groups 3–4 (high Fisher group), which included five Fisher group 4 patients.Of the 190 patients analyzed, 22 (11.6%) presented with chronic hydrocephalus and underwent shunt placement surgery. A severe H and H grade (grade 3–5) and high Fisher group (group 3–4) were significant risk factors for chronic hydrocephalus. Twelve LP shunt surgeries and ten ventriculoperitoneal (VP) shunt surgeries were performed. All patients showed symptom improvement as confirmed by imaging results. In the LP shunt group, there were no procedure-related complications. One patient in the VP shunt group developed ventricular hemorrhage and one patient in each group developed a postoperative infection.LP shunting, which is considered relatively less invasive, yielded similar results as VP shunting; therefore, it may be an option for managing chronic hydrocephalus after endovascular treatment for SAH.

Haemodynamic changes in cerebral circulation are associated with the natural ageing process and associated pathology, leading to the development of incapacitating neurological and neurovascular diseases. Due to inherent biological limitations, current literatures mostly aimed at studying the correlation descriptively or quantifying the relationship in vitro or using computational models. In this paper, a model of a carotid-jugular fistula in the rat was used to create a haemodynamic insult to the intracranial arterial circulation and subsequent venous drainage. An arterial-venous (AV) fistula was created in 12 rats, 6 of which are normotensive Wistar-Kyoto strain (WKY) and the rest spontaneously hypertensive strain (SHR) with an additional 6 in each strains designed as controls without previous surgery. After 4 weeks of convalescence, all 24 rats were euthanised and their cerebral circulation was examined histomorphologically. We confirmed an intrinsic morphological difference between normotensive WKY and hypertensive SHR and found a modest but significant arterial shrinkage in both strains induced with AV fistula. We also reported that alterations in blood flow are also associated with marked extracellular matrix changes. We concluded that the model was suitable for studying the relative contributions of altering haemodynamic patterns and venous drainage on cerebrovascular changes. We also found that hypertension modulated cerebral vascular changes in addition to disrupted blood flow.

Computational fluid dynamics simulations can provide important hemodynamic insights for investigating the effectiveness of carotid artery stenting, but its accuracy is dependent on the boundary conditions such as the outflow pressure, which is difficult to obtain by measurements. Many computational fluid dynamics simulations assume that the outflow pressure is constant ( P = 0), but this method is likely to produce different results compared to clinical measurements. We have developed an alternative estimation method called the minimum energy loss method based on the concept of energy loss minimization at flow bifurcation. This new method has been tested on computational fluid dynamics simulation of two patients treated with carotid artery stenting, and its flow ratio at internal carotid artery and wall shear stress distribution was compared with the constant zero outlet pressure method. Three different procedure stages (prestent, poststent, and follow-up) were analyzed. The internal carotid artery flow ratio using the minimum energy loss method generally matched well with ultrasound measurements, but the internal carotid artery flow ratio based on zero outlet pressure method showed a large difference. Wall shear stress distributions varied between methods in response to the change in internal carotid artery flow rate. This study demonstrates the importance of accurate outlet boundary condition for assessing the long-term efficacy of carotid artery stenting and the risk of restenosis in treated patients.

Introduction Intracranial vertebro-basilar artery dissecting aneurysm (iVBD) can be a cause of subarachnoid hemorrhage (SAH), posterior circulation ischemia or local symptoms such as headache. Patients of iVBD with SAH are usually treated with trapping by endovascular procedures or clipping, because re-bleeding of iVBD is fatal in acute stage. However, in terms of a treatment for unruptured iVBD, its proper strategy is still controversial. In general, conservative approaches have been suggested because unruptured iVBD doesn’t have an aggressive clinical course. But some cases have an aggressive and malignant course, especially cases with basilar artery (BA) dissection extending from vertebral artery (VA). Appropriate timing and strategy for BA dissection extending from VA are less well-established because the treatment is challenging. The purpose of this presentation is to evaluate the hemodynamic findings on each iVBD status by computational fluid dynamics (CFD) and relation of them with thrombosis formation and growing dissection. Materials and methods Five patients diagnosed with iVBD were analyzed each clinical course, configuration of dissecting aneurysm and flow features. All patients are unruptured, two had BA dissection extending from VA and three had no extension to BA. We analyzed their flow status using CFD technology. Results Our results demonstrated one possibility that the angle between bilateral VA and BA causes the high impingement on the wall of aneurysm where has high pressure and divergent WSS vector. It means blood flow is unstable. On the other hand, cases without dissection extending to BA had more moderate flow in the dilated part of dissection because dissecting aneurysm located on low-angle vessel. Illustrative case 76-year-old male had BA dissection extending from VA. His dissecting aneurysm had gradually expanding and growing thrombosis formation caused compression of the brainstem. We treat coil embolization for dilated portion of intracranial left VA and occlusion with vascular plugs on extracranial left VA. In half day, his symptoms had worsed than preoperative period because of brain infarction and compression to brainstem with partial thrombosis in dissecting aneurysm. His results on CFD analysis has demonstrated flow from bilateral VA went into the same part of dilated wall and in left VA there were high pressure and wide flow instability. Conclusion In the future, to establish the timing and treatment strategy for BA dissection extending from VA, we need to continue tracking aneurysm status and analyze flow condition at dissecting aneurysm with CFD technology. Disclosures N. Uemiya: None. S. Ishihara: None. S. Kohyama: None. F. Yamane: None. T. Ootsuka: None. K. Mizokami: None. H. Neki: None. J. Niimi: None. E. Tsukagoshi: None.

Background Cognitive disorders, such as memory disturbances, are often observed following a subarachnoid hemorrhage. We present a very rare case where rupture of a posterior cerebral artery aneurysm caused restricted damage to the hippocampus unilaterally, and caused memory disturbances. Case presentation A 56-year-old, right-handed man, with a formal education history of 16 years and company employees was admitted to our hospital because of a consciousness disturbance. He was diagnosed as having a subarachnoid hemorrhage due to a left posterior cerebral artery dissecting aneurysm, and coil embolization was performed. Subsequently, he had neither motor paresis nor sensory disturbances, but he showed disorientation, and both retrograde and anterograde amnesia. Although immediate recall and remote memory were almost intact, his recent memory was moderately impaired. Both verbal and non-verbal memories were impaired. Brain computed tomography (CT) and magnetic resonance imaging (MRI) revealed a cerebral hematoma in the left temporal lobe involving the hippocampus and parahippocampal gyrus, and single-photon emission computed tomography (SPECT) demonstrated low perfusion areas in the left medial temporal lobe. Conclusions We suggest that the memory impairment was caused by local tissue destruction of Papez’s circuit in the dominant hemisphere due to the cerebral hematoma.