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Fenestration of the A1 segment of the anterior cerebral artery is a rare vascular anomaly with a high risk of saccular aneurysm at the proximal end of the A1 fenestration. These aneurysms have a high risk of rupture. However, conventional surgical clipping can be technically challenging due to the anatomical characteristics. We report a case of A1 fenestration with a ruptured aneurysm wherein we successfully achieved complete obliteration of the aneurysm with a new “single-lane” clipping technique. A 64-year-old woman presented with a ruptured saccular A1 aneurysm at the proximal end of an A1 fenestration, resulting in subarachnoid hemorrhage. Microsurgical clipping was attempted; however, adequate exposure of the aneurysm could not be achieved. The recurrent artery of Heubner originated near the distal end of the lateral limb of the A1 fenestration. The lateral limb of the A1 fenestration had no perforating arteries, according to surgical examination. Thus, the aneurysm neck and lateral limb were concurrently obliterated using a nonfenestrated clip, preserving the medial limb of the A1 fenestration. The antegrade flow of the recurrent artery of Heubner was detected using the retrograde flow of the distal part of the lateral limb of the A1 fenestration during intraoperative indocyanine green video angiography. The postoperative course was uneventful without any evidence of ischemic stroke. For A1 aneurysms arising from the proximal end of the A1 fenestration, this technique may be a useful treatment option. Before using this technique, careful surgical exploration should be performed to assess the A1 perforating arteries.

POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome is a rare multisystem disease characterized by plasma cell dyscrasia and overproduction of vascular endothelial growth factor, which is related to disease activity. Recent treatment strategies have improved survival of patients suffering from this disorder; however, ischemic stroke remains a poor prognostic factor. POEMS patients with ischemic stroke frequently develop cerebral large artery stenosis/ occlusion, followed by progressive stroke. Post literature review, we present an ischemic stroke case of quasi-moyamoya disease linked with this syndrome that was successfully treated with surgical revascularization. A 41-year-old woman diagnosed with POEMS syndrome developed progressive ischemic stroke due to quasi-moyamoya disease, despite decreased vascular endothelial growth factor level with lenalidomide and dexamethasone treatment. She underwent superficial temporal artery to middle cerebral artery bypass with encephalo-duro-myo-synangiosis bilaterally. The postoperative course was uneventful. Two years and five months after the stroke, neuroimaging demonstrated bypass patency, neovascularization after encephalo-duro-myo-synangiosis, and no recurrence of stroke. Our case is the first to report successful surgical revascularization for a POEMS patient. Surgical revascularization may be a useful treatment option for patients with quasi-moyamoya disease associated with POEMS syndrome, especially for those who develop refractory ischemic stroke despite reduced vascular endothelial growth factor level.

Acupuncture is a popular alternative therapy worldwide and is generally safe. However, serious acupuncture-related complications can occur. Intracranial complications caused by a migrated acupuncture needle are extremely rare. Herein we report a surgical case of intracranial acupuncture needle migration and discuss the key technical aspects of the procedure. We additionally performed a review of the relevant literature. A 55-year-old woman presented with migration of a broken acupuncture needle via the posterior cervical skin. Computed tomography (CT) showed that the needle migrated intra- and extradurally via the atlanto-occipital junction. CT angiography revealed that the needle tail was located adjacent to the right distal horizontal loop of the vertebral artery. Meanwhile, the needle tip was positioned in the premedullary cistern adjacent to the medulla oblongata via the right lateral medullary cistern. Emergent surgical removal was conducted. Intradural exploration was required as the needle was not found in the epidural space. The needle penetrated the adventitia of the right intradural vertebral artery. We failed to pull out the needle toward the epidural space. After the needle was completely pulled into the intradural space, it was successfully removed without bleeding complication. Postoperative CT showed no evidence of residual needle fragment. The patient was discharged home without any sequelae. To the best of our knowledge, this is the first case of penetrating vertebral artery injury caused by radiologically confirmed acupuncture needle migration. An intracranially migrated needle should be removed urgently to prevent further migration causing brainstem, cranial nerve, and vessel injuries. The surgical strategy should be selected according to needle location and direction.

Putaminal hemorrhage is a common type of spontaneous cerebral hemorrhage. However, to our knowledge, there have been no reports of sequential cerebral hemorrhage and infarction in the same perforating arterial territory. Herein, we present the first reported case of the sequential development of putaminal hemorrhage and corona radiata infarction in the same lenticulostriate arterial (LSA) territory. Early intensive blood pressure lowering treatment may have aggravated ischemic damage. If a patient presents with motor weakness that cannot be explained by putaminal hemorrhage, the sequential development of corona radiata infarction in the same LSA territory should be ruled out.

Symptomatic large pineal cyst (PC) remains a rare entity. The stable natural course of asymptomatic PCs is well established. However, large cysts may cause pressure-related symptoms necessitating surgical intervention. The surgical strategy for symptomatic PCs is still controversial. Regardless of the approach, total resection of the cyst is not mandatory. The endoscopic approach allows cyst fenestration in patients with associated obstructive hydrocephalus. On the other hand, the necessity of simultaneous endoscopic third ventriculostomy (ETV) is still debatable. Here, we report a case of a woman who underwent endoscopic cyst fenestration, biopsy, and third ventriculostomy for a large symptomatic PC and discuss the surgical strategy. A 30-year-old woman presented with headache and diplopia, MRI showed a large PC and ac- companying obstructive hydrocephalus. Simultaneous cyst fenestration, biopsy and ETV with endoscopy was successfully completed. She had an uneventful recovery period with immediate relief of symptoms. Although, the aqueduct was communicated due to cyst shrinkage, the patency of the third ventricular stoma was demonstrated in long-term follow-up scans. Based on clinical course of the present case, we concluded that ETV in addition to cyst fenestration should be considered necessary and beneficial in cases of large symptomatic PC with associated hydrocephalus whenever an endoscopic intraventricular approach is considered., This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Optimal shaping of a microcatheter tip is a key factor in cerebral aneurysm coiling. However, safe cannulation and stabilization of a microcatheter can be technically challenging with small aneurysms requiring precise microcatheter shaping. We devised a new microcatheter shaping technique which bends a microcatheter tip in the intended direction by placing and keeping the tip in the selected branch of the parent artery for 5 minutes: endovascular shaping technique. Our method can complete microcatheter shap-ing only inside the patient’s body; an endovascularly shaped microcatheter will never face a straightening deformity and rotation problem associated with catheter reinsertion. The aim was to assess the feasibility and safety of endovascular shaping for small aneurysm coiling. Clinically, 10 consecutive challenging small terminal-type aneurysms (< 5 mm) treated with endovascular shaping were included. We retrospectively analyzed the newly acquired bend angle of a microcatheter tip after the shaping, the procedural success, and clinical outcomes. An artificial vascular model was used to confirm our findings. In all the 10 patients (three middle cerebral artery, four anterior communicating artery, and three basilar artery aneurysms), the endovascularly shaped microcatheters were bent toward the placement branch at an average of 21.7° and excellently guided into the aneurysms. Coil embolization was successfully accomplished without any complications. The results of the vascular model experiment demonstrated that an endovascularly shaped microcatheter acquired new bend angle toward the placement branch. Endovascular shaping was feasible and safe for small terminal-type aneurysm coiling. Our method can provide accurate shaping and stability during aneurysm coiling procedure.

Optimal shaping of a microcatheter tip is a key factor in cerebral aneurysm coiling. However, safe cannulation and stabilization of a microcatheter can be technically challenging with small aneurysms requiring precise microcatheter shaping. We devised a new microcatheter shaping technique which bends a microcatheter tip in the intended direction by placing and keeping the tip in the selected branch of the parent artery for 5 minutes: endovascular shaping technique. Our method can complete microcatheter shaping only inside the patient’s body; an endovascularly shaped microcatheter will never face a straightening deformity and rotation problem associated with catheter reinsertion. The aim was to assess the feasibility and safety of endovascular shaping for small aneurysm coiling. Clinically, 10 consecutive challenging small terminal-type aneurysms (< 5 mm) treated with endovascular shaping were included. We retrospectively analyzed the newly acquired bend angle of a microcatheter tip after the shaping, the procedural success, and clinical outcomes. An artificial vascular model was used to confirm our findings. In all the 10 patients (three middle cerebral artery, four anterior communicating artery, and three basilar artery aneurysms), the endovascularly shaped microcatheters were bent toward the placement branch at an average of 21.7° and excellently guided into the aneurysms. Coil embolization was successfully accomplished without any complications. The results of the vascular model experiment demonstrated that an endovascularly shaped microcatheter acquired new bend angle toward the placement branch. Endovascular shaping was feasible and safe for small terminal-type aneurysm coiling. Our method can provide accurate shaping and stability during aneurysm coiling procedure.