Intracranial aneurysm is common in stroke and, once rupturing, will cause disaster to patients. Nowadays, endovascular treatment has become a routine to reduce the risk of intracranial aneurysms rupture. Successive endovascular methods, like balloon-assisted coiling, stent-assisted coiling, and flow diversion, have become new choices for doctors. More and more doctors have been entering this field. Understanding the current general situation is crucial for more medical workers to learn the endovascular treatment of intracranial aneurysms. In the past, many devices and ideas about the treatment of intracranial aneurysms appeared. Although developing unceasingly, endovascular treatment still has some deficiencies to overcome. The advantages and drawbacks of current endovascular methods are discussed.

Objective: We sought to investigate how priming the tube between air versus air mixed with saline ex vivo influenced suction force. We examined how priming the tube influenced peak suction force and time to achieve peak suction force between both modalities. Methods: Using a Dwyer Instruments (Dwyer Instruments Inc., Michigan City, IN, USA), INC Digitial Pressure Gauge, we were able to connect a .072 inch aspiration catheter to a rotating hemostatic valve and to aspiration tubing. We recorded suction force measured in negative inches of Mercury (inHg) over 10 iterations between having the aspiration tube primed with air alone versus air mixed with saline. A test was used to compare results between both modalities. Results: Priming the tube with air alone compared to air mixed with saline was found to have an increased average max suction force (-28.60 versus -28.20 in HG, p<0.01). We also identified a logarithmic curve of suction force across time in which time to maximal suction force was more prompt with air compared with air mixed with saline (13.8 seconds versus 21.60 seconds, p<0.01). Conclusions: Priming the tube with air compared to air mixed with saline suggests that not only is increased maximal suction force achieved, but also the time required to achieve maximal suction force is less. This data suggests against priming the aspiration tubing with saline and suggests that the first pass aspiration primed with air may have the greatest suction force.

Objective: We evaluated the role of subgaleal closed suction drains in postoperative epidural hematoma (EDH) and wound complications following pterional craniotomy for cerebral aneurysm. Methods: We reviewed 5,280 pterional craniotomies performed on 5,139 patients between January 2006 and December 2020. A drain was placed subgalealy and tip of drain was positioned between the bone flap and the deep temporalis. 1,637 cases (31%) had a subgaleal suction drain. We analyzed demographic and clinical variables related to EDH requiring evacuation and wound complications in patients with and without drains. Univariate and multivariate logistic regression analyses were performed to determine the associated risk factors. Results: Fourteen cases (0.27%) of EDH requiring evacuation and 30 cases (0.57%) of wound complications were identified. Univariate analysis found that drain insertion, subarachnoid hemorrhage (SAH), and operation time were associated with EDH, while drain insertion, SAH, male gender, older age, and longer operation time were associated with wound complications. Multivariate analysis found no significant association between drain use and EDH (OR=1.62, p=0.402) or wound complications (OR=1.45, p=0.342). Conclusions: Routine use of subgaleal closed suction drains may not be necessary after pterional craniotomy, as drain insertion was not associated with a reduced risk of EDH requiring evacuation or wound complications.

Objective: The incidence of spontaneous intracerebral hemorrhage (ICH) in young people is relatively low; however, it leads to devastating lifelong neurologic deficits. We focused on spontaneous ICH occurring in young adults between 30 and 50 years of age. Methods: We retrospectively reviewed the records of 139 patients, aged 30-50 years, diagnosed with spontaneous ICH between 2011 and 2021. Cases of ICH attributable to discernible causative lesions were excluded. Demographic data, laboratory results, image findings, and clinical outcome were analyzed. Results: After exclusions, 73 patients were included in this study. Common characteristics among the study patients included male sex (83.6%), high body mass index (>25 kg/m², 45.8%), smoking history (47.2%), heavy alcohol consumption (30.6%), previously diagnosed hypertension (41.1%), high serum triglyceride level (>150 mg/dL, 33.3%), and microbleeds or white matter changes observed on magnetic resonance images (51.3%). In the multivariate analysis, previously diagnosed hypertension was the sole significant risk factor for cerebral small vessel (OR 7.769, P=0.031). Age, brain stem location, Glasgow Coma Scale score at admission, and hematoma volume were associated with poor outcomes. Conclusions: Hypertension, obesity, smoking, and cerebral small vessel disease were important factors associated with non-lesional spontaneous intracerebral hemorrhage in young patients. Radiologic changes corresponding to cerebral small vessel disease appeared in young patients (in their 30s) and they were associated with hypertension.

Objective: Reconstruction methods, including stent-assisted coiling, multiple telescopic stents, and flow diverters, are preferred modalities for the treatment of unruptured vertebral artery dissecting aneurysms (VADAs). We aimed to compare the clinical outcomes between two reconstructive flow diversion techniques: single flow diverter (FD) device and multiple telescopic stenting (TS). Methods: We retrospectively reviewed the clinical data of 39 patients with unruptured VADAs. Of these, 17 patients were treated with multiple TS and 22 with a single FD device. Aneurysm characteristics and clinical outcomes were compared between the two groups. Results: All aneurysms included in this study successfully achieved flow diversion, regardless of the treatment modality and duration. However, the mean procedure duration to complete the diversion was shorter in the FD group. Subgroup analysis in TS group showed that there were no significant clinical differences between the low-profile visualized intraluminal support and Enterprise stents, except for the mean procedure duration. Conclusions: Both the single FD and multiple TS methods showed excellent angiographic and clinical outcomes in the treatment of unruptured VADAs. However, single FD required a shorter procedure duration and was associated with faster achievement of complete flow diversion.

Objective: As the prevalence of neuroendovascular interventions increases, it is critical to mitigate unnecessary radiation for patients, providers, and health care staff. Our group previously demonstrated reduced radiation dose and exposure during diagnostic angiography by reducing the default pulse and frame rates. We applied the same technique for basic neuroendovascular interventions. Methods: We performed a retrospective review of prospectively acquired data after implementing a quality improvement protocol in which pulse rate and frame rate were reduced from 15 p/s to 7.5 p/s and 7.5 f/s to 4.0 f/s respectively. We studied consecutive, unilateral middle meningeal artery embolizations treated with particles. Total radiation dose, radiation per angiographic run, total radiation exposure, and exposure per run were calculated. Multivariable log-linear regression was performed to account for patient body mass index (BMI), number of angiographic runs, and number of vessels catheterized. Results: A total of 20 consecutive, unilateral middle meningeal artery embolizations were retrospectively analyzed. The radiation reduction protocol was associated with a 39.2% decrease in the total radiation dose and a 37.1% decrease in radiation dose per run. The protocol was associated with a 41.6% decrease in the total radiation exposure and a 39.5% decrease in exposure per run. Conclusions: Radiation reduction protocols can be readily applied to neuroendovascular interventions without increasing overall fluoroscopy time and reduce radiation dose and exposure by 39.2% and 41.6% respectively. We strongly encourage all interventionalists to be cognizant of pulse rate and frame rate when performing routine interventions.

Partial trisomy of the long arm of chromosome 17 (17q) is a rare but clinically recognized syndrome that involves facial dysmorphisms, skeletal abnormalities, and global developmental delay, as well as various reports of cardiovascular, renal, and central nervous system abnormalities. This report presents a novel neuroradiologic finding of diffuse enlarged, tortuous cortical veins with physiological antegrade flow in a child with a microduplication of the distal end of 17q. To our knowledge, this finding has not been described previously. Although the exact cause for the cortical vascular anomaly is currently unknown, this duplicated region contains genes of interest for future studies that focus on normal and abnormal angiogenesis.

Giant cerebellar cavernomas in children are rare and must be differentiated from hemorrhagic cerebellar tumors. The diagnosis and treatment of giant cerebellar cavernomas is challenging, but complete surgical resection can lead to favorable outcomes and complete neurological recovery in most cases. We present a case of eight months old baby who was diagnosed with a giant cavernoma resulting in secondary obstructive hydrocephalus with neuropsychiatric presentations. The patient underwent a paramedian craniotomy surgery with a suboccipital approach and complete surgical resection of the cavernoma was done. Over nine months of observation, the child showed improvement in their ability to walk and fully recovered from a neurological perspective. We also conducted a literature review to identify eleven cases of giant cerebellar cavernomas in children, including our case. The data were analyzed to determine the clinical features, treatment, and outcomes of giant cerebellar cavernomas in children.

While mechanical thrombectomy is known to be effective for distal medium vessel occlusion (DMVO) as well as large vessel occlusion, tortuous DMVO are predisposed to vessel injury during stent retriever thrombectomy. Furthermore, getting access to the thrombus may be difficult during suction thrombectomy using a dedicated suction catheter. Most studies describe DMVO treatment using stent retrievers and dedicated suction catheters, but there are limited studies reporting DMVO treated with suction thrombectomy using a microcatheter. Herein, we describe three cases of DMVO treated with suction thrombectomy that was performed using a microcatheter and subsequently showed good results. Therefore, suction thrombectomy using a microcatheter is a viable alternative treatment for tortuous DMVO.

Cranial nerve palsies can be presenting signs of intracranial aneurysms. There is a classic pairing between an aneurysmal vessel and adjacent nerves leading to cranial neuropathy. Isolated abducens nerve palsy can be a localizing sign of an unruptured vertebrobasilar circulation aneurysm. Aneurysms involving Anterior Inferior Cerebellar Artery (AICA) and Posterior Inferior Cerebellar Artery (PICA) have been reported to be associated with abducens nerve palsy. The symptoms in unruptured aneurysms are due to the mass effect on adjacent neurovascular structures. Most of the abducens nerve palsy resolves following microsurgical clipping. Here, we present a rare case of an unruptured Posterior Cerebral Artery (PCA) aneurysm presenting with abducens nerve palsy and diplopia associated with contralateral hemianopsia which markedly improved following endovascular coil embolization.

Primary Angiitis of the Central Nervous System (PACNS) is an uncommon disease with kaleidoscopic clinical manifestations. Ischemic strokes are commoner than their hemorrhagic counterpart. Intracranial pseudoaneurysms are rarely reported in PACNS cohorts. We hereby describe the case of a 39-year-old female, who presented for evaluation of acute onset of left middle cerebral artery (MCA) ischemic stroke, with cerebral angiogram showing multifocal stenosis and irregularities in intracranial blood vessels with an aneurysm arising from the lenticulostriate branch of the left MCA M1 segment. A diagnosis of probable PACNS was made and patient initiated on immunomodulatory treatment with corticosteroids. 12 weeks follow up neuroimaging studies revealed resolution of the previously described intracranial aneurysm, thereby postulating the possibility of a pseudoaneurysm related to the underlying angiitis.

This is a unique case of metastatic pheochromocytoma of the cervical spine treated with preoperative embolization and subsequent en bloc resection. A 65-year-old man with metastatic pheochromocytoma presented with two weeks of worsening neck pain, left arm and leg weakness and paresthesia, and urinary incontinence. Magnetic resonance imaging showed a metastatic osseous lesion at C6 with severe stenosis and spinal cord compression. The patient underwent successful preoperative angiographic embolization with a liquid embolic agent followed by C5-C7 laminectomy, en bloc tumor resection, and C3-T2 posterior spinal fusion. Six weeks postoperatively, the patient reported improving strength and resolving neck pain and paresthesias. While there is no standard paradigm for the treatment of metastatic pheochromocytomas of the cervical spine, preoperative embolization may minimize intraoperative blood loss and hemodynamic instability during subsequent surgical resection.

Flow diverter (FD) is increasingly used in the management of wide necked cerebral aneurysms. Despite a reported lower efficacy in middle cerebral artery (MCA) aneurysms, they are still being utilised. Microsurgery is best considered as an index treatment, but can also be a safe and effective treatment when encountering a persistent MCA aneurysm after prior FD. As there is a paucity in literature and more cases of failed FD are expected to appear, we want to add our experience to the existing literature. The microsurgical management of a persistent MCA bifurcation aneurysm, 3 years after a p48 MW HPC Flow Diverter (phenox GmbH, Bochum Germany) insertion is reported and the relevant literature discussed.