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Sachio Suzuki, Akira Kurata, Taketomo Ohmomo, Takao Sagiuchi, Jun Niki, Masaru Yamada, Hidehiro Oka, Kiyotaka Fujii, and Shinichi Kan

A recent report on the International Subarachnoid Aneurysm Trial documented greater efficacy of endovascular surgery for ruptured aneurysms compared with clip occlusion surgery. Therefore, endovascular surgery is now widely used for the management of intracranial aneurysms. Endovascular coil embolization for lesions less than 3 mm in maximum diameter is still controversial, however, because high complication rates have been reported. We present criteria for selection of patients who have very small aneurysms and delineate management procedures that allow

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Akira Kurata, Hidehiro Oka, Taketomo Ohmomo, Hitoshi Ozawa, Sachio Suzuki, Kiyotaka Fujii, Shinichi Kan, Yoshio Miyasaka, and Harue Arai

common neurovascular complication in EDS Type IV cases is the spontaneous direct CCF. 1, 2, 4, 6, 7, 14 Carotid artery dissection, fistula formation, and intracranial aneurysm rupture are other typical disorders. All of these vascular complications are very life-threatening. Nevertheless, diagnostic angiography, 3, 4, 14 endovascular surgery, 4, 6, 14 and surgical intervention 3 should be avoided if at all possible because of associated high morbidity and mortality rates. 2–5, 14 Case Report History and Examination This 44-year-old man reported weakness

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Jeffrey T. Nelson and Nicholas C. Bambakidis

I n this thought-provoking opinion piece, Panesar and colleagues review the relevant challenges facing the delivery of stroke intervention in the current medical landscape and suggest an emerging technology—telerobotic endovascular surgery—as a possible solution. 8 In 2015, five randomized controlled trials demonstrating the clear benefit of endovascular thrombectomy (ET) revolutionized the treatment of acute ischemic stroke. 2 , 4–6 , 10 ET is an extremely effective treatment; 1 in 2.6 patients obtain benefit from the treatment compared to 1 in 10 for

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Grant Sinson, Matthew F. Philips, and Eugene S. Flamm

✓ The application of a number of procedures that can be considered intraoperative endovascular neurosurgery has enhanced our ability to treat cerebral aneurysms from the abluminal surface. This study identifies a role for these techniques in the management of difficult aneurysms. A review of the last 1202 aneurysms undergoing direct clipping by the authors disclosed that these methods were used in 62 cases. Of these aneurysms, 36 arose from the internal carotid artery, 12 from the middle cerebral artery, eight from the vertebrobasilar distribution, and six from the anterior cerebral artery.

The indications for applying these methods were large size (12–60 mm), intraluminal thrombus, broad neck, plaque at the neck, the potential compromise of branches at the base of the aneurysm, or a combination of these problems. The most frequently chosen intraoperative technique was suction decompression with direct removal of plaque and thrombus using suction, dissection, and/or ultrasonic aspiration. The application of temporary clips was required in all cases in which the aneurysm was opened before definitive clipping. No special pharmacological cerebral protective regimen was used. In one case in which a greater occlusion time was anticipated, cardiopulmonary bypass with profound hypothermia was performed.

A favorable outcome was achieved in 73% of these difficult cases. An increased neurological deficit after surgery was seen in 11%, and the mortality rate was 8%. These methods should be considered and can be anticipated before surgery for unusual aneurysms. Many cases now being considered for embolization may be more suitable for definitive surgical obliteration.

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Yoshikazu Nakajima, Koichi Iwatsuki, Katsunori Ishii, Sachiko Suzuki, Toshiyuki Fujinaka, Toshiki Yoshimine, and Kunio Awazu

techniques of endovascular surgery, it would be possible to remove the cholesterol ingredient selectively without injuring the arterial sclerotic lesion itself. 5 Topics for future studies include the following: 1) the extent to which atherosclerotic lesions (plaques) regress in an actual organism; and 2) clinical applications of this cholesterol ester removal phenomenon, which may be applicable for various clinical interventions. For example, in CA stent insertion, FEL irradiation, which removes cholesterol ester in atheromas before stent placement, may be a useful

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Akira Kurata, Sachio Suzuki, Kazuhisa Iwamoto, Kuniaki Nakahara, Madoka Inukai, June Niki, Kimitoshi Satou, Masaru Yamada, Kiyotaka Fujii, Shinichi Kan, and Toshiro Katsuta

cases. Abbreviations: FU = follow-up; TAE = transarterial embolization; TVE = transvenous embolization Methods Since 1992, we have treated 76 patients with dural CCFs using endovascular surgery. The most recent 18 patients underwent transvenous embolization in addition to transarterial embolization. In 3 of these 18 patients, a conventional venous approach via the IPS failed. One dural CCF had only cortical venous drainage, another mainly drained into the same cortical veins but with slight inflow into the SOV and IOV, and the remaining CCF mainly drained into

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Fjodor A. Serbinenko, Jury M. Filatov, Aldo Spallone, Mikhail V. Tchurilov, and Valery A. Lazarev

collateral circulation who were scheduled to undergo therapeutic ICA occlusion. 2, 6, 7, 17, This combination of ICA occlusion and EC-IC anastomosis is usually performed as a two-stage procedure, in which the bypass is carried out first and the ICA is occluded subsequently either gradually or abruptly. The “N.N. Burdenko” Institute of Neurosurgery pioneered endovascular surgery 15 and has had extensive experience in the definitive endovascular treatment of intracranial aneurysms. 9 In cases of giant unruptured aneurysms of the ICA, an attempt at occluding the lesion

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Christopher L. Taylor, Debra Steele, Thomas A. Kopitnik Jr., Duke S. Samson, and Phillip D. Purdy

studies may be due to the fact that we treated all patients with microsurgery or endovascular surgery and that our follow-up period was longer. In the Danish Aneurysm Study reported by Rosenorn and Eskesen 6 the 2-year mortality rate was lower in patients harboring aneurysms between 5 and 10 mm in diameter (39%) than in patients with aneurysms smaller than 5 mm (47%) or those with lesions between 11 and 24 mm (51%). Of the survivors, however, patients with aneurysms measuring 10 mm or smaller were more likely to have attained a “normal daily functional capacity

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Brian M. Corliss, Adam J. Polifka, Neil S. Harris, Brian L. Hoh, and W. Christopher Fox

indications have arrived on the market. Devices in use range from carotid artery stents for treatment of cervical carotid artery stenoocclusive disease (an area in which interventional neuroradiology, endovascular neurosurgery, interventional cardiology, and peripheral endovascular surgery overlap), to low metal surface area buttressing stents for intracranial use as adjuncts to standard microcoil embolization techniques, to flow diverters such as the PED, to the new frontier of combination buttress/flow-diverting devices like the PulseRider (Codman/Pulsar Vascular), which

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Kimon Bekelis, Dan Gottlieb, Nicos Labropoulos, Yin Su, Stavropoula Tjoumakaris, Pascal Jabbour, and Todd A. MacKenzie

, with a growing number of hybrid neurosurgeons performing both clipping and coiling. 1 Endovascular coiling is also performed by radiologists and other proceduralists who solely focus on this approach for the treatment of cerebral aneurysms. It is often questioned whether hybrid neurosurgeons can perform endovascular surgery as successfully and safely as providers focusing only on coiling. However, limited literature exists that has attempted to answer this question. De Vries and Boogaarts published a single-center series 6 on the outcomes of coiling of ruptured