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Ramazan Jabbarli, Daniela Pierscianek, Karsten Wrede, Philipp Dammann, Marc Schlamann, Michael Forsting, Oliver Müller, and Ulrich Sure

F irst described by Walter Dandy in 1938, 5 microsurgical clipping of cerebral aneurysms has been regarded for many decades as the only treatment option for potentially fatal aneurysm sacs. 11 Although endovascular coiling of cerebral aneurysms increasingly displaces clipping at the present time, 13 clipping is still superior with regard to occlusion rates and rebleeding risk. 12 Nevertheless, the complete microsurgical closure of an aneurysm cannot be achieved in all cases. The reported rate of clip remnants varies between 1.6% and 42% 2 , 7 , 10

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Mayumi Kubota, Masahiro Shin, Makoto Taniguchi, Toru Terao, Jun Nakauchi, and Hiroshi Takahashi

remaining liquid maintained its hydrophobic character. We estimated that it increased the local CSF viscosity and acted like a wall exaggerating the arachnoid adhesion, leading to functional block of CSF in the subarachnoid space. Another unique finding is that the contrast medium, changing its form, still had a potential as an inflammatory inducer. At surgery, the remnants maintained their hydrophobic liquid form well, whereas some of them changed into cheeselike material, keeping their radiopaque appearance on the x-ray film. By contrast, the liquid remnants had lost

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Atif Haque, Jack M. Raisanen, Samuel L. Barnett, and Duke S. Samson

giant aneurysm. The aneurysm was ligated with a surgical clip and detached from the parent vasculature without excision. Instead of a foreign body serving as the nidus for infection, the current case represents what the authors believe to be the first reported one of a devascularized aneurysm remnant leading to intracranial infection. Case Report Initial Presentation and Diagnosis This 61-year-old man, with a medical history significant for diabetes mellitus, tobacco use, hyperlipidemia, hypertension, cataracts, and bladder surgery, presented with

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Roxanna M. Garcia, Taemin Oh, Tyler S. Cole, Benjamin K. Hendricks, and Michael T. Lawton

separation plane. This interplay between tissue sensitivity and extreme eloquence makes it difficult, if not impossible, to avoid leaving a remnant on occasion. The largest institutional surgical case series by a single neurosurgeon reported a rate of residual or recurrent BSCM of 11% (29 of 260 patients). 4 The natural history and management of residual or recurrent BSCMs are poorly described in the literature. 4 , 8–10 Current findings suggest that completely resected BSCMs do not recur de novo in the same location, which implies that some residual BSCM or remnants are

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the aneurysm from the remnant of neck. 1 In Fig. 3 of the report by Hieshima, et al. , a portion of the neck between the subtraction negative image of the balloon and the left posterior cerebral artery can clearly be seen filling, despite the claim in the legend that the aneurysm is completely occluded. It is unfortunate that the authors have neither discussed the potential effects of leaving a remnant of the aneurysm neck untreated nor pointed out that this has occurred in the case reported here, as demonstrated in Fig. 3. Figure 4 does not show this small

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Motoharu Hayakawa, Yuichi Murayama, Gary R. Duckwiler, Y. Pierre Gobin, Guido Guglielmi, and Fernando Viñuela

has produced encouraging results in preventing rebleeding during the acute phase of subarachnoid hemorrhage. 4, 6, 10, 14, 27, 43 In a recent clinical study, Viñuela, et al., 43 reported that complete GDC occlusion was achieved in 70.8% of small aneurysms with small necks, 31.2% of small aneurysms with wide necks, 35% of large aneurysms, and 50% of giant aneurysms. A neck remnant was observed in 21.4% of small aneurysms with small necks, 41.6% of small aneurysms with wide necks, 57.1% of large aneurysms, and 50% of giant aneurysms. A neck remnant is not

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Xavier Boileau, Han Zeng, Robert Fahed, Fabrice Bing, Alina Makoyeva, Tim E. Darsaut, Pierre Savard, Benoit Coutu, Igor Salazkin, and Jean Raymond

experiments were followed by tests of feasibility and efficacy in a canine bifurcation aneurysm model that is known to recur after endovascular coiling. 27 We aimed to assess the feasibility and efficacy of bipolar RFA of aneurysm remnants after coil embolization. Methods Simulations Electrical fields were studied using a simplified virtual lateral wall aneurysm model that assumed geometrical electrodes and uniform tissue resistance (200 Ωcm). RFA applications using electrodes schematized as polygons or cylinders were analyzed using finite element software (QuickField

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Venelin Miloslavov Gerganov, Amir Samii, Arasch Akbarian, Lennart Stieglitz, Madjid Samii, and Rudolf Fahlbusch

morbidity. 4 , 8 , 25 , 34 It provides an objective estimation of the surgical radicality. 17 , 24 The high-field strength iMR imaging is currently regarded as the most advanced modality for obtaining reliable intraoperative resection control. 12 , 25–27 A recent study by the senior author's (R.F.'s) former group 26 showed that iMR imaging's superior image resolution led to an increase in the rate of detecting tumor remnants: 26% with low–field strength to 39% with high–field strength MR imaging. However, iMR imaging requires an expensive setup, and the procedure

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Sven Berkmann, Sven Schlaffer, and Michael Buchfelder

symptomatic tumor persistence or further progression. Early imaging by dynamic MRI within 3 days after surgery can effectively differentiate tumor remnants from postoperative changes. 25 For patients with severe deficits and large tumor remnants, timely additional tumor reduction may be reasonable. For example, it is known that in patients with visual acuity decrease or visual field deficiencies, early decompression of the optic structures significantly improves visual outcomes. 3 , 13 , 22 Nevertheless, some patients experience relief of symptoms despite spacious tumor

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Kent R. Thielen, Douglas A. Nichols, Jimmy R. Fulgham, and David G. Piepgras

T he goal of cerebral aneurysm clipping is complete obliteration and exclusion of the entire aneurysm from the arterial circulation. Previous reports have documented that postoperative aneurysm remnants may be the result of technical or anatomical difficulties associated with initial clip placement, slippage of a placed clip, or regrowth of an aneurysm sac from an incompletely excluded aneurysm neck. 2, 3, 11, 20 The danger of hemorrhage persists if the aneurysm is not completely excluded from the circulation. 2, 4–6, 11, 20, 25 Previous reports have