Establishment of a clinician-led guideline on the diagnosis and treatment of Hirayama disease using a modified Delphi technique

ObjectiveTo establish a clinician-led guideline for the diagnosis and treatment of Hirayama disease (HD) using a modified Delphi technique.MethodsBased on a combination of a systematic review and opinion of ten experts, a protocol for the consensus of the diagnosis, treatment and follow-up assessment of HD was established. A modified 3-round Delphi survey was then performed by more than 40 panelists from various countries of the world. Both levels of evidence and levels of agreement were derived in all statements of finial guideline.ResultsA total of 47 experts from 6 countries were enrolled in the expert panel in this study. Highly consistent results were achieved during the three Delphi rounds. An expert-led guideline finally constructed includes 24 statements related to diagnosis, treatment and follow-up assessment of HD.ConclusionsThe modified Delphi technique used in this study resulted in an expert-led guideline concerning several clinical aspects of HD.SignificanceThis clinician-led guideline may provide a helpful direction for clinical practice with regard to the diagnosis and treatment of HD.     

Sandwich technique using fibrin-coated collagen fleece for sellar reconstruction in large dural defects during transsphenoidal surgery

PurposeVarious surgical methods to prevent intraoperative and postoperative cerebrospinal fluid (CSF) leaks during transsphenoidal approach (TSA) surgeries have been reported, but surgical techniques to address large dural defects have been less thoroughly investigated in the literature. The authors retrospectively evaluated the usefulness of the sandwich technique using fibrin-coated collagen fleece (TachoSil) to prevent intraoperative CSF leakage from large dural defects in TSA surgery.MethodsIn total, 101 cases of intraoperative CSF leaks were observed among 465 patients who underwent TSA surgery at a single university hospital between 2002 and 2014. Among them, cases with Grade 3 intraoperative CSF leakages and large diaphragmatic/dural defects were reconstructed via the sandwich technique using TachoSil or via the conventional technique using simple intrasellar packing with fat or synthetic materials, and these cases were enrolled in this study.ResultsA total of 28 cases with Grade 3 intraoperative CSF leakages were identified and analyzed. The sandwich technique using TachoSil was applied in 13 cases, and the conventional technique was applied in 15 cases. The postoperative CSF leakage was significantly decreased by the sandwich technique as compared to the conventional technique (retrospectively, 0 cases vs. 4 cases (30.8%); P = 0.044).ConclusionThe sandwich technique using TachoSil can effectively prevent CSF leakage in cases with large dural defects during TSA surgery.     

Endoscopic technique: A new model of subarachnoid hemorrhage in rats

Abstract

It has become increasingly evident that the pathophysiology of cerebral vasospasm following subarachnoid hemorrhage (SAH) which described the ischemic consequences of cerebral arterial constriction is complex and multifactorial. In an attempt to study cerebral vasospasm, numerous investigators have used experimental animal models that resemble cerebral vasospasm in humans. No ideal model for SAH has been found as yet, and hence the quest for such a model continues. We developed an endoscopic technique that permits a direct vision of internal carotid artery and puncturing the artery to provoke SAH. This model will closely reflect the clinical setting of an aneurysm rupture. The onset of SAH was characterized by a sudden decrease of cerebral blood flow (CBF) and cerebral blood volume (CBV) by at least 40% in the first 20 min. Following this initial drop, there was an increase in the CBF and the CBV, however, they remained significantly below the base line values, at the end of 1 h. This study describes a new model of SAH in rat that simulates the clinical phenomenon of ruptured intracranial aneurysm that also produces cerebral vasospasm. [Neurol Res 2001; 23: 627-630]     

Percutaneous transluminal angioplasty of internal carotid artery: A preliminary report of seesaw balloon technique

Abstract

Percutaneous transluminal angioplasty (PTA) has become a common neurosurgical procedure. This technique, however, has been rarely used for stenosis of the internal carotid artery because of the resultant embolization with debris following balloon manipulation. We present a case of internal carotid artery stenosis with a complaint of transient mono-ocular blindedness, whose ischaemic attack was relieved by PTA operation. In this case, we applied endovascular treatment for carotid stenosis, known as ‘seesaw balloon technique’, which prevented cerebral embolization with debris from the lesion. This technique may simplify the endovascular treatment for distally located carotid stenosis and shorten the operation time. [Neurol Res 1993; 15: 356-358]     

Triple stimulation technique findings in vascular Parkinsonism and Parkinson’s disease

ObjectiveOne of the predominant clinical features that differentiates vascular Parkinsonism (VP) from Parkinson’s disease (PD) is the pyramidal sign. The triple stimulation technique (TST) is one of the most sensitive methods for comparing upper motor neuron involvement in patients with VP and PD. This study aimed to evaluate the usefulness of the TST as a diagnostic tool for VP.MethodsThirteen VP patients, 18 PD patients and 10 age-matched healthy controls were enrolled in this study. We obtained basic participant demographic information and transcranial magnetic stimulation (TMS) parameters, including the TST amplitude ratio, from all participants. We compared the TMS parameters among the VP, PD and control groups.ResultsThe TST amplitude ratio was significantly lower in the VP group than in the PD and control groups (71.59 ± 11.86 vs. 96.42 ± 5.11 and 97.70 ± 3.82, respectively; p < 0.01). The TST amplitude ratio was positively correlated with scores obtained on the United Parkinson’s Disease Rating Scale-III, which reflects motor function.ConclusionsThe TST is an effective and easy technique that offers improved diagnostic sensitivity in patients with VP by assessing upper motor neuron involvement. The TST may also represent a useful monitoring tool for evaluating disease progression.SignificanceThis study is the first to assess pyramidal involvement in patients with VP using the collision technique.     

Indirect measurement of aneurysm wall thickness using digital stethoscope

Abstract

Objective: No existing in vivo technique can measure aneurysm wall thickness for evaluation of rupture risk. Intracranial aneurysms produce bruits at a special range of frequency that are highly influenced by the wall thickness. Understanding of the mechanism that generates bruits may allow us to learn aneurysm behavior non-invasively.

Methods: A new theory was proposed to account for an interaction between an aneurysm and its parent vessel. Four patients with ophthalmic aneurysms were studied with a digital electronic stethoscope before and after endovascular treatment. Energy spectra of bruits were obtained from digital recording at both eyes. Change of energy spectra was used as an objective indication for aneurysm bruits. Additional four cases were obtained from a previous report.

Results: Aneurysm bruits are affected by both aneurysm size and wall thickness. These sounds disappear after coil embolization and parent artery occlusion, but not by stenting. Both large and small aneurysms generate sounds at high frequency. Aneurysms at 6 mm produced very low frequency sound. Wall thickness decreases with aneurysm size, and the decrease is more pronounced at 8 mm.

Conclusions: Interaction between an intracranial aneurysm and its parent vessel is important in interpretation of aneurysm bruits. An analysis of in vivo measurements shows a rapid decline in wall thickness for 8 mm aneurysms.     

Y-Stent embolization technique for intracranial bifurcation aneurysms

Wide-necked bifurcation aneurysms often require the use of the technically complex Y-stent technique, which has recently been shown to narrow bifurcation angle in a hemodynamically favorable manner. We sought to evaluate the single center efficacy and safety of Y-stent supported aneurysm coil embolization. All patients undergoing Y-stent supported coiling between September 2006 and December 2012 were identified; records were analyzed for procedural results and complications, with follow-up evaluated for occlusion rate and neurological adverse events. Twenty consecutive patients underwent technically successful Y-stent supported coiling, with complete aneurysm occlusion achieved in 19/20 cases (95%). There were no peri-procedural clinically evident neurological complications following Y-stenting. Clinical follow-up was available for a mean of 20.0 months and radiographic follow-up was available for a mean of 18.5 months. During the follow-up period, three patients (15%) required re-treatment with through-stent coiling for recanalization. At latest follow-up, Raymond grade I occlusion was achieved in 16 patients (80%), Raymond grade II occlusion achieved in four patients (20%) and Raymond grade III occlusion in zero patients. Y-stenting for complex intracranial aneurysms appears effective in achieving durable aneurysm occlusion with an acceptable safety profile. Though the procedure is technically more complex than single-stent procedures, the Y-stent configuration should be considered when single-stent supported coiling is not feasible or sufficient.     

Reconstructive endovascular approach for a cavernous aneurysm in infancy

Abstract

We report a unique case of endovascular arterial reconstruction using stent and coils in a symptomatic cavernous aneurysm presented in infancy. A 3-year-old infant presented with a partial cavernous sinus syndrome secondary to a bilobulate cavernous aneurysm with subarachnoid extension. Direct clipping represented a considerable challenge and trapping after bypass grafting was considered too risky. A combined endovascular approach using stent and coils was performed. A 4 × 18 mm balloon-expandable stent was then placed across the aneurysm orifice allowing the complete obliteration of the remnant with coils implanted through the stent mesh. Digital substraction angiography documented patency of the ICA lumen and complete obliteration of the aneurysm. A 24-months angiographic follow-up was performed confirming persistent aneurysm exclusion and patency of the parent vessel with no signs of in-stent de novo stenosis. Reconstructive endovascular technique using stent and coils allowed the treatment of a complex vascular condition. The cavernous lesion was excluded from the circulation while preserving normal flow through the parent vessel and its branches. Long-tern follow up is a major concern, specially in pediatric patients but the 24 months angiographic follow-up is encouraging.     

Long-term aneurysm recurrence and de novo aneurysm formation after surgical treatment of unruptured intracranial aneurysms: a cohort study and systematic review

ABSTRACT

Objective: There is a relative lack of literature on long-term aneurysm recurrence and de novo aneurysm formation following surgical treatment of unruptured intracranial aneurysms. This retrospective single-center cohort study, therefore, analyzes the incidence of aneurysm recurrence, and the incidence of de novo aneurysms formation in patients with at least 10yrs of radiological follow-up. The data are put into the context of a systematic review of the literature.

Methods: Patients that underwent surgical treatment of an unruptured intracranial aneurysm at the Basel University Hospital were retrospectively identified. The rate of recurrent or de novo aneurysm formation was assessed for all patients with imaging follow-up ≥10yrs. A systematic review including studies with a mean follow-up period of ≥10yrs was then performed.

Results: A total of 95 patients had undergone surgical treatment of an unruptured intracranial aneurysm between 1994 and 2008. Twenty-one patients (22.1%) had available imaging follow-up ≥10yrs (mean: 13.1yrs). In these patients, aneurysm recurrence and de novo aneurysm formation were equally found in 23.8% (n = 5; 1.8%/yr). There was no case of aneurysm rupture from a recurrent or a de novo aneurysm. The systematic literature review covered a combined cohort of 1778 patients over a mean follow-up period of 14.0yrs. In this cohort, the aneurysm recurrence rate was 16.4% (0.7%/yr), and the rate of de novo aneurysm formation was 6.2% (0.4%/yr).

Discussion: Despite some discrepancy regarding the incidence, both cohorts show a non-negligible long-term risk of aneurysm recurrence and de novo aneurysm formation, which warrants life-long imaging follow-up.

Abbreviations: SD: standard deviation; DSA: digital subtraction angiography; CTA: computed tomography angiography; MRA: magnetic resonance angiography; MCA: middle cerebral artery; ACA: anterior cerebral artery; ACommA: anterior communicating artery; ICA: internal carotid artery; ADPKD: autosomal dominant polycystic kidney disease; MeSH: Medical Subject Headings     

Double waffle-cone technique using twin Solitaire detachable stents for treatment of an ultra-wide necked aneurysm

Several stent-supported coiling techniques have been devised for treating wide-necked bifurcation aneurysms including the Y-stent and waffle-cone constructs. The Y-stent technique is not technically possible with obtusely oriented daughter vessels, and the waffle-cone method is inadequate for aneurysms with necks exceeding the stent’s maximal expansion diameter. We describe here the novel use of the Solitaire electrolytically detachable slotted stent (Solitaire, ev3, Irvine, CA, USA) featuring large-sized cells to fashion a concentric “double waffle-cone” construct. This method enabled the doubling of the neck coverage to treat an ultra-wide necked middle cerebral aneurysm with obtusely oriented daughter branches. The technique relies on the intra-cell crossing of the first stent using the second stent delivery microcatheter and fine tuning the relative position with the aid of cross-sectional cone-beam computed tomographic angiography to achieve optimal coverage of the neck prior to detachment of the stents in position. A retrievable stent with large cells such as the Solitaire device is optimal for this application given the need for relative adjustment of the deployment before final stent release to avoid under- or over-penetration of the distal stent struts into the aneurysm dome. An additional advantage of this approach over the kissing-stent technique is the absence of intraluminal stent struts, which was confirmed here by down-the-barrel cross-sectional imaging. The double waffle-cone construct enabled the successful coiling of the aneurysm with no post-procedural ischemic events detected on diffusion-weighted MRI and with stable complete embolization and no residual filling or in-stent stenosis at 6 month follow-up.     

Self-closing aneurysm clip: a historical review

Abstract

Objective: To analyse the self-closing aneurysm clip historical evolution.

Materials and methods: The authors reviewed the self-closing aneurysm clip's 50-year history. Major neurosurgical books, journals, testimonials, authors' personal experience, and scientific databases were analysed.

Results: Self-closing aneurysm clip malfunction was found to be related to different clip strengths (too strong or too weak) and clip's corrosion or fracture due to diverse stainless steel biocompatibility issues. It was found that 301, 401, 402, 58, and 17-7 PH alloys were not suitable for human implantation due to high risk of corrosion. In counterpart, 316MOSS, Elgiloy, Phynox, and titanium alloys were more biocompatible and less prone to corrosion. The last group showed no motion on the magnetic field. Titanium clip has shown to be artifact free on computerized tomography followed by high-grade cobalt–chromium clip all the other aneurysms clip present a significant artifact. The Federal Drugs and Administration/American Society of Testing and Materials (FDA/ASTM) was a major contributor on safety development of self-closing aneurysm clip.

Conclusion: Our 36-year self-closing aneurysm clip experience is reported.     

Carotid Micromesh Stent for the Cervical Carotid Artery Dissecting Aneurysm in a Patient with Vascular Eagle Syndrome

ObjectivesAn elongated styloid process may cause vascular Eagle syndrome that includes cervical carotid artery (CCA) dissection with stenosis and aneurysm formation. There are only four reported cases with vascular Eagle syndrome-related CCA dissecting aneurysm treated with carotid artery stenting (CAS). This is the first report of applying a dual-layer nitinol micromesh stent (CASPER) for vascular Eagle syndrome-related CCA dissecting aneurysm.Case presentationA 38-year-old man presented with a sudden onset of aphasia and right hemiplegia. Cerebral angiography demonstrated the left CCA dissecting aneurysm. The superior trunk of the left middle cerebral artery (MCA) was also occluded, and emergent thrombectomy was performed. Computed tomography with angiography (CTA) revealed that a 33 mm-long styloid process compressed the CCA at the aneurysm formation. Three weeks later, a CASPER stent was applied for the CCA aneurysm under the flow reversal system. Immediately after stent placement, blood flow in the aneurysm became stagnant, and postoperative CTA demonstrated regression of the aneurysm. The aneurysm did not recur for 6 months with no styloid process resection.ConclusionsThe dual-layer nitinol micromesh stent (CASPER) was useful to treat vascular Eagle syndrome-related CCA dissecting aneurysm.     

Assessing the upper motor neuron in amyotrophic lateral sclerosis using the triple stimulation technique: A multicenter prospective study

ObjectiveTo evaluate the relevance of transcranial magnetic stimulation (TMS) using triple stimulation technique (TST) to assess corticospinal function in amyotrophic lateral sclerosis (ALS) in a large-scale multicenter study.MethodsSix ALS centers performed TST and conventional TMS in upper limbs in 98 ALS patients during their first visit to the center. Clinical evaluation of patients included the revised ALS Functional Rating Scale (ALSFRS-R) and upper motor neuron (UMN) score.ResultsTST amplitude ratio was decreased in 62% of patients whereas conventional TMS amplitude ratio was decreased in 25% of patients and central motor conduction time was increased in 16% of patients. TST amplitude ratio was correlated with ALSFRS-R and UMN score. TST amplitude ratio results were not different between the centers.ConclusionsTST is a TMS technique applicable in daily clinical practice in ALS centers for the detection of UMN dysfunction, more sensitive than conventional TMS and related to the clinical condition of the patients.SignificanceThis multicenter study shows that TST can be a routine clinical tool to evaluate UMN dysfunction at the diagnostic assessment of ALS patients.     

Distal radial access for cerebral aneurysm embolization

ObjectivesTo demonstrate the feasibility and safety of distal radial access for embolization of ruptured and unruptured cerebral aneurysms.MethodsThis study is a retrospective review of our prospective cerebral aneurysm embolization database. Between January and September 2019, distal radial access was considered for consecutive subjects addressed for cerebral aneurysm embolization at our institution. All procedures were performed by the same experienced operator. Technical success was defined as distal radial access with insertion of the sheath and completion of the intervention without change of access site to conventional femoral access. Primary safety endpoint was the in hospital + 30 days incidence of radial artery occlusion. Secondary endpoints included intra-procedural complications and neurologic complications at discharge and at 30 days.ResultsFifty-seven patients with cerebral aneurysms underwent 61 embolization procedures. Twenty eight embolizations were performed using coils, 8 used a stent-assisted coil technique, 22 used a balloon-assisted coil technique, and 3 used a flow diverter. One patient (1.6%) required crossover to femoral access. Three patients developed coil-induced thrombus that required intra-arterial Tirofiban injections. Two patients were asymptomatic and one patient presented confusion due to right frontal ischemia. One periprocedural aneurysm rupture occurred without clinical impact. Radial artery occlusion and hand ischemia were not observed.ConclusionFindings of the present study showed the feasibility of distal transradial access for cerebral aneurysm embolization without increasing the risk of the procedure.     

Coil embolization of a large, wide-necked aneurysm using a double coil-delivered microcatheter technique in combination with a balloon-assisted technique.

The present paper describes a double coil-delivered microcatheter technique used in combination with a balloon-assisted technique to treat a patient with a large, wide-necked basilar tip aneurysm with detachable coil treatment. The aneurysm was completely occluded using this technique. There was no recanalization or any neurological deterioration within 12 months of embolization.     

微导管辅助三维弹簧圈技术栓塞宽颈基底动脉顶端动脉瘤

目的探讨颅内宽颈动脉瘤血管内治疗的方法。方法采用做导管辅助二维弹簧圈技术对1例男性55岁脯动静脉畸形(AVM)伴发基底动脉顶端宽颈动脉瘤病人行双侧股动脉入路，先将1条Prowler14微导管置于右侧大脑后动脉内以挡住瘤颈，随后将另1条Pmwler10做导管置于动脉瘤内。先置入1个三维GDC，使其良好成篮，随后送入4枚GDC，完全致密填塞动脉瘤，最后用NBCA闭塞了50％的AVM。结果造影显示载瘤动脉通畅，术后病人神经功能完好无损。结论微导管辅助三维弹簧圈技术栓塞对于治疗某些宽颈动脉瘤是可行的方法。     

Implantation of Two Flow Diverter Devices in a Child With a Giant,Fusiform Vertebral Artery Aneurysm: Case Report

BackgroundIntracranial aneurysms in children and adolescents are uncommon; they account for 0.5% to 4.6% of the total intracranial aneurysms cases.MethodsA 15-year-old boy presented with a 6-month history of occipital headache that worsened over time. A magnetic resonance imaging scan revealed a giant, fusiform aneurysm of the V4 segment of the right vertebral artery with mass effect but no signs of hemorrhage. This lesion was confirmed by the catheter digital subtraction angiography. The posterior inferior cerebellar artery arose from the distal part of the aneurysm. Two flow-diverter devices were implanted in the V4 segment of the right vertebral artery. Follow-up angiograms performed 1 and 2 years after the procedure revealed a total aneurysm occlusion.ConclusionFlow-diverter device implantation may be a viable alternative to parent artery occlusion in a symptomatic, giant, fusiform vertebral artery aneurysm in a child.     

Functional detection of the original generation of hippocampal cells planted on to the micro-fluidic chip with artificial neuronal network using the patch clamp recording technique: a preliminary study

Purpose: The design of pattern that limits the hippocampal cells growth is an important explore for realizing a simplified artificial neuronal network in vitro.

Materials and methods: In this study, we examined the pattern in micro-fluidic chip to stipulate the hippocampal cells adhesion, growth and the formation of a functional neuronal network in vitro. Patch clamp recording technique was used to detect the growth situation and biological function of the haippocampal cells on the micro-fluidic chip which could simulate environment in vivo.

Results: We showed that the number of neurons cultured was about 5000–6000 cells on the micro-fluidic chip, which was conductive to the hippocampal cells growth. The result of patch clamp recording technique showed the signals of sodium and potassium channels, meanwhile, it also revealed the signals of synaptic connection.

Conclusions: These findings involve placing cells in specific locations to create organized structures, and explore the spread function of synaptic on the micro-fluidic chip.     

The use of Teflon as wrapping material in aneurysm surgery

Abstract

Even if clipping is the ideal and only complete treatment of the intracranial aneurysm, wrapping is a well-known alternative technique when aneurysm clipping is not feasible, or is not completely satisfactory. We present a technique of wrapping using fibres of Teflon material shaped in strings or in pledgets, arranged on or around the area to be treated and fixed by fibrin glue. This Teflon technique was used during the years 1990 to 1992, in 44 treated aneurysms (33% or all aneurysms treated during the same period), and in 3 situations: 1) to reinforce a residual or additional ectasia next to the dipped aneurysm, usually proximal to the clip (25 cases, i.e., 57%), 2) to treat an arterial ectasia, so called preaneurysmal ectasia, which proved not clippable at surgery (10 cases, 23%) and 3) to protect a nervous or vascular neighbouring structure which was compressed by the clip grip (9 cases, 20%). No complication was noted in relation to this technique. Up to now, no other known wrapping material has received worldwide approval for being completely innocuous and effective. The Teflon material has been widely used in neurosurgical microvascular decompression and in cardiovascular surgery. In these fields, its reliability, safety, and lack of harmful effects have been widely recognized and should also apply in aneurysm surgery. A very long follow-up will be necessary to assess the outcome for this new wrapping technique. [Neurol Res 1994; 16: 224–227]