The Pipeline Flex (PF) (Covidien/Medtronic, Irvine, CA, USA) is an endovascular microcatheter delivery system for the curative reconstruction of parent arteries harboring large/giant and wide-necked intracranial aneurysms. We describe our initial experience and complications associated with use of the PF system. Between November 2015 and June 2017, 34 intracranial aneurysms involving the internal carotid artery between the petrous and superior hypophyseal segments underwent 37 endovascular treatments with the PF system. A total of 14 complications were experienced in 12 procedures. The mean follow-up duration was 11.2 months. Seven major complications, defined as ipsilateral stroke, occurred during 6 procedures: 3 procedure-related ischemic strokes, 1 delayed ischemic stroke, 2 delayed intracerebral hemorrhages, and 1 carotid cavernous fistula resulting from delayed aneurysmal rupture. In 1 patient, symptoms were still present 3 months after the procedure. Of the other 7 complications, 6 recovered completely by 3 months after the procedure. The complication rate for treatment with PF was 32.4% (12/37). At 3 months after the procedure, the morbidity rate was 5.9% (2/34) and the mortality rate was 0%. Angiographic follow-up examination of 20 aneurysms at 6 months revealed no filling (0%) in 7 aneurysms, entry remnant (< 5%) in 9, and subtotal filling (5-95%) in 4. This finding suggests that PF placement is effective for the treatment of large/giant and widenecked intracranial aneurysms.

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Flow diverters have been introduced as a novel treatment modality for large to giant cerebral aneurysms. To obtain baseline data for comparison, we analyzed a series of patients who underwent traditional surgical or conservative treatment.
We retrospectively studied 48 patients with large to giant cerebral aneurysms (≥15 mm in size) treated in our institute between 2007 and 2016. Ages ranged from 24 to 81 years (average, 65 years). Among the 11 men and 35 women in the study, 8 had aneurysms at the C3-C5 segment of the internal carotid artery (ICA: according to Fischer's classification), 10 at the C2 segment, and 14 at the C1 segment; 5 had aneurysms at the middle cerebral artery; and 11 had aneurysms in the posterior circulation. Twenty-nine aneurysms were symptomatic (13 were hemorrhagic and 16 presented with mass signs) and 19 were asymptomatic. Cases were retrospectively analyzed according to treatment modality and outcomes, and the natural history was evaluated in cases in which patients did not undergo surgery for more than a year.
Nine of 13 aneurysms that did not undergo surgery when first discovered became symptomatic and/or enlarged and were subsequently treated surgically. Final treatment methods were as follows: conservative treatment in 6, external obliteration (aneurysm clipping or trapping, followed by thrombectomy) in 19, internal obliteration (aneurysm packed with coils) in 5, and flow alteration with or without bypass in 16, of which 3 were performed with external obliteration and 3 with internal obliteration. Outcomes in patients with ICA aneurysms at the C3-5 and C2 segments were favorable (modified Rankin Scale [mRS] score 0 to 2) in 17 of 18 (94%). On the other hand, 11 of 19 patients (58%) with aneurysms at C1 of the ICA or middle cerebral artery experienced favorable outcomes. In the remaining cases, cerebral ischemia including perforating artery involvement led to worse outcomes. Only 2 (18%) of 11 patients with posterior circulation aneurysms had favorable outcomes. Aneurysms that were initially managed conservatively enlarged by an average of 3.5 mm per year.
Treatment outcomes with use of flow diverters for complex cerebral aneurysms may yield results that are comparable or superior to those of traditional treatment.

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A 65-year-old female presented with right oculomotor nerve palsy due to a large internal carotid artery (ICA) cavernous aneurysm. She underwent ligation of the right ICA with an external carotid artery to middle cerebral artery high-flow bypass (HFB).
Although her postoperative course was uneventful, she developed a cerebral infarction at the right internal capsule 5 months after surgery.
Cerebral angiography revealed a filling defect at the origin of the anterior choroidal artery. We suspected that the blood current from HFB and the posterior communicating artery formed a “currentrip” at the C1 segment of the right ICA. Soon after introduction of antithrombotic therapy, her symptoms completely resolved.
Angiography 3 months after the stroke revealed no filling defect at that site.
This is the first report demonstrating the occurrence of ischemic stroke in the chronic phase of carotid ligation surgery with HFB. Hence, careful observation is required for these patients, even after discharge.

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Maximization of tumor resection and minimization of surgical morbidity during glioma surgery depends on two fundamental requirements, i.e., determination of the resection border and preservation of the involved arteries and veins. Techniques to preserve the involved vascular structures must consider deep-situated narrow arteries including the perforating arteries. This presentation will focus on the anterior choroidal arteries, subependymal arteries originating from the lateral posterior choroidal arteries, thalamotuberal arteries, and thalamogeniculate arteries. Damage to these arteries during glioma resection carries the risk of postoperative hemiparesis. Postoperative diffusion-weighted magnetic resonance imaging may demonstrate infarction at different parts of the descending motor pathway. Preservation of these arteries is one of the most important procedures to prevent adverse events caused by glioma resection. Detailed knowledge of the anatomy is essential to preserve these arteries.

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Direct surgery for internal carotid-anterior choroidal artery (IC-AChA) aneurysms has been considered difficult due to the complicated anatomy and fragile nature of the AChA. IC-AChA aneurysms are thought to have a higher risk of rupture regardless of size and patient age. In fact, our institution has experienced many ruptured IC-AChA aneurysms of relatively small size (< 5 mm), or in younger patients (<30 years old). We analyzed the clinical characteristics and outcomes in 111 patients who underwent direct surgery for IC-AChA aneurysms between 2001 and 2014. We had 1, 406 cases of direct surgery for unruptured cerebral aneurysms between 2001 and 2014, involving 434 male and 972 female patients, with average ages of 58.0 and 61.0, respectively. Of these, 111 were cases of IC-AChA aneurysm, involving 45 male and 56 female patients, with respective average ages of 59.2 and 57.4. In 85 cases (77%), the sizes of the IC-AChA aneurysms were less than 5 mm. We performed 99 neck clippings, including 7 cases of clipping on wrapping and 5 cases with wrapping. All direct surgeries were performed via trans-sylvian approaches in order to expose every branch of the AChA and to keep blood flow intact. Fortunately, we did not encounter any cerebral infarctions in the AChA perfusing region after any clipping operation, and had favorable outcomes in 108 cases (97.3%). Despite technical difficulty, our results demonstrated that surgery for IC-AChA aneurysms can be safely performed if painstaking approaches are used to avoid harming the blood flow in the anterior choroidal artery.

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Background and Purpose: Spontaneous intracerebral hemorrhage (ICH) can induce epileptic seizures. This study aimed to identify the incidence and risk factors of seizures in patients with ICH. We also investigated whether surgical intervention for hematoma was correlated with the occurrence of seizures.
Methods: A total of 478 adult patients (237 males, 241 females; age 23-101 years) enrolled in this study. Sixty-nine patients underwent removal of hematoma by craniotomy or stereotactic aspiration. Univariate and multivariate logistic regression analyses were used to assess the association of clinical factors with epileptic seizures.
Results: Seizures occurred in 26 (5.4%) patients with ICH, including early seizures (within 7 days of ICH) in 13 and late seizures (occurring >7 days after ICH) in 13. Univariate analysis revealed that hematoma in any lobe was significantly correlated with seizures. Multivariate analysis revealed that hematomas in the frontal lobe (odds ratio [OR]: 11.15; 95% confidence interval [CI]: 2.94-42.24; p = 0.0004), temporal lobe (OR: 3.49; 95% CI: 1.23-9.89; p = 0.0187), and occipital lobe (OR: 6.41; 95% CI: 1.48-27.83; p = 0.0131) were significantly correlated with seizures. Surgical intervention for hematoma was not associated with seizures. Eleven (84.6%) of 13 patients with late seizures went on to experience recurrent seizures, in contrast to only 2 (15.4%) of 13 with early seizures.
Conclusions: Cortical involvement of ICH was a risk factor of seizures. Surgical intervention for ICH did not influence occurrence of seizures. Late seizures are liable to recurrence, are compatible with unprovoked seizures, and may be diagnosed as epilepsy after a first seizure.

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Ocular ischemic syndrome must be distinguished from diabetic retinopathy. Patients with bilateral differences in the degree of retinopathy are likely to have ocular ischemic syndrome; however, diagnosis is often difficult.
We report a case of bilateral ocular ischemic syndrome with bilateral common carotid artery stenosis in which the cause of visual impairment required 5 months to diagnose. A 71-year-old man at high risk of arteriosclerosis due to hypertension, diabetes, and hyperlipidemia was found to have mild bilateral internal carotid artery stenosis on ultrasonography. He presented to an ophthalmology clinic with bilateral visual impairment and remained under observation for a diagnosis of diabetic retinopathy. Visual impairment progressed, with neovascularization of the iris and neovascular glaucoma in the right eye. Ocular ischemic syndrome was suspected; however, the existing internal carotid artery stenosis showed no evidence of progression. Computed tomography angiography (CTA) revealed bilateral common carotid artery stenosis. The interval from appearance of symptoms to the start of therapy was 5 months. Functional recovery of the right eye was regarded as unrealistic. After 2 separate stenting procedures for each eye, subjective symptoms in the left eye improved, but no improvement was identified in the right eye.
Even if little bilateral difference in retinopathy is present, early comprehensive testing is necessary, including evaluation of the common carotid artery, while also considering a diagnosis of ocular ischemic syndrome.

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Eagle's syndrome presents with a series of symptoms caused by an elongated styloid process and/or the ossification of part of the entire stylohyoid ligament. Symptoms of the classic type are caused by factors such as irritation and compression of the lower cranial nerve, sore throat and dysphagia, facial pain, and neck pain. The other rare type is caused by compression or dissection of the carotid artery, causing a transient ischemic attack or stroke. This report describes a case of Eagle's syndrome with cerebral infarction caused by internal carotid artery (ICA) dissection, treated with endovascular revascularization of the ICA and surgical resection of the styloid process. A 51-year-old woman presented with sudden onset of right hemiparesis and aphasia. Magnetic resonance imaging revealed left ICA occlusion. Endovascular recanalization therapy for the ICA occlusion was initiated, and recanalization with thrombolysis of the cerebral infarction (TICI) grade IIb was achieved. Carotid artery dissection with intraluminal thrombus was observed at the extracranial portion. Computed tomographic angiography on day 6 revealed the dissected ICA compressed by the elongated styloid process. On day 24, the elongated styloid process was resected extraorally, and successful decompression of the ICA was achieved. ICA dissection caused by an elongated styloid process has been reported frequently. Eagle's syndrome is rare but is one of the important diseases to consider in the differential diagnosis of extracranial carotid artery dissection.

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We report a case of bypass surgery for a cerebrovascular ischemic event caused by giant cell arteritis (GCA). A 70-year-old female with transient right hemiparesis was admitted to our hospital. Diffusion-weighted imaging showed acute infarction of the left subcortical watershed areas. Magnetic resonance angiography (MRA) showed severe stenosis at the left cavernous portion of the intracranial internal carotid artery. Despite intravenous anticoagulation therapy, her right hemiparesis worsened. An emergent left superficial temporal artery-middle cerebral artery (STA-MCA) bypass was performed. The intima of the STA was markedly hypertrophic. We identified abnormal tissue and part of the STA was sent for pathological examination. After bypass surgery, the neurological findings transiently improved; however, exacerbation of the right hemiparesis and aphasia occurred on the second postoperative day. Increasing acute cerebral infarction was identified on magnetic resonance imaging, and MRA showed that the bypass was occluded. An occipital artery (OA)-MCA anastomosis was added, but the bypass occluded again. The postoperative pathologic diagnosis was GCA in both the STA and OA. Strokes associated with GCA are rare and difficult to distinguish from atherothrombotic cerebral infarction. When a donor blood vessel abnormality is observed during bypass surgery, rapid pathological diagnosis is recommended to avoid bypass failure.

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Dural arteriovenous fistula (DAVF) is occasionally associated with venous/sinus stenosis. In some cases, venous congestion and venous hypertension due to venous/sinus stenosis can induce clinical symptoms. The authors report a case of transverse-sigmoid sinus DAVF treated with transvenous embolization and venous/sinus angioplasty and stenting.
A 46-year-old man presented with psychiatric symptoms and was diagnosed with Cognard type IIa+b DAVF of the left transverse-sigmoid sinus. Retrograde venous drainage was directed toward the right side via confluence. Venous/sinus stenosis in the right internal jugular vein and transverse sinus with supratentorial venous congestion were observed. DAVF was transvenously embolized, and venous/ sinus angioplasties were performed. Balloon angioplasty was performed for stenosis at the transverse sinus, and stent angioplasty was performed for stenosis at the internal jugular vein because the stenosis was not sufficiently dilated with balloon angioplasty. DAVF was totally obliterated, and the venous congestion immediately improved. The patient's clinical symptoms gradually improved postoperatively.
Venous/sinus angioplasty and stenting should be considered as a treatment for venous/sinus stenosis associated with DAVF.

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When unexpected hemorrhage occurs during an operation, the neurovascular surgeon must immediately perform safe and secure hemostasis. Inappropriate hemostasis can lead to a circulatory disorder, cerebral edema, and hemorrhage. We describe safe and secure troubleshooting of different causes of hemorrhage, while presenting typical cases of cerebral aneurysm surgery. The following are discussed: 1. cerebral cortical vein 1) oozing, 2) small hemorrhage, 3) thick vein requiring reconstruction; 2. venous sinus 1) mild bleeding, 2) moderate bleeding, 3) severe bleeding; 3. bleeding from a lacerated aneurysmal neck; 4. new techniques using suction. Hemostasis with maintenance of normal structure was performed in all cases. The following are detailed methods used for each case. In 1.1) Gelfoam (Pfizer) soaked in saline was used; 1.2) minimum suturing was done; 1.3) frontal basal vein-radial vein-superficial middle cerebral vein anastomosis was performed. In 2.1) hemostatic material was used; 2.2) Goretex was placed over the bleeding site and covered with Gelfoam soaked in fibrin; 2.3) with sinus packing using neurosurgical pads for hemostasis, reconstruction of the sigmoid sinus using a saphenous venous patch was safely and quickly performed. In 3. the lacerated aneurysmal neck was repaired with 10-0 nylon interrupted sutures. Usual clipping based on closure line clipping was performed after securing hemostasis. In 4. in a narrow and deep operative field, use of the suction tip with the left hand enables cleaning of the bleeding point and self-sealing. Postoperative courses were uneventful and transfusion was not required. Appropriate troubleshooting without short-cuts is increasingly necessary because less invasive endovascular surgery can be easily performed.

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