No abstract

We describe a supra-diaphragmatic ectopic pituitary adenoma that was safely removed using the extended endoscopic endonasal approach, and discuss the value of three-dimensional (3D) endoscopy and intra-operative magnetic resonance imaging (MRI) to this type of procedure.A 61-year-old-man with bitemporal hemianopsia was referred to our hospital, where MRI revealed an enhanced suprasellar tumor compressing the optic chiasma. The tumor extended on the planum sphenoidale and partially encased the right internal carotid artery. An endocrinological assessment indicated normal pituitary function. The extended endoscopic endonasal approach was taken using a 3D endoscope in the intraoperative MRI suite. The tumor was located above the diaphragma sellae and separated from the normal pituitary gland. The pathological findings indicated non-functioning pituitary adenoma and thus the tumor was diagnosed as a supra-diaphragmatic ectopic pituitary adenoma. Intra-operative MRI provided useful information to minimize dural opening and the supra-diaphragmatic ectopic pituitary adenoma was removed from the complex neurovascular structure via the extended endoscopic endonasal approach under 3D endoscopic guidance in the intra-operative suite. Safe and effective removal of a supra-diaphragmatic ectopic pituitary adenoma was accomplished via the extended endoscopic endonasal approach with visual information provided by 3D endoscopy and intra-operative MRI.KEywords: Chiasmatic cistern, Intraoperative MRI, Suprasellar tumor, Tuberculum sellae ÖZGenişletilmiş endoskopik endonazal yaklaşım kullanılarak güvenli bir şekilde çıkartılan bir supra-diyafragmatik ektopik hipofiz adenomu tanımlanmakta ve bu tür işlemde üç boyutlu (3B) endoskopi ve intraoperatif manyetik rezonans görüntülemenin (MRG) değeri tartışılmaktadır.Bitemporal hemianopsili, 61 yaşında bir erkek hasta hastanemize sevk edildi ve MRG'de optik kiazmayı sıkıştıran, kontrast tutan bir suprasellar tümör görüldü. Tümör, planum sfenoidale üzerine uzanmaktaydı ve sağ internal karotid arteri kısmen çevrelemişti. Endokrin değerlendirme normal pitüiter işlev gösterdi. İntraoperatif manyetik rezonans görüntüleme (MRG) odasında bir 3D endoskop kullanılarak genişletilmiş endoskopik endonazal yaklaşım gerçekleştirildi. Tümör diyafragma sella üzerinde bulunuyordu ve normal hipofiz bezinden ayrılmıştı. Patolojik bulgular işlev görmeyen bir hipofiz adenom düşündürüyordu ve tümöre bu şekilde bir supra-diyafragmatik ektopik hipofiz adenom tanısı konuldu. İntraoperatif MRG dural açıklığı minimuma indirmek için faydalı bilgiler sağladı ve supra-diyafragmatik ektopik hipofiz adenom intraoperatif MRG odasında 3B endoskopi kılavuzluğu altında genişletilmiş endoskopik endonazal yaklaşımla kompleks nörovasküler yapıdan çıkarıldı. Supra-diyafragmatik ektopik hipofiz adenomun güvenli ve etkin bir şekilde çıkarılması 3B endoskopi ve intraoperatif MRG tarafından sağlanan görsel bilgiler ve genişletilmiş endoskopik endonazal yaklaşım yoluyla gerçekleştirildi.

Background: Cervical aneurysms are rare, accounting for <1% of all arterial aneurysms, including dissecting, traumatic, mycotic, atherosclerotic, and dysplastic aneurysms. Symptoms are usually caused by cerebrovascular insufficiency; local compression or rupture is rare. We present the case of a 77-year-old man with a giant saccular aneurysm of the cervical internal carotid artery (ICA), which was treated with aneurysmectomy and side-to-end anastomosis of the ICA. Case Description: The patient had experienced cervical pulsation and shoulder stiffness for 3 months. The patient had no significant medical history. An otolaryngologist performed the vascular imaging and referred the patient to our hospital for definitive management. Neurological deficits were not observed. Digital subtraction angiography showed a giant cervical aneurysm with a diameter of 25 mm within the ICA, and there was no evidence of thrombosis within the aneurysm. Aneurysmectomy and side-to-end anastomosis of the cervical ICA were performed under general anesthesia. After the procedure, the patient experienced partial hypoglossal nerve palsy but fully recovered with speech therapy. Postoperative computed tomography angiography revealed the complete aneurysm removal and patency of the ICA. The patient was discharged on postoperative day 7. Conclusion: Despite several limitations, surgical aneurysmectomy and reconstruction are recommended to eliminate the mass effect and to avoid postoperative ischemic complications, even in the endovascular era.

The purpose of this study was to demonstrate the efficacy of a 14-coil (Target XL) for framing in coil embolization of small cerebral aneurysms. Methods: Between January 2017 and December 2018, 46 patients underwent coil embolization of a small cerebral aneurysm that was less than 5 mm in maximum diameter. They were categorized into 26 patients in whom only 10-coils were used and 20 in whom Target XL was used for framing. The volume embolization rate (VER) and recanalization rate were compared between the two groups. Results: Although there were two patients in whom Target XL was replaced with a 10-coil for framing, no adverse events associated with the use of Target XL were noted. The mean VER of the first framing coil was significantly higher in aneurysms that were framed with Target XL than in those framed with a 10-coil (Target XL 22.6 ± 4.5%, 10-coil 17.9 ± 8.4%; p = 0.03). Furthermore, the mean VER at the end of the procedure was significantly higher in aneurysms with Target XL used for framing than in those embolized using only 10-coils (14-coil: 36.8 ± 7.8%, 10-coil: 32.0 ± 6.5%; p = 0.03). No recanalization was observed in aneurysms for which Target XL was used for framing, whereas five aneurysms embolized using only 10-coils were recanalized. Conclusion: Target XL may be safe and feasible as a framing coil in coil embolization of small cerebral aneurysms, which may result in a high VER, low recanalization rate, and good outcome.

Differentiating acute aortic dissection that develops cerebral ischemic symptoms in stroke practice is very important for avoiding inappropriate IV rt-PA therapy beyond delaying treatment of acute aortic dissection. Although acute aortic dissection with cerebral ischemic symptoms is infrequent, it may exist in patients who are suspected of stroke with neurological symptoms such as unconsciousness and aphasia. Acute aortic dissection can be non-specific and may depend on various symptoms such as where the tear is located in the aorta. In order to not miss out acute aortic dissection that develops with cerebral ischemic symptoms without chest and back pain, it is necessary to understand the clinical findings of acute aortic dissection such as low blood pressure, difference of right and left blood pressure, mediastinal widening on chest X-ray, and high D-dimer. In an auxiliary imaging operation, cervical MRA is useful not only for the evaluation of pathophysiology of cerebral infarction but also to diagnose acute aortic dissection. We report two cases of acute thoracic aortic dissection that developed with cerebral ischemic symptoms without chest pain along with a literature review.

There have been no delayed ischemic complications related to stent-assisted coil embolization (SACE) of cerebral aneurysms at our institution. We demonstrate our strategies for stent placement and postoperative management of antiplatelet therapy to reduce the risk of ischemic complications. Methods:We analyzed 57 cases of SACE retrospectively. In the procedure, an appropriate stent was selected and placed to fit the arterial wall without impeding on small arterial branches. Two different antiplatelet drugs, including clopidogrel, were used. Six to twelve months after surgery, follow-up angiography was performed to assess the safety of terminating antiplatelet therapy. In cases in which antiplatelet therapy was tapered, the two antiplatelet drugs were switched to clopidogrel alone, and it was subsequently tapered and finally discontinued.Results: There were 49 cases of SACE in which postoperative antiplatelet therapy was tapered. Among these cases, antiplatelet therapy was discontinued in 35 cases. The mean duration of dual antiplatelet therapy was 10.6 ± 2.8 months, and the mean duration of total antiplatelet therapy was 15.0 ± 2.1 months. Three patients developed SACE-related ischemic stroke, which developed in the early phase after surgery in all. Conclusion:Antiplatelet therapy can safely be terminated in most cases of SACE. In order to reduce the risk of ischemic complications, stent selection, stent placement, and management of antiplatelet therapy should be performed appropriately. Furthermore, careful follow-up should be continued even after the termination of antiplatelet therapy. Keywords▶ stent-assisted coil embolization, ischemic complications, antiplatelet therapy, clopidogrel This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

The purpose of this study was to investigate the efficacy of percutaneous transluminal angioplasty (PTA) for symptomatic middle cerebral artery stenosis by analyzing cerebral blood flow (CBF).Methods: Between January 2016 and December 2018, six patients with symptomatic middle cerebral artery stenosis underwent CBF analysis by single-photon emission computed tomography (SPECT) with acetazolamide challenge before and after PTA for stenosis. They were retrospectively reviewed, and the blood flow in the area of the affected middle cerebral artery before and after angioplasty was compared. Results:The mean stenosis rate and length of lesion before angioplasty were 76.4 ± 5.4% and 6.5 ± 2.1 mm, respectively. Balloon angioplasty without stenting was performed on all patients. The mean residual stenosis rate just after angioplasty was 45.4 ± 9.3%. No periprocedual complications developed, and there were no notable cerebral ischemic events during the postprocedural follow-up period. One patient underwent repeat angioplasty for restenosis. Although there was only a mild decrease in blood flow at rest, the cerebrovascular reserve (CVR) in the area of the affected middle cerebral artery was markedly decreased before angioplasty (mean, 3.6 ± 4.3%). After angioplasty, the CVR was significantly improved (mean, 18.0 ± 4.7%, p <0.01).Conclusions: PTA for symptomatic middle cerebral artery stenosis can be safely performed using appropriate interventional techniques for select patients. Reduced CVR due to stenosis can be improved after angioplasty, which may reduce the risk of cerebral ischemic events. Keywords▶ middle cerebral artery stenosis, percutaneous transluminal angioplasty, cerebrovascular reserve, single-photon emission computed tomography This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

We report a case of collaborative treatment using surgical and radiological approaches for a ruptured dissecting aneurysm around the proximal posterior cerebral artery (P1-P2) and the posterior communicating artery. A 37-year-old woman was admitted to our hospital with a severe headache for 3 days. On admission, a computed tomography scan revealed a subarachnoid hemorrhage and a cerebral angiogram showed a dissecting aneurysm involving the proximal posterior cerebral artery (P1-P2) and posterior communicating artery. Although parent artery occlusion was indispensable for complete treatment, it posed the risk of ischemic complications in the right posterior cerebral artery distribution. A preoperative assessment of her three-dimensional digital subtraction angiogram en