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This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient’s neurological condition (modified Rankin Scale score 2).

BackgroundWoven EndoBridge (WEB) deployment remains challenging in aneurysms with a complex shape or orientation.ObjectiveTo show that embolization of wide-neck bifurcation aneurysms using the WEB device balloon remodeling-assisted technique is a feasible and elegant endovascular solution compared with other techniques, such as balloon remodeling or stent-assisted coiling.Materials and methods10 cases (10 aneurysms in 9 patients) of balloon remodeling-assisted WEB treatment of unruptured complex bifurcation aneurysms were treated in our institution and retrospectively analyzed. Details of clinical presentations, technical details, perioperative and postoperative complications, and outcomes were collected. Immediate and long-term angiographic results were also evaluated.ResultsAneurysms included six middle cerebral artery aneurysms, one anterior communicating artery aneurysm, one posterior communicating artery aneurysm, one basilar artery aneurysm, and one T-shaped carotid aneurysm. Mean dome width was 6.55 mm, mean neck size 4.5 mm, mean height 4.79 mm, and mean dome-to-neck ratio was 1:1.46. Treatment was performed exclusively with the balloon remodeling-assisted WEB technique in all cases. The device was successfully deployed in every case. Periprocedural thromboembolic or hemorrhagic events did not occur. The modified Rankin Scale score at discharge was 0 for all patients. At mid-term or long-term angiographic follow-up, adequate occlusion was observed in 7 aneurysms from 8 controlled cases (87.5%), and one patient (2 aneurysms) did not have angiographic follow-up.ConclusionThe balloon remodeling-assisted WEB technique seems to be a safe and effective solution for endovascular treatment of unruptured wide-neck bifurcation aneurysms with specific complex anatomy. However, further studies are needed to evaluate the rate of complications and long-term efficacy.

BackroundThe treatment of wide neck bifurcation aneurysms remains challenging despite the introduction of new techniques (Y stenting, waffle cone technique, or flow diverter stents). The Woven EndoBridge (WEB) device is an innovative solution for this type of cerebral aneurysm. A new WEB 17 is now available and has been designed to offer smaller sized devices to optimize navigability and delivery.MethodsBetween February 2017 and April 2018 all patients treated with the WEB 17 device in our center were retrospectively reviewed. 25 patients with 28 non-ruptured aneurysms were identified and analyzed. Three patients with two aneurysms both treated with the WEB device were identified.ResultsThe device was successfully deployed in all cases. Procedure related morbidity was 4% and mortality was 0%. In one case, a delayed postprocedural thromboembolic event occurred owing to device protrusion. Technical success, complications, angiographic outcomes, procedural data, and follow-ups are reported. The modified Rankin Scale score at discharge was 0 for 24 patients (96%). At the 3, 6, or 9 month follow-up, angiograms were taken of 21 of the 25 patients (84%) (24 of 28 aneurysms had been controlled); 3 patients (3 aneurysms) did not receive angiographic follow-up at the time of submission of this work. Complete occlusion was achieved in 22 of 24 aneurysms (91.66%), and 2 of 24 aneurysm (8.33%) showed a neck remnant.ConclusionsThe WEB 17 is safe and technically feasible, according to this retrospective single center analysis. For very small bifurcation aneurysms, the WEB 17 seems to have lower complication rates than stent assisted techniques. However, further studies are needed to evaluate the complication rate and long term efficiency.

BackgroundDirect punctures of intracranial tumors have rarely been described in the literature.ObjectiveTo assess the feasibility, safety, efficacy, and advantages of using 3D DSA-guided direct puncture rather than the traditional transarterial route to preoperatively devascularize intracranial lesions in particular clinical situations, paying special attention to any correlation with surgical observations; we present the largest series to date.MethodsBetween July 2015 and July 2016, data from all presurgical embolizations performed in our institution were prospectively collected. Information on tumor type, location, size, eventual bone erosion, complications, devascularization percentage, and estimated blood loss was analyzed.ResultsTumors of four patients (two meningioma, two endolymphatic sac tumor) were embolized using direct puncture. 3D XperGuide planning software was used in all procedures. Embolization was feasible in all cases. In one case, a small craniotomy was specifically performed to allow needle positioning. In all cases n-butyl cyanoacrylate was used. No ischemic or hemorrhagic complications related to embolization occurred. Complete or near complete devascularization was obtained in all cases. In one case, surgery was not performed and the patient was monitored. Resection was complete without significant blood loss in two cases, and resection was incomplete but satisfactory in one case.ConclusionsIn selected cases, 3D-guided direct puncture of intracranial tumors appears safe, feasible, and efficient for preoperative embolization.