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Introduction: To evaluate the effects of the multiple burr hole (MBH) revascularization on ischemic type adult Moyamoya disease (MMD) by computed tomography perfusion (CTP). Methods: Eighty-six ischemic MMD patients received CTP 1 week before and 3 weeks after MBH operation. Fifty-seven patients received it again at 6 month and underwent digital subtraction angiography (DSA) and mRS follow-up. Cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP), and relative values of ischemic symptomatic hemispheres were measured. Differences in pre- and post-surgery perfusion CT values were assessed. Results: There were significant differences of CBF, TTP, and relative time to peak (rTTP) in ischemic hemisphere between 1 week before and 3 weeks after surgery, and no significant difference in relative cerebral blood flow (rCBF), CBV, relative cerebral blood volume (rCBV), MTT, relative mean transit time (rMTT). According to whether there was symptom improvement or not on 3 weeks after MBH, the rTTP value was not statistically significant in the patients whose symptoms were not improved at all on 3 weeks after operation. Six-month follow-up showed that CBF, rCBF, and rCBV values were significantly higher than those before operation. Postoperative MTT, TTP, rMTT, and rTTP values were significantly lower than those before operation. Conclusion: CTP is a sensitive method to obtain functional imaging of cerebral microcirculation, which can be a noninvasive assessment of the abnormalities of intracranial arteries and cerebral perfusion changes in MMD before and after surgery. CBF and TTP map, especially the relative values of TTP, seems to have the capability of being quite sensitive to the presence of altered brain perfusion at early time after indirect revascularization. [ABSTRACT FROM AUTHOR]

Certain cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) are difficult to access through transarterial or transvenous routes and may necessitate access through direct transorbital puncture of the superior ophthalmic vein (SOV) or the CS. However, to be successful, the accurate design of the puncture route and guidance are crucial. This study aimed to report our preliminary clinical experience using cone-beam computed tomography (CT) with real-time fluoroscopic overlays for image guidance during transorbital needle puncture. Between December 2017 and July 2018, 3 patients with CS DAVFs were treated via a transorbital puncture to establish access to the CS under the guidance of XperGuide planning software either via direct CS puncture or through the SOV. The guidance trajectory was superimposed onto the real-time fluoroscopic image during needle puncture. Once access was established, the CS DAVFs were treated with a combination of liquid embolic materials and coils. Image guidance aided to avoid at-risk structures and treatment resulted in all cases in complete obliteration of the CS DAVFs as verified by control angiography without peri- or postprocedural complications. Endovascular embolization of CS DAVFs via direct transorbital puncture aided by image guidance provided an alternative option when more conventional approaches are deemed not possible. [ABSTRACT FROM AUTHOR]

Objectives: We performed this study to report our experience using a stepwise stent deployment technique for the treatment of tandem intracranial aneurysms.Methods: Patients with intracranial tandem aneurysms that were treated with a stepwise stent deployment technique between May 2009 and June 2013 were retrospectively reviewed.Results: Twenty-one patients with 42 tandem aneurysms were identified (11 men, 10 women), with a mean age of 53.7 years (range, 17-82 years). Subarachnoid haemorrhage was confirmed in 12 patients using computed tomography at onset. Complete occlusion was achieved in 20 of the aneurysms (47.6%) after the procedure, neck remnant in 9 (21.4%), and aneurysm remnant in 13 (31.0%). The perioperative complications included in-stent thrombosis in one case and vasospasm in two cases, none of which left a permanent neurological deficit. The modified Rankin Scale (mRS) score at discharge was 0-2 in 20 cases and 3 in one case. The follow-up angiograms available for 17 patients showed complete occlusion in 26 aneurysms, improved in 4, and stable in 4. All of the patients had mRS scores of 0-1 during the clinical follow-up period.Conclusions: The stepwise stent deployment technique is feasible and helpful in the treatment of intracranial tandem aneurysms.Key Points: • Treating wide-necked intracranial aneurysms with stent-assisted coiling is preferable. • Tandem wide-necked intracranial aneurysms can be treated with a single stent. • Stepwise stent deployment is technically feasible for embolizing tandem intracranial aneurysms. [ABSTRACT FROM AUTHOR]