In spite of the developing endovascular era, large (15-25 mm) and giant (>25 mm) wide-neck cerebral aneurysms remained technically challenging. Intracranial flow-diverting stents (FDS) were developed to address these challenges by targeting aneurysm hemodynamics to promote aneurysm occlusion. In 2011, the first FDS approved for use in the United States market. Shortly thereafter, the Pipeline of Uncoilable or Failed Aneurysms (PUFS) study was published demonstrating high efficacy and a similar complication profile to other intracranial stents. The initial FDA instructions for use (IFU) limited its use to patients 22 years old or older with wide-necked large or giant aneurysms of the internal carotid artery (ICA) from the petrous segment to superior hypophyseal artery/ophthalmic segment. Expanded IFU was tested in the Prospective Study on Embolization of Intracranial Aneurysms with PipelineTM Embolization Device (PREMIER) trial. With further post-approval clinical data, the United States FDA expanded the IFU to include patients with small or medium, wide-necked saccular or fusiform aneurysms from the petrous ICA to the ICA terminus. However, IFU is more restrictive in South Korea than in United States. Several systematic reviews and meta-analyses have sought to evaluate the overall efficacy of FDS for the treatment of cerebral aneurysms and consistently identify FDS as an effective technique for the treatment of aneurysms broadly with complication rates similar to other traditional techniques. A growing body of literature has demonstrated high efficacy of FDS for small aneurysms; distal artery aneurysms; non-saccular aneurysms posterior circulation aneurysms and complication rates similar to traditional techniques. In the short interval since the Pipeline Embolization Device was first introduced, FDS has been firmly entrenched as a powerful tool in the endovascular armamentarium. As new FDS are developed, established FDS are refined, and delivery systems are improved the uses for FDS will only expand further. Researchers continue to work to optimize the mechanical characteristics of the FDS themselves, aiming to optimize deploy ability and efficacy. With expanded use for small to medium aneurysms and posterior circulation aneurysms, FDS technology is firmly entrenched as a powerful tool to treat challenging aneurysms, both primarily and as an adjunct to coil embolization. With the aforementioned advances, the ease of FDS deployment will improve and complication rates will be further minimized. This will only further establish FDS deployment as a key strategy in the treatment of cerebral aneurysms.

Background Endoscopic surgery is helpful in evacuating intracranial hematomas. However, the indication and the craniotomy location are still unclear in the endoscopic evacuation of acute subdural hematomas (SDHs). This study evaluated the feasibility and efficacy of endoscopic treatment of acute SDH via a normal small craniotomy. Methods A normal small craniotomy (∼ 3 × 4 cm) as a surgical window was made at the superior temporal line around the coronal suture on the lesion side. A 4-mm rigid endoscope with a 0-degree lens was introduced into the subdural space, and the hematoma was evacuated using irrigation and suction devices with various angles. Endoscopic surgery was performed in 13 older adult patients with acute SDH. Adequacy of the hematoma evacuation, bleeding control, and clinical outcomes were analyzed. Results The mean age of the patient was 78.6 years (range: 65–89 years). Four cases of cortical arterial bleeding were encountered and controlled with bipolar cauterization. No re-bleeding was observed postoperatively in any patient. Near-total hematoma removal was achieved. Remnant hematoma was scanty and located in the parietal area. No further craniectomy was required after the endoscopic surgery. The outcome at discharge was closely related to the patient's level of consciousness before the operation. Conclusion A small craniotomy around the superior temporal line provides an optimal window to evacuate an acute SDH and achieve hemostasis using an endoscope. Endoscopic evacuation of acute SDHs could be effective in selected cases.

ObjectiveProtocols for posterior circulation ischemic stroke have not been established by randomized clinical trials. Mechanical endovascular thrombectomy (MET) devices are evolving, and many of these devices already developed or in development are suitable for posterior circulation MET.Materials and MethodsWe investigated the medical records of patients who underwent MET for posterior circulation ischemic stroke from January 2012 to August 2016. Fifteen patients were included. MET was performed in patients with or without injected intravenous tissue plasminogen activator. MET was considered in patients with a National Institute of Health Stroke Scale score of 4 or more, older than 18 years, with definite occlusion of the basilar artery or posterior cerebral artery (PCA), and who arrived at the hospital within 24 hours from onset.ResultsThe direct catheter aspiration technique was used in five cases, and the stent retrieval technique was used in seven cases. The stent retrieval technique with the direct aspiration technique was used in three cases. Recanalization failed in two cases. Basilar occlusion without PCA involvement is the only effective factor of successful recanalization (p = 0.03). Successful recanalization (p = 0.005) and the presence of a posterior communicating artery (p = 0.005) affected the good outcome at discharge.ConclusionAn early diagnosis and active MET may improve the patient outcome. MET may help recanalization and good flow restoration and the potential for a good outcome.