Most cases with chronic subdural hematoma (CSDH) are treated by simple irrigation and drainage, then more than eighty percent of them result in good recovery. But we sometimes encounter intractable cases with hematoma re-collection, which is considered of repeated bleeding from macrocapillary in the hematoma capsule. Embolization of the middle meningeal artery (MMA) is considered to be useful to eliminate the blood supply to this structure. The authors experienced seven cases of intractable CSDH treated by MMA embolization and no recurrence took place in all cases for up to 15 months. Endovascular treatment may be a good alternative modality for recurrent CSDH.

ESD was thus found to be feasible for the treatment of rectal tumors, with promising results although the follow-up periods were short. ESD may therefore be indicated for rectal tumors which are not resectable en bloc by conventional procedures, in order to improve the patients' quality of life.

Objective Advances in vascular reconstruction devices and coil technologies have made coil embolization a popular and effective strategy for treatment of relatively wide-neck cerebral aneurysms. However, coil protrusion occurs occasionally, and little is known about the frequency, the risk factors and the risk of thrombo-embolic complications. Method We assessed the frequency and the risk factors for coil protrusion in 330 unruptured aneurysm embolization cases, and examined the occurrence of cerebral infarction by diffusion-weighted magnetic resonance imaging (DW-MRI). Result Forty-four instances of coil protrusion were encountered during coil embolization (13.3% of cases), but incidence was reduced to 33 (10% of cases) by balloon press or insertion of the next coil. Coil protrusion occurred more frequently during the last phase of the procedure, and both a wide neck (large fundus to neck ratio) (OR = 1.84, P = 0.03) and an inadequately stable neck frame (OR = 5.49, P = 0.0007) increased protrusion risk. Coil protrusions did not increase the incidence of high-intensity lesions (infarcts) on DW-MRI (33.3% vs 29% of cases with no coil protrusion). However, longer operation time did increase infarct risk ( P = 0.0003). Thus, tail or loop type coil protrusion did not increase the risk of thrombo-embolic complications, if adequate blood flow was maintained. Conclusion Coil protrusion tended to occur more frequently in cases of wide-neck aneurysms with loose neck framing. Moderate and less coil protrusion carries no additional thrombo-embolic risk, if blood flow is maintained, which can be aided by additional post-operative antiplatelet therapy.

Objective Preoperative embolization of meningioma is commonly performed; however, there is no consensus on the best embolic material to reduce intraoperative blood loss and surgery time. Method We retrospectively assessed the safety and efficacy of 56 cases of preoperative embolization of the middle meningeal artery with N-butyl cyanoacrylate (NBCA) in 105 cases of surgery for meningioma. We also defined a blood loss to tumor volume ratio to compensate for bias caused by tumor volume, and analyzed limited cases (the embolized group n = 52, the non-embolized group n = 21) of the convexity, the parasagittal region, the falx, and the sphenoidal ridge. Result The blood loss to tumor volume ratio was significantly less in the embolized group ( p < 0.007). Preoperative embolization could be useful for cases with the external carotid artery as the dominant feeder vessel ( p < 0.02); however, the efficacy decreased for cases with an internal carotid artery feeder. Transient complications occurred in four cases (hemiparesis secondary to edema: two cases; intratumoral bleeding: one case; trigeminal nerve disorder: one case). The cases that showed a postoperative increase in edema or intratumoral bleeding were large tumors with the early filling of veins. For such cases, surgeons should pay close attention to slow injection speed and higher NBCA viscosity, not to cause the occlusion of draining vessels. Conclusion Tumor embolization with NBCA can be safely performed, and the procedure significantly reduces intraoperative blood loss.

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