Journal of Cerebrovascular and Endovascular Neurosurgery最新文献

One of the common complications that can occur during coil embolization of cerebral aneurysms, is migration of coil lump alone. The removal of these migrated coils has been reported on a few occasions. On the other hand, rare complications would include the migration of the coil with subsequent stent dislocation. Currently, there is no standardized method to correct the complications of stent dislocation, and very few instances of this complication have been reported previously. In this report, we introduce a case of coil migration combined with stent dislocation. This occurred during coil embolization of an unruptured aneurysm of the distal, left internal carotid artery for a 52-year old woman. We retrieved both the damaged stent and migrated coil using another retrievable stent successfully with no more further complications. In the present report, we describe in detail how we corrected the complication successfully stent, and we discuss why this rescue maneuver is reasonable option for the complication mentioned above.

A giant thrombosed extracranial internal carotid artery aneurysm (ECCA) is extremely rare and its treatment is challenging. Despite the advance of endovascular technique, open surgery is still considered a first-line treatment in giant thrombosed ECCA. We describe a case of giant thrombosed ECCA which was successfully treated by aneurysmectomy and graft interposition with the technical details.

Objective: Although chronic carotid artery occlusion seems to be associated with significant risk of ischemic stroke, revascularization techniques are neither well established nor widespread. In contrast, extracranial-intracranial bypass is common despite the lack of evidence regarding neurological improvement or prevention of ischemic events. The aim of current review is to evaluate the effectiveness of various methods of recanalization of chronic carotid artery occlusion.

Methods: Comprehensive literature search through PubMed, Scopus, Cochrane and Web of Science databases performed. Various parameters were assessed among patients underwent surgical, endovascular and hybrid recanalization for chronic carotid artery occlusion.

Results: 40 publications from 2005 to 2021 with total of more than 1300 cases of revascularization of chronic carotid artery occlusion have been reviewed. Further parameters were assessed among patients underwent surgical, endovascular and hybrid recanalization for chronic carotid artery occlusion: mean age, male to female ratio, mean duration of occlusion before treatment, rate of successful recanalization, frequency of restenosis and reocclusion, prevalence of ischemic stroke postoperatively, neurological or other symptoms improvement and complications. Based on proposed through reviewed literature indications for revascularization and predictive factors of various recanalizing procedures, an algorithm for clinical decision making have been formulated.

Conclusions: Although treatment of chronic carotid artery occlusion remains challenging, current literature suggests revascularization as single option for verified neurological improvement and prevention of ischemic events. Surgical and endovascular procedures should be taken into account when treating patients with symptomatic chronic carotid artery occlusion.

Basilar artery (BA) perforator aneurysms are exceedingly rare causes of subarachnoid hemorrhage. Therefore, the natural history and optimal treatment have not been established, and surgical, endovascular, and conservative management have been used. However, there is no consensus on the optimal treatment strategy. Herein, we report the case of a 52-year-old man presenting with a ruptured BA perforator aneurysm. First, we deployed an Enterprise stent from the left P1 segment to the BA because the microcatheter could not enter the aneurysm. Then, we deployed a helical coil on the orifice of the BA perforator. Finally, we deployed another Enterprise stent, sandwiching the helical coil between the two Enterprise stents. The aneurysm was completely obliterated without recurrence on the follow-up angiography. Our technique of sandwiching the small helical coil between two Enterprise stents might help other surgeons by offering another feasible treatment option for ruptured BA perforator aneurysms.

Objective: The purpose of this study was to determine the efficacy of a 3D-printed aneurysm simulation model (3DPM) in educating patients and improving physicians' comprehension and performance.

Methods: This prospective study involved 40 patients who were diagnosed with unruptured intracranial aneurysms (UIAs) and scheduled for surgical clipping or endovascular coiling and randomly divided into two groups (the 3DPM group and the non-3DPM group). The 3DPM was used in preoperative consultation with patients and intraoperatively referenced by surgeons. The patients, 7 neurosurgical residents, and 10 surgeons completed questionnaires (5-point Likert scale) to determine the usefulness of the 3DPM.

Results: Patients in the 3DPM group had significantly higher scores in terms of their understanding of the disease (mean 4.85 vs. 3.95, p<0.001) and the treatment plan (mean 4.85 vs. 4.20, p=0.005) and reported higher satisfaction during consultation (5.0 vs. 4.60, p=0.036) than patients in the non-3DPM group. During patient consultation, 3DPMs were most useful in improving doctor-patient communication (mean 4.57, range 4-5). During clipping surgery, the models were most useful in assessing adjacent arteries (mean 4.9, range 4-5); during endovascular coiling, they were especially helpful in microcatheter shaping (mean 4.7, range 4-5).

Conclusions: In general, 3DPMs are beneficial in educating patients and improving the physician's performance in terms of surgical clipping and endovascular coiling of UIAs.

Objective: The purpose of this study was to evaluate the effectiveness of middle meningeal artery embolization (MMAE) in elderly high-risk patients with symptomatic chronic subdural hematoma (CSDH) in terms of reduction in hematoma volume and recurrence rate.

Methods: We retrospectively reviewed data prospectively collected from nine patients who underwent 13 MMAE for CSDH between June 2017 and May 2022. The volume of the subdural hematoma was measured using a computer-aided volumetric analysis program. Hematoma volume changes during the follow-up period were analyzed and clinical outcomes were evaluated.

Results: The mean follow-up period was 160 days (range, 46-311 days). All procedures were technically successful and there were no procedure-related complications. Of the 13 MMAE, 84% (11 out of 13 hemispheres) showed mean 88% of reduction on follow-up volumetric study with eight cases of complete resolution. There was one refractory case with MMAE which had been performed multiple burr-hole trephinations, for which treatment was completed by craniotomy and meticulous resection of multiple pseudomembranes. There was no recurrent case during the follow-up period, except for refractory case.

Conclusions: MMAE for CSDH in selected high-risk elderly patients and relapsed patients might be effective. Despite the small cohort, our findings showed a high rate of complete resolution with no complications. Further prospective randomized trials are warranted to evaluate its usefulness as a primary treatment option for CSDH.

The prevalence of aneurysm formation in adults with Moyamoya disease (MMD) is higher than that in the general population. The treatment strategy is often individualized based on the patient's disease characteristics. A 22-year-old man was diagnosed with MMD after presenting a small thalamic intracerebral and subarachnoid hemorrhage in the quadrigeminal cistern. Cerebral angiography revealed a small aneurysm (2.42 mm) in the left anterior choroidal artery. Since the hemodynamics in the left hemisphere was compromised, an indirect bypass surgery was performed. The patient's condition deteriorated postoperatively because of poor perfusion of the internal carotid artery, and massive hydration was required. During neurocritical care, the aneurysm increased in size (5.33 mm). An observation strategy was adopted because of the distal aneurysmal location and the high risk involved. Subsequently, the patient recovered, and newly developed collateral flow appeared from the external carotid artery. Additionally, a dramatic size reduction of the aneurysm (1.51 mm) was noticed. Our case suggests that MMD-related dissecting aneurysms on a distal cerebral artery, which present a high risk of embolization, could be managed by indirectly reducing the hemodynamic burden. Massive hydration in such cases should be avoided or balanced to avoid the risk of rapid growth and aneurysm rupture.

Moyamoya disease (MMD) is a rare progressive steno-occlusive cerebrovascular disorder. Currently, revascularization surgery is used as optimal treatment to overcome MMD. However, revascularization for MMD has reported several complications. Also, iatrogenic complications such as pseudoaneurysms formation or dural arteriovenous fistulas (dAVFs) formation-has been identified in rare cases after the surgical intervention for revascularizations. We describe two cases. In first case, the patency of the anastomosis site was good and saccular type pseudoaneurysm formation was found at parietal branch of posterior middle meningeal artery (MMA) in transfemoral cerebral angiography (TFCA) performed on the twelfth day after surgery. We decided to treat pseudoaneurysm by endovascular embolization the next day, but the patient was shown unconsciousness and anisocoria during sleep at that day. Computed tomography showed massive subdural hemorrhage at the ipsilateral side, thus we performed decompressive craniectomy and hematoma evacuation. In second case, the patency of the anastomosis site was good and dAVF formation at right MMA was found in TFCA performed on the sixth day after surgery. We performed endovascular obliteration of the arteriovenous fistula under local anesthesia. Pseudoaneurysm formation or dAVF formation after revascularization surgery is an exceptional case. If patients have such complications, practioner should carefully screen the patients by implementing digital subtraction angiogram to identify anatomic features; as well as consider immediate treatment in any way, including embolization or other surgery.

Objective: To describe the roadmapping technique and our three-year experience in the management of intracranial aneurysms in the hybrid operating room.

Methods: We analyzed all patients who underwent surgical clipping for cerebral aneurysms with the roadmapping technique from January 2017 to September 2019. We report demographic, clinical, and morphological variables, as well as clinical and radiological outcomes. We further describe three illustrative cases of the technique.

Results: A total of 13 patients were included, 9 of which (69.2%) presented with subarachnoid hemorrhage, with a total of 23 treated aneurysms. All patients were female, with a mean age of 47.7 years (range 31-63). All cases were anterior circulation aneurysms, the most frequent location being the ophthalmic segment of the internal carotid artery (ICA) in 11 cases (48%), followed by posterior communicating in 8 (36%), and ICA bifurcation in 2 (8%). Intraoperative clip repositioning was required in 9 aneurysms (36%) as a result of the roadmapping technique in the hybrid operating room. There were no residual aneurysms in our series, nor reported mortality.

Conclusions: The roadmapping technique in the hybrid operating room offers a complementary tool for the adequate occlusion of complex intracranial aneurysms, as it provides a real time fluoroscopic-guided clipping technique, and clip repositioning is possible in a single surgical stage, whenever a residual portion of the aneurysm is identified. This technique also provides some advantages, such as immediate vasospasm identification and treatment with intra-arterial vasodilators, balloon proximal control for certain paraclinoid aneurysms, and simultaneous endovascular treatment in selected cases during a single stage.