Journal of Cerebrovascular and Endovascular Neurosurgery最新文献

Objective: Simultaneous anterior cerebral artery (ACA) and middle cerebral artery (MCA) occlusion is rare. We investigated the clinical and radiological outcomes of patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy.

Methods: We analyzed the clinical and radiological outcomes of 12 patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy from January 2018 to December 2020. The clinical outcome was assessed using the modified Rankin Score (mRS) after 3 months of thrombectomy. The radiological outcome was assessed using the thrombolysis in cerebral infarction (TICI) score.

Results: The median National Institutes of Health Stroke Scale score at hospital arrival was 18 (interquartile range, 16-20). M1 was the most common occlusion lesion (n=8), and A3 was the most common lesion in the ACA (n=6). Six patients were first treated for MCA occlusion and later for ACA occlusion (MCA group). Other patients were first treated for ACA occlusion and later for MCA occlusion (ACA group). There was no difference in clinical outcomes between the MCA and ACA groups (p=0.180). Successful recanalization (TICI ≥2b) of MCA was achieved in 10 patients (83.3%). Successful recanalization of ACA was achieved in 10 patients (83.3%). Successful recanalization of both ACA and MCA occlusion was observed in eight patients (66.7%). Three patients (25%) had good clinical outcomes (mRS ≤2).

Conclusions: In our series, simultaneous ACA and MCA occlusion showed relatively poor successful recanalization rates and poor clinical outcomes despite treatment with mechanical thrombectomy.

The hypoglossal canal (HC) is an unusual location of the posterior fossa dural arteriovenous fistula (AVF), which usually occurs in the transverse or sigmoid sinus. Herein, we report a case of HC dural AVF successfully treated with transvenous coil embolization using detachable coils in a 68-year-old woman who presented with headache and left pulsatile tinnitus for 2 months. Brain magnetic resonance imaging (MRI) and cerebral angiography revealed left HC dural AVF. The pulsatile bruit disappeared immediately after the procedure. Follow-up MRI showed complete disappearance of the fistula. Precise localization of the fistula through careful consideration of the anatomy and transvenous coil embolization using a detachable coil can facilitate the treatment for HC dural AVF.

Procedure-related subarachnoid hemorrhage (SAH) after mechanical thrombectomy is known to be a clinically benign presentation. However, the treatment in the presence of definite contrast leakage without vessel rupture is controversial. Here, we report a case in which a salvage technique was performed for procedure-related SAH after mechanical thrombectomy for a proximal M3 occlusion. A 56-year-old female patient presented with global aphasia and right hemiparesis within 2 hours after symptom onset. The initial National Institute of Health Stroke Scale score of the patient was 18 points, and Computed tomography (CT) angiography showed that the superior division of the left middle cerebral artery (MCA) was occluded. We decided to treat the patient with mechanical thrombectomy. Control angiography showed a left proximal M3 occlusion. We performed mechanical thrombectomy with a partially deployed technique using a Trevo 3 mm stent (Stryker). Control angiography showed recanalization of the occluded vessel but contrast leakage after stent retrieval. We decided to treat the lesion presenting with contrast leakage with stenting using a Neuroform Atlas 3 mm stent (Stryker). Serial control angiography continued to show contrast leakage of the recanalized artery. We decided to treat the lesion with temporary balloon occlusion using a Scepter C balloon catheter (MicroVention). The patient recovered and had a modified Rankin scale score at discharge of 0. Given the results of our case, stenting and subsequent repeat temporary balloon occlusion should be considered for SAH with contrast leakage after mechanical thrombectomy, as spontaneous cessation of the arterial bleeding is unlikely.

Ruptured giant aneurysms in the posterior circulation with poor grade subarachnoid haemorrhage (SAH) are associated with poor outcome. In this report four patients with ruptured giant vertebral artery aneurysms who presented acutely with World Federation of Neurosurgical Societies (WFNS) grade five SAH are reviewed. All 4 cases required intubation and ventilation on arrival. Brainstem reflexes were intact in all of them. Early endovascular parent artery coil occlusion was done in two cases. Two other cases were treated with early surgical proximal parent artery clip occlusion. Two cases required ventriculoperitoneal shunting. All cases achieved good recovery with full functional independent outcome at two years follow up. MR angiogram at two years documented resolution of aneurysms. In conclusion good outcome may be possible in some cases of ruptured giant vertebral artery aneurysms with WFNS grade five SAH.

Objective: Vertebral artery dissecting aneurysm (VADA) is a rare and critical disease. VADA rupture can cause subarachnoid hemorrhage which is a major complication of VADA due to their high rebleeding rate and poor outcome. In the present study, ruptured and unruptured VADAs were compared by analyzing angiographic findings to determine useful predisposing factors for VADA rupture for appropriate treatment selection.

Methods: Subjects with VADA treated during a 10-year period were retrospectively identified. The 57 cases diagnosed with VADA were divided into ruptured (n=15) and unruptured (n=42) groups. In addition, each case was analyzed using angiographic 3-dimensional (3-D) reconstructed images. Factors such as length, dilated and stenotic diameter, shape, and vessel around the vertebral artery (VA) were measured and statistically compared.

Results: In the ruptured group, stenotic findings of the affected lesion were more common and severe than in the unruptured group. The average stenotic diameter was 2.27 mm (vs. 2.84 mm). And stenotic degree was 62% and 53% in the ruptured and unruptured groups, respectively. Posterior communicating artery (PcomA) flow was more common in the ruptured group (87% vs. 55%, p=0.028). Conclusions: Based on angiographic findings, stenotic lesions, which may be influenced by PcomA flow, are more common in ruptured VADAs.

Transvenous endovascular treatment is the first choice for treating most cavernous sinus dural arteriovenous fistulas (CDAVFs). Among several available venous routes, the inferior petrosal sinus is the most commonly used. We report a case of CDAVF treated with endovascular treatment via the middle temporal vein (MTV). A 65-year-old man presented with unilateral chemosis and exophthalmos for approximately two months. Digital subtraction angiography showed a right CDAVF with predominant venous drainage toward the right superior ophthalmic vein. The superior ophthalmic vein primarily drained into the dilated MTV. Both sides of the inferior petrosal sinus were occluded; therefore, transvenous embolization was performed via the MTV route. The fistula was completely obliterated. The patient's symptoms improved and the postoperative course was uneventful. The transfemoral approach via the MTV to treat CDAVF provides a crucial alternative when other venous routes are difficult or impossible to navigate with a catheter.

Objective: Despite the usefulness of pterional craniotomy (PC), its cosmetic outcome is questionable. Electrocautery (EC) causes injuries to adjacent structures, and it could be a factor that affects the cosmetic outcome. Evaluation of cosmetic outcome is difficult because it is often determined by patient's subjective criteria. The objective of this study is to compare the cosmetic outcome after EC versus non-electrocautery (NEC) dissection of the temporalis muscle for PC by analyzing long-term follow-up data determined from both physician and patient's aspects.

Methods: Patients at follow-ups between January 2014 and April 2021 after PCs were enrolled. The keyhole (KH) site, the inferior margin of the temporal line of the frontal bone (ITL), the mid-temporal (mid-T) area, and the posterior incision line (PIL) were inspected by a physician to check the presence of depressions. Patient's cosmetic satisfaction was categorized into satisfactory, intermediate, or unsatisfactory by a survey. The presence of osteolysis was checked from the radiological images. Patients were classified into two groups; one with EC dissection and another with NEC retrograde dissection using a double-ended dissector.

Results: The incidences of depression at the mid-T area and osteolysis were higher in the EC group (p=0.001, p＜0.001). The percentage of satisfactory cosmetic outcome was lower in the EC group (p=0.002). The presences of depression at the mid-T area and osteolysis were related with lower rate of satisfactory outcomes (p＜0.001, p＜0.001). Conclusions: NEC dissection causes less destruction to adjacent structures and brings better cosmetic outcome after PC.

Posterior Cerebral Artery aneurysms are scarce, yet its territory is frequently associated to large and giant aneurysms. Treatment is mostly a binary option between microsurgical clipping and endovascular coiling. Hybrid approaches are an option too, whereas innovation with less frequent techniques such as endoscope-controlled and endoscope-assisted procedure may provide a safer surgical approach with same successful results. Hereby we report a case of a 53 years old male examined at the ER after presenting generalized seizures and altered state of consciousness. Upon arrival, neurological evaluation revealed homonymous right hemianopia. Computed tomography (CT) scan revealed a subarachnoid hemorrhage and left parieto-occipital intraparenchymal hemorrhage with intraventricular extension; computed tomography angiogram (CTA) revealed an aneurysm at the left posterior cerebral artery (PCA) in its P4 segment. We performed a vascular exploration with drainage of the occipital and intraventricular hematoma through a single endoscopic port through transulcal approach guided by neuronavigation, in addition to clipping and aneurysmectomy. The combination of microsurgical clipping with previous Endoport-guided endoscopic procedure may be a surgical-operative option that not only may facilitate the approach to the desired lesion, but also provides a safer surgical scenario.

Objective: Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization.

Methods: A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012-Apr 2014) and post-IAT protocol (May 2014-Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration.

Results: Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p＞0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p＜0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p＞0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p＜0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p＜0.05), and 79.1±47.5 vs. 58.4±75.3 (p＜0.05) in three steps, respectively. Conclusions: We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.

Giant serpentine aneurysms (GSAs) are a rare subgroup of intracranial aneurysms. Separate inflow and outflow flow due to intraluminal thrombosis is the most distinguishing feature of GSAs. In treating these lesions, surgical clipping and ligation were the main treatments in the past, but bypass for revascularisation and endovascular therapies (EVTs) for deconstructive purposes are more prominent today. A 51-years-old male patient presented with headache and mild right hemiparesis. He had a GSA arising from the left fetal type posterior cerebral artery (fPCA) that was out of follow-up for six years. Radiological images revealed midline shifting and mesencephalon compression. We performed endovascular parent artery coil occlusion. The symptoms of the patient improved at the first-month follow-up. Even if there is a mass effect in GSAs, deconstructive EVT is a safe and feasible method for managing these lesions.