Neurointervention最新文献

There are few documented cases of bradycardia or asystole occurring during Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs), although these events are more commonly observed in open neurosurgical procedures, particularly those involving the skull base. We present a case treated for a ruptured paramedian occipital DAVF. During the administration of Squid into the middle meningeal artery, while balloons were inflated in the large occipital arteries bilaterally to control the flow during embolization of the DAVF, the patient experienced an abrupt episode of sinus bradycardia, which recurred after a second injection of Squid. After temporarily halting the injections and deflating the balloons, a third injection was successfully administered without complications, allowing total exclusion of the fistula.

The treatment of carotid stenosis complicated by severe vessel tortuosity can present challenges in distal vessel selection and device delivery. This article reports the use of a steerable microcatheter (SM) for carotid artery stenting (CAS) in such cases. A 67-year-old male with transient lower extremity weakness and bilateral cerebral infarctions was found to have bilateral carotid stenosis. CAS was planned for both carotid arteries due to coronary artery disease. The left carotid artery exhibited severe stenosis with a 90-degree angle between the common and internal carotid artery (ICA). Anticipating difficulty in navigating the device, we used a 2.4 Fr SM. By adjusting the catheter tip to align with the ICA, we successfully guided the wire distally. Following the catheter exchange, a distal protection device was deployed, and CAS was completed successfully. SMs provide exceptional vascular selectivity and support, improving success in complex cases.

Purpose: Mechanical thrombectomy (MT) for distal medium vessel occlusions (DMVOs) in the middle cerebral artery (MCA) is less established than for large vessel occlusions. This study evaluates the safety and efficacy of MT in DMVOs, comparing it with M1-segment occlusions.

Materials and methods: This retrospective study analyzed 218 patients who underwent MT for isolated M1 (n=123) or distal M2+M3 (n=35) occlusions between January 2020 and August 2023. Outcomes included procedural complications, hemorrhagic events, reperfusion rates, and clinical severity and disability at admission and discharge. Multivariate logistic regression identified predictors of favorable outcomes (modified Rankin Scale≤2) at discharge.

Results: Median admission National Institutes of Health Stroke Scale (NIHSS) scores were higher in the M1 group (13, interquartile range [IQR]: 8) compared to the distal M2+M3 group (8, IQR: 7; P<0.001), with significant improvements at discharge in both groups (6 [IQR: 8] for M1 and 2.5 [IQR: 5] for M2+M3; P=0.025). Favorable outcomes were more frequent in the M2+M3 group (50.0%) compared to M1 (28.1%; P=0.023). Recanalization rates (modified Thrombolysis in Cerebral Infarction≥2b) were excellent (>90% in both groups; P=0.300). Procedural complications were rare, with vessel perforations occurring infrequently (M1: 1.6%; M2+M3: 2.9%; P=0.531). Symptomatic intracranial hemorrhage rates were similarly low (2.4% vs. 2.9%; P=0.889). Multivariate analysis identified younger age (P=0.045) and lower NIHSS (P=0.061) as predictors of favorable outcomes in distal occlusions.

Conclusion: MT is safe and effective for DMVOs of the MCA, demonstrating significant improvements in clinical outcomes and comparable complication rates to MT for M1-segment occlusions. Given the typically less severe presentations in DMVO and similar risk profiles, careful patient selection and individualized treatment remain critical.

Delayed rupture of intracranial aneurysms after endovascular treatment is a rare but serious complication. We report the first documented case of late aneurysmal rupture following treatment with a Contour intrasaccular device. A patient in their 60s with a basilar tip aneurysm underwent endovascular treatment using a 14-mm Contour device. Fifteen months later, the patient presented with a fatal intraventricular hemorrhage, and imaging revealed device displacement and aneurysm growth. This case underscores the importance of meticulous device sizing and follow-up, especially for large aneurysms.

Torcular dural sinus malformations (tDSMs) with high-flow fistulas pose complex management challenges due to their vascularity and the delicate neuroanatomy involved. This report presents the case of a child with tDSM and hydrocephalus, who underwent 3 staged embolization procedures but required a redo intervention due to residual malformation and venous hypertension. Utilizing the pressure cooker technique (PCT) in a redo setting allowed for high-pressure, targeted embolic delivery with minimized reflux, achieving near-complete occlusion and significant symptom relief. This case highlights PCT's potential to improve outcomes in multi-stage treatments of high-flow tDSM, reducing reflux and enhancing safety in technically demanding cases.

The Woven EndoBridge (WEB) device has emerged as a promising alternative to endovascular coiling. This case report demonstrates the use of stent-assisted WEB deployment for the embolization of multiple wide-neck posterior cerebral artery (PCA) aneurysms. A middle-aged patient was diagnosed with 3 unruptured aneurysms in the P3 and P4 segments of the right PCA, with sizes ranging from 2.5 mm to 6.6 mm. Given the small vessel diameter and distal location of the aneurysms, a combined approach was adopted. Coil embolization was performed for the most distal aneurysm, while stent-assisted WEB deployment was used for the proximal and middle aneurysms. The "flower bud" technique facilitated the safe positioning of the WEB device in challenging anatomical conditions. The procedure was successfully completed without complications, and the patient was discharged on postoperative day 7 with no neurological deficits. Follow-up at 3 months confirmed adequate embolization of all aneurysms, with in-stent stenosis managed conservatively.

We report a rare case of a left internal mammary artery (LIMA) originating from the left thyrocervical trunk (TCT), which arose directly from the aortic arch. A patient in their 70s presented with bilateral distal internal carotid artery aneurysms, diagnosed through computed tomography angiography performed for headache evaluation. Transfemoral cerebral angiography confirmed the aneurysms and incidentally revealed the anomalous origins of the TCT and LIMA, as well as a left vertebral artery directly arising from the aortic arch. This case emphasizes the importance of recognizing such rare anatomical variations prior to diagnostic or interventional procedures. Thorough preoperative evaluation is critical to avoid complications, particularly in coronary artery bypass grafting and head and neck tumor embolization.

Scalp arteriovenous fistulas (AVFs) are rare vascular anomalies characterized by abnormal connections between arterial and venous systems in the scalp. These lesions can lead to significant complications, including chronic headaches, tinnitus, cosmetic deformities, and in severe cases, high-output cardiac failure or intracranial hemorrhage. We present a case of a middle-aged female patient with a 20-year history of a pulsating mass on the left parietal scalp. Magnetic resonance imaging and cerebral angiography confirmed the presence of a scalp AVF with multiple arterial feeders from the external carotid artery and venous drainage into the left external jugular vein. Due to the tortuosity of the feeding arteries, a transarterial approach was unsuccessful, leading to the decision to perform transvenous embolization with balloon occlusion using Onyx-18. The procedure resulted in complete obliteration of the AVF without complications. This case highlights the efficacy of transvenous embolization with balloon occlusion as a treatment option for complex scalp AVFs, particularly when transarterial access is challenging.