Journal of neuroendovascular therapy最新文献

Objective: Mechanical thrombectomy has become an established treatment for acute ischemic stroke caused by acute intracranial artery occlusion, but periprocedural complications may adversely affect outcomes. This study aimed to identify clinical and procedural factors associated with periprocedural complications following mechanical thrombectomy and to clarify their impact on prognosis.

Methods: We conducted a multicenter observational study of patients who underwent mechanical thrombectomy for acute intracranial artery occlusion between January 2016 and June 2022 across 11 stroke centers in Fukushima Prefecture, Japan. Data were collected from a retrospective registry (January 2016-December 2019) and a prospective registry (January 2020-June 2022). Periprocedural complications were defined as adverse events occurring during or within 24 h after the procedure, including hemorrhagic, ischemic, device-related, and extracranial complications. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of periprocedural complications.

Results: A total of 487 patients were included in the analysis. Periprocedural complications occurred in 66 patients (13.6%). The most frequent procedure-related events were perforator injury (n = 18, 3.7%), vessel perforation (n = 9), and contrast-induced hemorrhage (n = 4). Post-procedural complications mainly included hemorrhagic transformation (n = 16). Compared with patients without complications, those with complications had a higher prevalence of atrial fibrillation (62.1% vs. 46.6%, p = 0.019), less frequent intravenous recombinant tissue plasminogen activator use (37.9% vs. 52.0%, p = 0.033), and longer puncture to recanalization time (76.5 vs. 57 min, p = 0.012). Symptomatic intracranial hemorrhage occurred exclusively in the complication group (31.8% vs. 0%, p <0.001). Patients with complications had a lower rate of favorable functional outcomes (modified Rankin Scale score 0-2 at 90 days, 18.2% vs. 42.6%, p <0.001). Multivariable analysis identified atrial fibrillation (odds ratio [OR] 1.885, 95% confidence interval [CI] 1.084-3.276, p = 0.025) and prolonged procedure time (per minute; OR 1.007, 95% CI 1.001-1.013, p = 0.017) as independent predictors of periprocedural complications.

Conclusion: Atrial fibrillation and longer procedure time were independently associated with periprocedural complications. Perforator injury and hemorrhagic transformation were major contributors to adverse events, with symptomatic intracranial hemorrhage leading to severe disability or death in most affected patients.

Objective: Treatment with flow diverters requires follow-up imaging. Conventional CT suffers from beam-hardening artifacts caused by the stent, complicating the evaluation. This study introduced the SOMATOM X.cite (Siemens Healthineers, Forchheim, Germany) scanner to improve imaging quality for stent follow-up and examined its image output (stent condition).

Methods: From January 2021 to April 2024, 27 patients treated with flow diverters were imaged using SOMATOM X.cite, conventional CT, and the ARTIS icono D-Spin system (Siemens Healthineers). The aneurysm locations included the internal carotid artery-specifically, 11 cases in the paraclinoid segment and 8 in the cavernous segment, as well as the vertebral artery in 8 patients. The aneurysm sizes were ≥10 mm (14 cases) and 5-10 mm (13 cases). The image quality of the stented parent artery was subjectively scored on a 2-point scale, adapted from a previous report in which a 3-point scale had originally been used, as follows: 1 = moderate (evaluation could be made but information was lacking compared with DSA), and 2 = good (image could be evaluated similarly to DSA).

Results: Compared with conventional contrast-enhanced CT, the SOMATOM X.cite significantly reduced beam-hardening artifacts around the stent. In 26 of 27 cases, stent-condition CT images acquired with the SOMATOM X.cite were rated as 2 (good), providing clear visualization of the stent lumen and similar in quality to cone-beam CT. One case had reduced contrast, making aneurysm visualization difficult. In comparison, 27 conventional CT images were rated 1 (moderate).

Conclusion: The SOMATOM X.cite scanner provided high-quality imaging comparable to cone-beam CT; thus, it may be a useful tool for follow-up evaluation after flow diverter stenting.

Objective: Spinal arteriovenous shunt diseases in the sacral region are exceedingly rare and present unique challenges for endovascular access, particularly in patients with tortuous aortoiliac anatomy. While the transradial approach (TRA) is emerging as a less invasive alternative to transfemoral access, the left TRA with external upper-limb rotation may offer additional advantages for targeting sacral lesions.

Case presentation: We report a case of a 51-year-old woman presenting with progressive lower back pain, bilateral lower extremity weakness, and gait disturbance. Images revealed a perimedullary arteriovenous fistula (AVF) at the thoracolumbar level and an extradural AVF at the sacral region. After surgical treatment of the thoracolumbar lesion, the sacral extradural AVF was embolized using a left distal TRA, with the patient's left upper limb externally rotated by approximately 90°. A 6-Fr, 122-cm guiding sheath was advanced from the anatomical snuffbox into the right internal iliac artery, and the fistula was then accessed via the right lateral sacral artery using a microcatheter, followed by coil and liquid embolic agent deployment for complete occlusion.

Conclusion: The left TRA with external upper limb rotation represents a feasible, safe, and potentially advantageous technique for endovascular treatment of sacral vascular lesions, particularly in patients for whom transfemoral or right TRA are unsuitable.

Objective: Stent placement is sometimes used as a bailout strategy to preserve the parent vessel during coil embolization of cerebral aneurysms. However, in more challenging situations, a Y-stent configuration may be required, although its safety and efficacy remain uncertain, and no consensus has been established. This report describes a case in which Y-stent placement was used as a bailout strategy after coil deviation into the parent artery during endovascular treatment for a ruptured intracranial aneurysm.

Case presentation: A 41-year-old man presented to our hospital with the sudden onset of a severe headache. He was diagnosed with a subarachnoid hemorrhage caused by a ruptured wide-necked anterior communicating artery aneurysm and was transferred to our hospital for emergency coil embolization. During the procedure, the coil mass deviated from the parent artery, resulting in bilateral A2 occlusion. To restore blood flow, a bailout Y-stent technique was performed. Following antiplatelet loading, a Neuroform Atlas stent (Stryker, Kalamazoo, MI, USA) was deployed from the right A2 to A1, and this was followed by a 2nd Neuroform Atlas stent from the left A2 to A1, forming a Y configuration. Subsequently, sedation management was administered. Three days later, additional coil embolization was performed to achieve complete aneurysm occlusion. The patient recovered without neurological deficits, and dual antiplatelet therapy was gradually tapered. Follow-up cerebral angiography at 2 years confirmed complete aneurysm occlusion.

Conclusion: The Y-stent technique served as an effective bailout strategy for coil deviation in the wide-necked aneurysm, demonstrating favorable long-term outcomes. This case suggests that the Y-stent technique can provide a viable option for managing wide-necked aneurysms when coil deviation occurs.

Preoperative embolization of tentorial and subtentorial tumors represents a valuable adjunct to skull base surgery. Tentorial tumor resection can be challenging. However, brain tumors in the tentorial regions have a relatively complex angioarchitecture, and only a few studies have reported the safety and effectiveness of preoperative embolization for these tumors. This review examined the technical considerations and outcomes of 29 consecutive preoperative embolization procedures for tentorial tumors performed at our institution between September 2020 and August 2025. Tentorial tumors present unique challenges owing to their deep location, narrow surgical corridors, and complex angioarchitecture. The goal of embolization is to achieve tumor necrosis, as evidenced by the disappearance of contrast enhancement on postembolization MRI, which makes the tumor softer and less vascular during subsequent resection. We detail the technical approaches for embolization from the 3 main feeder categories: medial feeders (meningohypophyseal trunk [MHT] and inferolateral trunk [ILT]), lateral feeders (middle meningeal and occipital arteries), and inferior feeders (ascending pharyngeal artery [APA]). Technical success was achieved in 96.6% of cases (28/29), with embolization from the MHT or ILT in 53.6% of cases and APA in 21.4%. Multiple feeders were targeted in 46.6% of the cases. N-butyl cyanoacrylate was the predominant embolic agent (85.7%), followed by coils (39.3%) and particles (35.7%). Post-embolization neurological complications occurred in 2 cases (7.1%), both involving cranial nerve palsies. At least partial tumor necrosis was achieved in 60.7% of the cases, with complete disappearance of contrast enhancement in 10.7%. Our experience demonstrates that preoperative embolization of tentorial tumors can be performed effectively with acceptable risks in the context of highly complex procedures. When performed with appropriate technical expertise and detailed knowledge of functional vascular anatomy, it provides substantial benefits for subsequent surgical resection.

Objective: Accurate localization of thrombi in middle cerebral artery (M2) segment occlusions remains technically challenging but is essential for successful mechanical thrombectomy. We report a novel visualization technique that uses the aspiration catheter system itself to delineate the thrombus, thereby minimizing the risks associated with conventional microcatheter-based contrast injections.

Case presentation: An 81-year-old woman presented with acute ischemic stroke caused by an occlusion of the left M2 inferior trunk. Aspiration thrombectomy was performed using the described visualization technique. After positioning the aspiration catheter proximal to the thrombus, the inner microcatheter and guidewire were withdrawn, and contrast medium was gently injected at low pressure through the intermediate catheter. This approach produced a stagnant contrast column that clearly outlined the proximal surface of the clot as a meniscus sign, confirming direct catheter-thrombus contact. Complete reperfusion (thrombolysis in cerebral infarctions grade 3) was achieved after 2 aspiration passes, with no procedural complications observed.

Conclusion: This novel technique offers a simple, safe, and effective method for direct thrombus visualization in M2 occlusions. By utilizing the intermediate catheter for controlled, low-pressure contrast injection, it may reduce the risk of distal embolization and simplifies the procedural workflow, potentially enhancing the rate of 1st-pass recanalization success. This technical note introduces the concept and provides preliminary evidence supporting further investigation and validation in larger patient cohorts.

Objective: Insertion of a guiding catheter (GC) system into the desired arterial site is crucial in mechanical thrombectomy (MT). This study assessed the factors of difficult GC access to the target carotid artery in patients with acute ischemic stroke in the anterior circulation.

Methods: In total, 174 patients who had undergone MT were retrospectively reviewed. The incidence of patients who could not undergo GC insertion to the target carotid artery, as well as the characteristics and outcomes of patients requiring a longer groin puncture-to-GC insertion time, were examined. The patients were divided into 3 groups based on the time from groin puncture to insertion into the target carotid artery: group A, within 10 min; group B, within 10-20 min; and group C, >20 min. In this study, the transfemoral catheter access was the primary option, and the approach site was changed based on the operator's discretion. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction grade ≥2B. A favorable outcome was defined as a modified Rankin Scale score of 0-2.

Results: Catheterization of the target carotid artery could not be performed in 8 (4.6%) patients, who were older and more likely to be female. The proportion of patients with a height ≤150 cm and the percentage of patients with a type III arch and/or tortuous common carotid artery (CCA) were high. The approach was changed in 4 (2.3%) patients, and GC insertion was successful in all cases. A significant difference was observed among the 3 groups in terms of age and the percentage of patients with a type III arch and/or CCA tortuosity and internal carotid artery occlusion. In addition, the time from groin puncture to recanalization significantly differed. The recanalization rate and the 90-day favorable outcome rate were significantly lower in patients with a groin puncture-to-GC insertion time >20 min.

Conclusion: We need to make an effort to insert the GC within 20 min while actively considering changes in the approach, particularly in older patients and those with a type III arch and/or tortuous CCA.

Brain arteriovenous malformations (bAVMs) are associated with a high risk of intracerebral hemorrhage, which causes severe complications in patients. Although the genetic factors leading to hereditary bAVMs have been extensively investigated, their pathogenesis are still under study. This review examines updated data on the molecular and genetic aspects of bAVMs, the architecture of microvasculature, the roles of angiogenic factors, and signaling pathways. The compiled information may help us understand the pathogenesis of both sporadic and hereditary bAVMs and develop appropriate preemptive treatment approaches.

The sphenoid wing dural arteriovenous fistulas (DAVFs) are clinically rare. They often present as non-sinus-type arteriovenous fistulas (AVFs) and may be associated with focal neurological deficits, intracranial venous hypertension, and intracranial hemorrhage. These cases are classified as lesser or greater sphenoid wing lesions. We searched the PubMed databases for studies evaluating the clinical presentation, surgical treatment, and endovascular treatment of these lesions and analyzed 37 cases from 22 papers. A total of 17 cases had lesser sphenoid wing AVFs, and the localization of the shunts could be divided into the sinus of the lesser sphenoid wing (SLSW) or the superficial middle cerebral vein (SMCV). Most SLSW AVFs drained into the cavernous sinus, but two cases drained directly into the deep middle cerebral vein via a bridging vein. All cases with shunts directly into the SMCV had reflux into the SMCV with varices. A total of 20 cases had shunts in the greater sphenoid wing, and the localization of the shunts varied, with shunt localization, and venous return morphology dependent on variations in middle fossa venous return. Most cases had shunts in the sphenobasal vein near the foramen ovale. However, some cases had shunts in the superior ophthalmic vein, sphenopetrosal vein, and laterocavernous sinus. Many were associated with cortical venous reflux. These lesions have been treated by surgical ligation of the drainage vein and transarterial or transvenous embolization. Recently, embolization has become the standard treatment for DAVFs due to advances in endovascular techniques. This paper reviewed and discussed the angioarchitecture, clinical presentation, and treatment of these lesions to clarify the characteristics of sphenoid wing DAVFs.