Journal of neuroendovascular therapy最新文献

In recent years, artificial intelligence (AI) has made remarkable progress. In the near future, AI will become an indispensable technology in daily clinical practice in the field of neuroendovascular therapy. Clinicians who understand the information processing and limitations of AI will create new and comfortable working styles. This article introduces current applications of AI in the field of neuroendovascular therapy and presents a vision for its future directions.

Objective: Bridging veins adjacent to the jugular foramen (JF-BVs) are rare drainage pathways in dural arteriovenous fistulas (DAVFs). We report a unique case of a transverse-sigmoid sinus DAVF (TS-DAVF) with retrograde venous drainage via a JF-BV, successfully treated with selective transvenous coil embolization.

Case presentation: A man in his 60s presented with a 2-month history of right-sided pulsatile tinnitus. Cerebral angiography revealed a high-grade TS-DAVF supplied by branches of the external carotid and vertebral arteries. Venous drainage involved a compartmentalized portion of the sigmoid sinus that drained into a JF-BV, continuing through the retrotonsillar and inferior vermian veins to the confluence of sinuses. Additional reflux occurred via the ipsilateral and contralateral TSs, the superior petrosal sinus, and cortical veins through the vein of Labbé. The right internal jugular vein was occluded at the cervical level. A transvenous approach via the contralateral jugular vein allowed catheter navigation via a compartmentalized portion of the jugular bulb separated by trabecular septations to reach the JF-BV. After superselective angiography confirmed its course, coil embolization was performed from the lateral medullary vein junction back to the sinus. Shunt flow was completely occluded while preserving normal cortical venous drainage. The patient's tinnitus resolved without neurological deficits.

Conclusion: To the best of our knowledge, this is the first reported case of selective transvenous coil embolization of a JF-BV draining a TS-DAVF. Preprocedural imaging with selective angiography and a multi-catheter system enabled safe and effective treatment. Selective JF-BV embolization may represent a viable therapeutic option for DAVFs with catheter-navigable compartments.

Objective: Two mechanical thrombectomy techniques are proposed for tandem occlusion of the anterior circulation: treating the extracranial carotid artery lesion first via an antegrade approach and treating the intracranial lesion first via a retrograde approach. Previous reports show that the retrograde approach has a shorter reperfusion time and a better prognosis, but re-occlusion of the intracranial lesion after recanalization may occur. We describe a case of tandem occlusion with repeated intracranial occlusions for mechanical thrombectomy using the retrograde approach and discuss possible countermeasures.

Case presentation: A 94-year-old woman presented with acute cerebral ischemia due to tandem carotid T occlusion of the left internal carotid artery (ICA) and severe stenosis of the cervical carotid artery. Mechanical thrombectomy via a retrograde approach was performed using a stent retriever, resulting in complete recanalization of the anterior circulation through the ICA after 1 pass. The thrombus dispersed distally from the cervical artery and re-occluded the M1 twice, requiring thrombus re-retrieval each time.

Conclusion: The retrograde approach to tandem occlusion can result in repeated re-occlusion after recanalization of the intracranial lesion. Thrombi in cervical carotid lesions are usually fragile. Prior thrombus aspiration from the balloon guiding catheter at the carotid lesion may prevent re-occlusion after recanalization of the intracranial lesion without sacrificing the time advantage of early recanalization via the retrograde approach.

Objective: Not many reports of subclavian artery occlusion complicated by vertebrobasilar junction aneurysm have been published, and no cases have been treated using a distal radial approach. Our case report highlights the effectiveness of this approach in comparison to previous findings.

Case presentation: An 82-year-old woman was referred to our hospital because of an enlarged vertebrobasilar junction aneurysm. The DSA and CTA results revealed a left subclavian artery occlusion, meandering of the descending aorta, and an aneurysm of the descending aorta. We performed coil embolization using the right radial and left distal radial artery approaches. Considering that the left subclavian artery occlusion was related to the aneurysm enlargement, we decided to perform left subclavian artery stenting. Left subclavian artery stenting was performed 1 month after coil embolization using the same approach. The patient was discharged on postoperative day 8 without complications.

Conclusion: Vertebrobasilar junction aneurysm and subclavian artery occlusion were treated via a safe and minimally invasive approach through the right radial and left distal radial artery approaches.

Objective: Complications in neuroendovascular therapy for cerebral aneurysm (AN) affect the clinical course of patients. Patient conditions, operating procedures, and operator expertise were highlighted as risk factors for complications. These risk factors often combine and constitute particularly strong risks, resulting in a worsened clinical course. In this study, we performed a multifactorial assessment of complication risks in neuroendovascular therapy.

Methods: We analyzed patient data from the Japanese Registry of NeuroEndovascular Therapy 3, which is a nationwide retrospective cohort study of neuroendovascular procedures conducted between 2010 and 2014. Patients who underwent coil embolization for a ruptured anterior communicating artery (Acom) AN, an internal carotid artery-posterior communicating artery (IC-PC) AN, or basilar artery bifurcation (BA-bif) AN were included in this analysis. Information on 16 explanatory variables and 1 objective variable for each patient was obtained from the dataset as nominal variables. The explanatory variables consisted of patient factors, procedural factors, and an operator factor. The objective variable was whether the following complications occurred: intraprocedural bleeding, postprocedural bleeding, and procedure-related infarction. The specific situations involving multiple risk factors associated with high complication rates were identified using a programmed method. The impact of the absence of a supervising physician was also assessed.

Results: A total of 2971 patients were analyzed. The complication rates for patients with Acom ANs, IC-PC ANs, and BA-bif ANs were 12.9%, 10.2%, and 13.7%, respectively. A total of 15 specific situations were identified as follows: 3 related to an Acom AN, with complication rates ranging from 19.3% to 20.3%; 4 related to an IC-PC AN, with complication rates ranging from 15.6% to 17.9%; and 8 related to a BA-bif AN, with complication rates ranging from 20.6% to 33.3%. In 4 of these situations, the absence of a supervising physician significantly impacted complication rates. For instance, the complication rate for patients with IC-PC AN treated under local anesthesia was 16.0% overall, but it was 23.8% without supervising physicians.

Conclusion: Multifactorial assessment based on patient, procedural, and operator factors provides more reliable risk estimations and will help improve the clinical course.

Objective: Mechanical thrombectomy (MT) is an important procedure in the treatment of acute cerebral infarction, and its effectiveness depends largely on timely intervention after the onset. In the United States, a tiered accreditation system of stoke centers has been established to provide MT efficiently. In Japan, however, despite the large number of medical institutions performing MT, the establishment of a tiered accreditation system has yet to be seen. The low number of cases treated per institution raises concerns about the economic sustainability of MT in Japan because significant capital and human resource investment are required. This study aims to investigate the cost structure of MT procedure and the break-even point in 2 different hospital settings in Japan.

Methods: We conducted a detailed cost analysis of MT at 2 distinct hospitals: Hospital A, a large public hospital in a government-designated city, and Hospital B, a private non-profit hospital in the Tokyo metropolitan area. Data collection involved face-to-face interviews with department heads and a structured survey based on the Japanese Hospital Accounting Standards, focusing on material, labor, and facility-related costs. Break-even points were calculated considering both fixed and variable costs, with adjustments made for the shared use of facilities in Hospital B.

Results: The total cost per case was 349256 yen in Hospital A and 245150 yen in Hospital B, respectively. The total cost per case was elevated to 559866 yen assuming only MT was performed at Hospital B. This figure was significantly higher than the reimbursement price of MT (331500 yen). The number of procedures needed to exceed the break-even point for MT was approximately 290 cases per year in Hospital A and 125 cases per year in Hospital B, respectively.

Conclusion: We conducted a break-even analysis of MT based on an interview survey. The number of cases required to cross the break-even point for MT alone was much higher than the actual number of MT procedures being performed in the 2 hospitals.

Clinical applications of telemedicine using digital technology are in demand in Japan and continue to expand. However, with some exceptions, it would be difficult to say that the current situation is adequate in terms of encouraging research and development, formulating guidelines that need to be established before telemedicine can spread, and providing support programs for these activities. The "Telestroke" telemedicine system for the treatment of stroke has been adopted in other countries due to the early establishment of a medical device program compatible with guidelines and the steady accumulation of evidence, creating a situation that leads the world. With optimization of the support program from the perspective of strategically produced evidence by governments and related organizations, and by taking these results as model cases for other regions, telemedicine in Japan is thought to progress to a new stage.

Objective: We report a case in which coil embolization was performed for an angiographically occult ruptured anterior communicating artery aneurysm (Acom AN).

Case presentation: A 91-year-old man was admitted to our hospital because of sudden deterioration of consciousness. Computed tomography (CT) revealed a diffuse subarachnoid hemorrhage in the basal cisterns, and CT angiography identified a 5-mm Acom AN. The next day, a catheter angiogram slightly visualized the neck portion of the Acom AN, despite no apparent visualization of the aneurysmal sac. We suspected intraluminal thrombosis of ruptured Acom AN, and intraaneurysmal coil embolization was performed to prevent re-rupture. By referring to the size and projection of the aneurysmal sac on CT angiography, a microcatheter was guided into the neck portion, and 3 platinum coils were successfully placed within the aneurysm without any complications. Eight days after coil embolization, recanalization of the aneurysm was suspected on magnetic resonance imaging (MRI). Another MRI obtained 17 days after coil embolization revealed gradual recanalization of the aneurysm, which was confirmed on catheter angiogram obtained 22 days after coil embolization. Additional intraaneurysmal coil embolization resulted in complete occlusion. Subsequently, the patient had an uneventful course without rebleeding and was transferred to a rehabilitation center.

Conclusion: We performed intraaneurysmal coil embolization for an angiographically occult ruptured Acom AN by referencing the neck position, aneurysm projection, and aneurysm size on CT angiography. Thus, angiographically occult aneurysms can be treated with endovascular coil embolization despite the need for close follow-up studies to detect recanalization.

Objective: Artificial intelligence (AI) holds promise for advancing neuroendovascular therapy through device evaluation, but its application in real-world clinical settings remains limited. We aimed to validate the feasibility of AI-based quantitative device evaluation during actual procedures by assessing the stability of the Rist radial access guide catheter (Medtronic, Dublin, Ireland), a novel device designed for the increasingly adopted transradial approach (TRA), during flow diverter stent (FDS) placement.

Methods: We retrospectively analyzed 4 cases of FDS placement using Rist via the TRA. Rist was tracked in recorded fluoroscopic videos using the AI technology of Neuro-Vascular Assist (iMed Technologies, Tokyo, Japan). The movement distance of Rist during FDS placement was calculated as a stability indicator.

Results: All procedures were successfully completed without any complications. Rist was introduced from the radial artery and positioned in the distal internal carotid artery. The maximum movement distances of the Rist during the procedures were 3.36, 6.63, 1.79, and 0.33 mm for each case, respectively, with an average of 3.03 mm. The maximum movement distances per minute were 1.68, 2.34, 1.19, and 0.46 mm/min, respectively, with a mean of 1.42 mm/min. These measurements suggest sufficient stability for the FDS procedures.

Conclusion: This study demonstrates the feasibility of using AI technology to quantitatively analyze Rist stability in TRA procedures. To the best of our knowledge, this is the 1st clinical evaluation of device function in a clinical setting using AI technology. Further studies with more cases are required to validate these findings. This method is promising for real-world device evaluation and development.

Objective: The optimal treatment strategy for large-vessel occlusion (LVO) related to intracranial atherosclerotic disease (ICAD), particularly for tandem lesions that complicate access and device delivery, remains unclear. We report a case in which angioplasty with a stent retriever (SR) and combined antithrombotic therapy was effective in treating re-occlusion associated with dissection of the residual stenosis after thrombectomy for acute atherosclerotic occlusion of the basilar artery (BA) with the left vertebral artery (VA) stenosis.

Case presentation: An 80-year-old woman was brought to our hospital with progressively worsening consciousness and tetra-paresis. MRA revealed occlusion of the middle to proximal portion of the BA. The patient underwent percutaneous transluminal angioplasty using a balloon catheter for severe stenosis at the origin of the left VA, followed by mechanical thrombectomy for the BA occlusion. While initial recanalization was achieved, residual stenosis in the proximal portion of the BA led to re-occlusion. An attempt at angioplasty with a balloon catheter failed to reach the stenotic segment due to stenosis and tortuosity of the left VA. Consequently, the SR was redeployed into the BA, and a loading dose of antiplatelet agents and intravenous anticoagulant were administered during prolonged deployment. Following the confirmation of BA patency, the SR was re-sheathed and removed. The patient achieved remarkable improvement in consciousness and tetra-paresis without postoperative re-occlusion of the BA.

Conclusion: Angioplasty with a SR and combined antithrombotic therapy may be a useful treatment option for ICAD-related LVO, particularly in cases such as tandem lesions that hinder access and make distal balloon catheter navigation challenging.