Journal of neuroendovascular therapy最新文献

Objective: This study aimed to simulate patient transportation to a mechanical thrombectomy (MT)-capable hospital within 60 minutes, taking into account patient volume (demand side of healthcare) and hospital capacity to accept patients (supply side of healthcare).

Methods: Simulations were conducted in Hyogo Prefecture, Japan. The estimates of the annual number of patients with stroke eligible for MT in 2020 were based on the incidence of stroke by age group and the percentage of patients with stroke indicated for MT in existing publications. Patients were then randomly placed on a 1 km² mesh map. The patients were randomly generated 100 times using R software (version 4.1.2; R Foundation for Statistical Computing, Vienna, Austria). Hospitals were selected based on 2 criteria: (1) actual provision patterns (39 hospitals) and (2) consolidated patterns (12 hospitals). Simulations were performed using ArcGIS Pro (version 10.8; Esri, Redlands, CA, USA) and Network Analyst extension (Esri) in 3 cases: (1) number of patients estimated from the population in 2020 transported to hospitals that provided MT, (2) number of patients estimated based on the 2020 population transported to selected hospitals in the case of consolidation, and (3) number of patients estimated based on 2040's projected population and transportation to the selected hospitals.

Results: In Case 1, the estimated annual number of patients undergoing MT in 2020 was 976. The average number of patients undergoing MT and transported was 961, indicating that 98% (961/976) of the total generated patients could be transported within 60 min. In Case 2, the average number of patients undergoing MT and transported was 940, indicating that 96.3% (940/976) of the total patients could be transported within 60 min. In Case 3, the average number of patients undergoing MT and transported was 1184, showing that 95.1% (1184/1244) of the total generated patients could be transported within 60 min. A few patients in rural areas and remote islands required longer transport times.

Conclusion: The simulations showed that patient estimates from the incidence of cerebral infarction by age group and the percentage of patients with stroke indicated for MT were similar to the actual values. The simulation was closed to reality when both the supply and demand sides of healthcare were considered. Thus, this simulation study informs future healthcare policy by demonstrating the geographic distribution of human and capital resources and potential cost reduction through consolidation, taking into account demographic changes.

Objective: An intraosseous arteriovenous fistula (AVF) is a rare fistula with an intracranial shunted pouch. A case of an intraosseous AVF at the squamous part of the occipital bone with spontaneous occlusion of diploic venous drainage is described.

Case presentation: The patient, a Japanese woman in her 80s, presented with headaches at the back of the head and a history of multiple unruptured cerebral aneurysms but no recent head trauma. MRA showed abnormal signals in the occipital diploic region, and DSA showed an intraosseous AVF with a shunted pouch in the squamous part of the occipital bone near the inion. This was not seen on MRA 6 months earlier. One month later, follow-up examinations showed spontaneous occlusion of the diploic venous drainage, leading to a change in retrograde drainage into the superior sagittal sinus. Transvenous coil embolization was performed, and the shunted pouch was completely occluded. Postoperatively, the patient's symptoms resolved, and subsequent follow-ups showed no recurrence of the AVF.

Conclusion: This case suggested that the vascular architecture of intraosseous AVFs might change over a short period. Transvenous embolization was effective in obliterating the intraosseous shunted pouch.

Objective: Flow diverters (FDs), first introduced in Japan in 2015, were initially limited to wide-necked large cerebral aneurysms, which pose a high treatment risk. However, based on the results of the PREMIER study, the indications have expanded since 2020, and the number of treatment cases is increasing in Japan. At our hospital, FD placement with adjunctive coil embolization has been actively performed for medium-sized cerebral aneurysms, as indicated in the PREMIER study; herein, we report the outcomes of this treatment.

Methods: Of the 25 patients with 28 aneurysms who underwent FD placement at our institution between April 2022 and June 2023, 15 with 17 wide-necked unruptured cerebral aneurysms with a maximum diameter of <12 mm in the internal carotid artery (ICA) or vertebral artery (VA) were included. Postoperative complications were investigated in each case, and the aneurysm occlusion status was assessed using ultrashort echo time (UTE)-MRA at 3 months postoperatively and angiography at 6 months postoperatively. Fifteen patients who underwent coiling or stent-assisted coiling (SAC) for the same criteria during the same period were compared. Baseline characteristics and treatment results were compared between FD and coiling/SAC cases.

Results: Four males and 11 females with a mean age of 61.7 ± 12.8 years were included, and the median follow-up period was 9 months (6-18 months). There were 14 aneurysms of the ICA and 3 of the VA, and the mean maximum aneurysm diameter was 7.9 ± 1.7 mm. All patients were treated using the Pipeline Flex with Shield Technology (Medtronic, Minneapolis, MN, USA), and 14 aneurysms (82.4%) were treated with adjunctive coil embolization. There were no symptomatic strokes in the perioperative period; only one patient receiving corticosteroid therapy for thyroid eye disease had asymptomatic ICA occlusion at 3 months. Fifteen aneurysms (88.2%) were not visible on UTE-MRA at 3 months postoperatively, and angiography at 6 months showed complete occlusion in 16 (94.1%) aneurysms. The coiling/SAC group had a smaller neck size and higher volume embolization ratio than the FD group; however, complete occlusion was higher in the FD group.

Conclusion: FD placement with adjunctive coil embolization for medium-sized cerebral aneurysms is expected to result in good occlusion rates in the early postoperative period.

Objective: Carotid artery stenting embolic protection devices offer various options, among which distal filter protection is the simplest and easiest to handle. However, compared to balloon protection systems, distal filter protection has more embolic complications. Therefore, we explored the risk factors of distal filter protection, intending to achieve a safer carotid artery stenting. This retrospective study was conducted to identify prognostic factors following carotid artery stenting with only distal filter protection from July 2010 to June 2021.

Methods: Information on patient background, procedures and devices, and complications was collected using medical records. The data pertaining to 187 patients were analyzed after excluding the data of patients in whom other protection devices (8 cases) were used. We used FilterWire EZ as the first choice for embolic protection device and SpiderFX when the patients had difficult-to-cross lesions.

Results: The patients' mean age was 71.9 ± 6.9 years, and 72 (38.5%) were symptomatic. Symptomatic (odds ratio: 2.02, p = 0.035) and difficult-to-cross lesions (odds ratio: 3.63, p = 0.0013) were factors independently associated with symptomatic complications.

Conclusion: This retrospective single-center study established independent prognostic factors for carotid artery stenting with distal filter protection. For patients with symptomatic lesions and severe stenosis or bends that are difficult to pass through, it is necessary to be careful when performing carotid artery stenting with distal filter protection.

Objective: Catastrophic antiphospholipid syndrome (CAPS) is a disease characterized by a poor prognosis and a high mortality rate, leading to systemic thrombosis. Approximately two-thirds of CAPS cases are associated with conditions such as infections, malignancies, surgical interventions, and events linked to the disease activity of systemic lupus erythematosus (SLE). Herein, we present a case of CAPS with multiorgan ischemia following ischemic stroke.

Case presentation: In this case report, a 33-year-old woman with a history of SLE and prolonged steroid use manifested impaired consciousness. Detection of the right internal carotid artery (ICA) occlusion led to successful ICA recanalization through endovascular thrombectomy. Postoperatively, she experienced pulmonary embolism and renal infarction. Although antiphospholipid syndrome (APS) was suspected, APS-related antibodies were negative. Anticoagulation therapy was initiated, presuming corticosteroid-induced thrombosis. However, she developed multiorgan thrombosis, culminating in multiple organ failure. Based on her clinical course, a diagnosis of CAPS was established. Intensive care and plasma exchange therapy were instrumental in her recovery, and she was discharged with a modified Rankin Scale score of 4.

Conclusion: When encountering multiorgan ischemia following ischemic stroke in a young adult patient with an autoimmune disease, the consideration of CAPS as a differential diagnosis is crucial, even if APS-related antibodies test negative.

Objective: Early intervention with mechanical thrombectomy (MT) is expected to improve the functional outcome in patients with large vessel occlusion (LVO); however, a method for the effective detection of these patients in a prehospital setting and early transport to MT-capable hospitals has not been established. This study aimed to analyze the clinical impact and diagnostic performance of the emergent large vessel occlusion (ELVO) screen and its influence on the transportation time.

Methods: The emergency medical services (EMS) in one of the secondary medical areas in Akita, Japan, introduced a prehospital triage system employing an ELVO screen and a rotation system of three MT-capable hospitals on December 1, 2021. Patients who were transferred to each of the three hospitals involved in the rotation system according to a predefined priority list from December 2021 to November 2022 were included in the triage group. Patients who underwent MT in the three hospitals before the introduction of the triage system were assigned to the pre-triage group. We compared the transportation time parameters between the two groups and analyzed the performance of the ELVO screen for the diagnosis of LVOs. This study was approved by the institutional review boards of all three hospitals.

Results: Time parameters were compared between the 37 and 42 patients who underwent MT and had detailed data in the triage (n = 351) and pre-triage (n = 43) groups, respectively. The time from door to puncture tended to decrease in the triage group in all hospitals, with one hospital showing a statistically significant shortening of 14 min (p = 0.018). In the triage group, 209 ELVO screen-positive patients were present, with 60 (28.7%) of these having LVO. The sensitivity, specificity, positive and negative predictive values, and area under the curve of the ELVO screen to detect LVO under the present triage system were 87.0%, 47.2%, 28.7%, 93.7%, and 0.671, respectively.

Conclusion: The present study demonstrated that the introduction of a triage system may have shortened the time required for MT. ELVO screen may be considered a useful marker for screening LVO in prehospital settings in terms of the sensitivity and negative predictive value; however, further improvement may be necessary to reduce the rate of false positive results.

Objective: We describe two cases of myelopathy onset due to intracranial dural arteriovenous fistulas (DAVFs) and present a literature review.

Case presentation: (Case 1) A 44-year-old man with subacute onset myelopathy underwent an MRI and DSA. MRI showed T2-hyperintensity from the medulla oblongata to the cervical spinal cord with vascular flow voids, suggestive of a spinal DAVF. Unexpectedly, cerebral angiography revealed a tentorial DAVF. (Case 2) A 47-year-old man with progressive myelopathy underwent a head and spinal MRI. Head MRI and MRA were considered to be normal. Spinal MRI revealed T2-hyperintensity in the cervical spinal cord without obvious vascular flow voids around the spinal cord. Contrast-enhanced MRI showed a patchy gadolinium enhancement in the same spinal cord region with the enhancement of perimedullary vessels. Although myelitis was initially suspected, subsequently spinal DAVF was suspected because cervical CTA revealed abnormal spinal venous drainage. Unexpectedly, cerebral angiography identified a foramen magnum DAVF.

Conclusion: Regarding unexplained cervical myelopathy, even the absence of spinal cord surface vascular flow voids cannot necessarily exclude venous congestive myelopathy due to the DAVFs. In such cases, the contrast-enhanced MRI and cervical CTA are useful for visualizing abnormal vessels around the brain stem and the cervical spine. Especially, the co-presence of the abnormal vessels around the brain stem can suggest the intracranial DAVFs. Not only spinal DAVFs but also intracranial DAVFs should be considered as the differential diagnoses for venous congestive cervical myelopathy, in which cases cerebral angiography including carotid angiography is essential.

Objective: Infection after carotid artery stenting (CAS) is rare. We report two dialysis cases of delayed stent infection associated with a carotid dual-layer stent (DLS), which occurred several months after deployment of the stent.

Case presentations: Case 1: A 74-year-old man receiving dialysis underwent CAS with DLS. Three months after CAS, the patient developed a high fever, neck pain, and neck swelling. Neck CT and carotid ultrasonography (CUS) indicated an abscess around the inserted DLS. The patient was treated with antibiotic agents and fully recovered. Case 2: A 73-year-old man receiving dialysis underwent CAS with DLS. Two months after CAS, this patient also developed a high fever, neck pain, and neck swelling. Contrast-enhanced neck CT indicated inflammatory effusion with an abscess and a giant infectious pseudoaneurysm. Endovascular stent graft reconstruction was employed urgently under antibiotic therapy to prevent its rupture. However, intracranial hemorrhage occurred postoperatively and left hemiparesis remained.

Conclusion: Delayed carotid stent infection is a rare but severe complication. The use of a DLS might be avoided during CAS for dialysis cases.

Objective: The angiography systems A (A) and B (B), both incorporated at our hospital, are equipped with metal artifact reduction (MAR) applications. In clinical practice, it is crucial to understand the characteristics of MAR in both systems given that endovascular treatments are occasionally administered with both. In this study, we compared the artifact reduction effects of MAR on equipment A and B and clarified the differences between the two systems.

Methods: An artifact evaluation phantom was created using a cylindrical water phantom and an iodine contrast medium. The phantom was imaged, MAR processing was performed on the obtained images, and an isotropic quantitative evaluation of artifacts was performed by extreme value statistical analysis using the Gumbel distribution.

Results: The MAR reduction effects were approximately 45% and 40% for equipment A and B at concentrations of 8300 and 6000, respectively. The MAR reduction effect in both devices exhibited different trends depending on the concentration.

Conclusion: In clinical procedures that make use of absorbents in medium concentrations of approximately 3000-5000, such as n-butyl-2-cyanoacrylate and Onyx, it is necessary to understand the MAR characteristics of both devices and consider the use of alternative devices as an option.