Journal of neuroendovascular therapy最新文献

Objective: Endovascular thrombectomy is widely performed for acute ischemic stroke due to proximal intracranial artery occlusion. The femoral artery is often selected for puncture. However, common carotid artery puncture may be considered in more challenging cases. When the internal carotid artery is occluded or obstructed by atherosclerosis, puncturing the distal internal carotid artery becomes necessary. This is rare and was reported in only 2 cases. We report here a case of endovascular thrombectomy using direct puncture of the internal carotid artery.

Case presentation: A 76-year-old male presented with sudden-onset right upper limb hemiparesis and mild dysarthria. Hospital admittance 1 hour later. Diffusion-weighted imaging (DWI) on head MRI revealed a hyperintense area in the left basal ganglia and corona radiata. MRA showed occlusion of the left internal carotid artery and the M2 segment of the left middle cerebral artery. Intravenous tissue plasminogen activator (tPA) was initiated, and endovascular thrombectomy was attempted. However, navigating the occluded left internal carotid artery was impossible. Symptomatic improvement was observed with tPA therapy causing recanalization of the M2 segment. Thus, further treatment was halted. Two days later, aphasia and complete right hemiparesis developed. MRA revealed no left anterior circulation flow. Under general anesthesia, an incision parallel to the left sternocleidomastoid muscle was made, and a direct puncture of the left internal carotid artery was performed to complete thrombectomy.

Conclusion: In difficult-to-access cases, especially when considering puncturing the cervical vessels, our report suggests that exposing the cervical vessels first can improve the hemostasis and puncture performance.

Objective: The global increase in methamphetamine abuse has increased the incidence of methamphetamine-associated cardiomyopathy (MACM), which is often complicated by left ventricular thrombosis and acute ischemic stroke. Here, we report a case of left internal carotid artery occlusion during acute heart failure treatment in a patient with MACM that led to mechanical thrombectomy.

Case presentation: A 54-year-old man with a history of approximately 30 years of methamphetamine abuse presented with dilated cardiomyopathy complicated by a left ventricular thrombus. On the night of admission for acute heart failure management, he experienced a sudden onset of consciousness disturbance, severe aphasia, and right hemiparesis. MRI revealed mild hyperintensities in the left cerebral hemisphere cortex and lenticular nucleus on diffusion-weighted imaging, with no abnormal signals on fluid-attenuated inversion recovery. He underwent mechanical thrombectomy, achieving complete reperfusion within 150 min; however, he experienced ipsilateral cerebral hyperemia that persisted for 30 days postoperatively. By the 90th postoperative day, moderate aphasia and mild paralysis of the right upper limb remained, with a modified Rankin Scale score of 3.

Conclusion: Left ventricular thrombosis is relatively common in patients with MACM, necessitating careful consideration of the risk of cardioembolic stroke.

Objective: Submucosal esophageal hematoma (SEH) is a rare complication of neuroendovascular therapy, and there are insufficient data on the management of antithrombotic therapy in cases of SEH. We report a case of SEH following flow diverter stenting for an unruptured cerebral aneurysm, successfully managed with conservative treatment, including short-term interruption of antiplatelet therapy.

Case presentation: An 80-year-old woman on clopidogrel and aspirin underwent Pipeline flow diversion with adjunctive coil embolization for an unruptured right internal carotid-posterior communicating artery aneurysm under general anesthesia without complications. Postoperatively, the patient developed chest pain, and CT revealed wall thickening from the middle to lower esophagus, leading to a diagnosis of SEH. SEH in this case was likely caused by a combination of antiplatelet therapy, anticoagulants, nasogastric tube insertion, and mechanical stimulation from intubation and extubation during the operation. The patient was managed conservatively with fasting and discontinuation of antiplatelet therapy. After CT confirmed hemostasis, antiplatelet therapy was resumed with intravenous ozagrel sodium on postoperative day 3, switching to oral prasugrel on day 7. Upper gastrointestinal endoscopy (UGE) on day 8 showed the submucosal hematoma replaced by ulcers and fistula formation. UGE on day 15 showed improvement, and CT on day 23 confirmed hematoma resolution. The patient was discharged on day 24 without symptoms or complications.

Conclusion: In addition to previously reported cases, the presented case suggests that conservative management with temporary antiplatelet interruption and early resumption after hemostasis can lead to favorable outcomes in SEH cases associated with neuroendovascular therapy requiring antiplatelet therapy.

Acute coronary syndrome (ACS) encompasses a spectrum of cardiovascular emergencies, including unstable angina and myocardial infarction, that require immediate and effective management to reduce morbidity and mortality. Antithrombotic therapy, including antiplatelet and anticoagulant medications, is fundamental in ACS management. We sought to organize the current status of antithrombotic management of ACS, including the concept of high bleeding risk (HBR), in line with the clinical diagnostic flow. ACS is an ever-changing condition; therefore, its diagnosis and treatment are conducted in parallel. While primarily a coronary artery disease, the diagnosis of ACS also includes conditions such as myocardial infarction with nonobstructive coronary arteries as a working diagnosis. This review collates the mechanisms and classification of ACS, showing the diagnostic flow and the antithrombotic agents used at each stage. It discusses strategies for dual antiplatelet therapy (DAPT) duration and de-escalation in patients undergoing percutaneous coronary intervention and addresses the management of patients requiring oral anticoagulation alongside antiplatelet therapy, highlighting the shift toward dual therapy to reduce bleeding risk. Antithrombotic agents are key treatments for ACS, with various available options. Their mechanisms and the approved dosing regimens differ regionally, especially between Japan and other countries. This review synthesizes the regional availability of each agent and compares the latest recommendations from Japanese and international guidelines for ACS management. The field of antithrombotic therapy in ACS is dynamic, influenced by the findings of ongoing clinical trials and emerging evidence. Key considerations include balancing antithrombotic benefits against bleeding risks, particularly in patients with HBR. Recent studies have explored shorter DAPT durations and novel antithrombotic agents, offering new insights for diverse patient populations. In this review, we provide a comprehensive comparison of guidelines and insights from the neuro-interventional field to assist clinicians in making informed decisions regarding ACS management. As ACS management evolves, continued international, cross-sectional collaboration and research are essential to refine guidelines and improve clinical practice.

Objective: Mirror image aneurysms located in the bilateral distal anterior cerebral arteries (ACAs) present significant technical challenges for both microsurgical and endovascular treatment due to their close proximity. To address these complexities, this technical note aims to describe a stepwise endovascular strategy for treating complex bilateral distal ACA kissing and mirror image aneurysms, highlighting key technical modifications such as preemptive bilateral stent deployment and selective microcatheter angiography.

Case presentation: A woman in her 60s presented with bilateral distal ACA mirror image aneurysms (right: 10 mm; left: 7 mm). Endovascular treatment was indicated due to their high-risk morphology and a family history of subarachnoid hemorrhage. To overcome anticipated challenges, a stepwise stent-assisted coil embolization strategy was employed. Key steps included preemptive bilateral Neuroform Atlas stent (Stryker, Kalamazoo, MI, USA) deployment validated by cone-beam CT before any coiling, and selective angiography via a microcatheter left in the proximal A2 segment to ensure clear visualization during coil embolization. The procedure was completed without complications, with no recurrence observed at 5-year follow-up.

Conclusion: The stepwise endovascular strategy, which incorporated preemptive bilateral stent deployment prior to any coiling and utilized selective angiography via microcatheter, enabled the safe and effective endovascular treatment of these complex bilateral distal ACA mirror image aneurysms. This technical strategy offers a practical reference for the endovascular management of similarly complex and anatomically constrained aneurysms.

Objective: We report 2 cases of ruptured intracranial dissecting aneurysms that were successfully treated with a flow diverter (FD) stent in the subacute phase, following urgent stent-assisted coiling (SAC) embolization.

Case presentation: Case 1: A 48-year-old male presented with a sudden-onset headache and altered consciousness. CT showed a diffuse subarachnoid hemorrhage (SAH). DSA revealed a right vertebral artery dissecting fusiform aneurysm (VADA). Considering that the perforating and anterior spinal arteries arose from the VADA, SAC was performed to preserve the perforating branch. Follow-up angiography revealed regrowth of the aneurysm without hemorrhage. Case 2: A 37-year-old male was involved in a car accident, followed by a sudden loss of consciousness. CT showed diffuse SAH, and DSA revealed a right internal carotid artery (ICA) blood blister-like aneurysm (BBA) on the anterior wall of the C2 portion. We performed SAC because of the difficulty in urgent high-flow bypass and trapping due to brain swelling. Follow-up angiography revealed regrowth of the aneurysm without hemorrhage. Each treatment involved SAC using the low-profile visualized intraluminal support (LVIS) stent (Terumo, Tokyo, Japan) and FD using the pipeline embolic device. The procedures were performed without complications.

Conclusion: To date, few studies on stepwise treatment with SAC and FD for refractory ruptured cerebral aneurysms, such as VADA and BBA of the ICA, have been reported. In addition to the cases reported, we also reviewed previous articles on treatment results, discussed antiplatelet therapy, and provided tips for the telescoping stent procedure.

Objective: A hyperplastic anterior choroidal artery (AchA) is a rare anomalous vessel that perfuses the posteromedial aspects of the cerebrum in place of the posterior cerebral artery. We describe 3 cases of hyperplastic AchA found among 61 patients with AchA aneurysms who underwent surgical or endovascular treatment at our institution.

Case presentation: All 3 cases were diagnosed as hyperplastic AchA type 2 according to the Takahashi classification, indicating an anomalous branching temporal artery perfusing the medial temporal lobe. We performed coil embolization for 2 cases and surgical clipping for the third. One embolization case experienced recurrence after 3 years and underwent clipping. All procedures were conducted without complications.

Conclusion: Hyperplastic AchA can be encountered during aneurysm treatment. These cases emphasize the importance of evaluating the vascular anatomy to determine the optimal treatment strategy.

Objective: Dural arteriovenous fistulas (dAVFs) in the paracavernous sinus of the sphenoid wing often present challenges for transvenous access because of their complex venous drainage patterns. Herein, we report the successful diagnosis and treatment of a greater sphenoid wing dAVF using a percutaneous transvenous approach via the Labbé vein.

Case presentation: A 48-year-old woman presented with tinnitus and was diagnosed with a greater sphenoid wing dAVF. The dAVF was fed by multiple meningeal arteries from the accessory meningeal artery. Shunted blood drained retrogradely into the superficial middle cerebral vein (SMCV) and bilateral inferior petrosal sinus (IPS) via the cavernous sinus (CS). Although communication was observed between the shunt pouch and the lateral part of the CS, the tortuous and narrow nature of this connection suggests difficulty in accessing the shunt pouch via the IPS. Conversely, the SMCV, which served as the primary outflow pathway, was adequately connected to the vein of Labbé with minimal difficulty, facilitating the passage of the microcatheter. The percutaneous transvenous approach via the Labbé vein successfully reached the SMCV and achieved complete obliteration with selective transvenous embolization (TVE) using coils. The symptoms of the patient improved postoperatively, and the patient was discharged without complications.

Conclusion: Greater sphenoid wing dAVFs often rely on the SMCV as the major drainage route, making venous approaches challenging. The route via the vein of Labbé through the cortical veins to reach the SMCV proved to be a valuable access route for TVE of greater sphenoid wing dAVFs.

Objective: Right aortic arch is a rare congenital anomaly. We report a case of mechanical thrombectomy for acute left medium-vessel occlusion due to a paradoxical embolism in a patient with a right aortic arch.

Case presentation: An 81-year-old woman presented with severe right-sided hemiparesis and aphasia. The National Institutes of Health Stroke Scale score was 16, MRI demonstrated a diffusion-weighted imaging Alberta Stroke Program Early CT score of 7, and MRA revealed left M2 occlusion. CTA revealed a right aortic arch with mirror image branching. Mechanical thrombectomy was conducted using the usual system, and effective recanalization was achieved with a stent retriever and aspiration catheter after 3 passes. CTA revealed pulmonary embolism and deep vein thrombosis (DVT) in the right deep femoral vein, and transesophageal echocardiography demonstrated a patent foramen ovale. Electrocardiography did not reveal atrial fibrillation, and other examinations did not reveal any other cause; therefore, a paradoxical cerebral embolism was diagnosed. After anticoagulant therapy, no recurrence of infarction, pulmonary embolism, or DVT was observed. Severe right hemiparesis and total aphasia did not improve, and the patient was discharged on day 37 after admission with a modified Rankin Scale score of 5.

Conclusion: Access to the left common carotid artery in right aortic arch cases can be anatomically challenging. Preoperative imaging evaluation of the access route is crucial for quick and safe mechanical thrombectomy.

Antithrombotic therapy plays a crucial role in secondary prevention following ischemic stroke from the acute phase. Numerous trials, along with a meta-analysis, contributed to establishing aspirin as the primary medication for secondary stroke prevention. According to the Cochrane Database of Systematic Review 2022, initiating antiplatelet therapy with aspirin at a dose of 160 mg to 300 mg daily within 48 hours of stroke onset reduces the risk of death or dependency at the end of follow-up. Other antiplatelet drugs, such as clopidogrel, cilostazol, prasugrel, and intravenous ozagrel sodium, are also available within the Japanese Health Care Insurance System. Two pivotal trials from the 2010s underscored the effectiveness and safety of dual antiplatelet therapy (DAPT) using aspirin and clopidogrel, administered for 21 days to 3 months following acute ischemic stroke or transient ischemic attack. However, the extension of DAPT with aspirin and clopidogrel beyond 3 months may result in substantial bleeding risks. Although prasugrel offers a rapid, potent, and consistent inhibition of platelet aggregation and can be used in place of clopidogrel, there is a lack of substantial real-world clinical data on its use in acute ischemic stroke. It is important to recognize that antiplatelet drugs might not be beneficial and could even increase the risk of hemorrhagic events in cardioembolic stroke. In cases of ischemic stroke with nonvalvular atrial fibrillation, direct oral anticoagulants are the primary choice if applicable. Warfarin continues to be the anticoagulant of choice for secondary stroke prevention in patients with mechanical valve replacements. In patients who have undergone intravenous thrombolysis, antithrombotic therapy is generally delayed for up to 24 hours, although there are no definitive guidelines for the period during and immediately after mechanical thrombectomy. This review provides an overview of the current status of antithrombotic therapy for acute ischemic stroke.