Journal of neuroendovascular therapy最新文献

Objective: LEONIS Mova high-flow type (SB-KAWASUMI LABORATORIES, Kanagawa, Japan) is a steerable microcatheter that enables angle adjustment of the catheter tip using a hand-operated dial, and available as a coaxial microcatheter system with a 1.6-F microcatheter. It was used to navigate an occluded inferior petrosal sinus (IPS) in a patient with cavernous sinus (CS) dural arteriovenous fistula (AVF).

Case presentation: A man in his 50s presenting with right eye congestion was diagnosed with dural AVF of the CS with bilateral occluded IPSs. The shunted pouch was located in the medial-lateral part of the right CS, with drainage into the superior ophthalmic vein. Transvenous embolization (TVE) from the femoral vein via the occluded IPS was performed. A 6-F guiding catheter was navigated to the right internal jugular vein, and LEONIS Mova high-flow type combined with a 1.6-F Carnelian MARVELS S microcatheter (Tokai Medical Products, Aichi, Japan) was navigated to the occluded IPS. The LEONIS Mova successfully engaged the IPS, and its tip was fixed by adjusting the curve. The microcatheter advanced smoothly into the right CS. After releasing the fixation of the LEONIS Mova, the microcatheter was advanced further into the CS, where the LEONIS Mova was once again fixed. The microcatheter was easily navigated to the shunted pouch, and targeted coil embolization of the shunted pouch, achieving complete occlusion of the dural AVF.

Conclusion: The LEONIS Mova steerable catheter offers flexible angle adjustment and strong support for catheter navigation within an occluded IPS during TVE for CS-dural AVF.

Objective: Contrast-induced encephalopathy (CIE) is a rare complication of endovascular procedures with an incompletely understood pathophysiology. Its intraoperative detection under general anesthesia can be challenging. We present a case of CIE occurring during aneurysm embolization, demonstrating varying severity across procedures and suggesting that somatosensory evoked potentials (SEPs) may help in early recognition.

Case presentation: A 63-year-old woman underwent endovascular coil embolization for a ruptured distal anterior cerebral artery aneurysm under general anesthesia, with intraoperative transcranial SEP monitoring. Contrast injection from the cervical internal carotid artery (ICA) during the procedure caused transient SEP attenuation, leading to mild post-procedural paresis and sensory impairment in the patient, both of which resolved within days. Six months later, DSA from the common carotid artery confirmed coil compaction. The patient underwent the examination and showed no signs of developing neurological symptoms. Repeat embolization was performed in the following month. During the 2nd procedure, contrast injection from the C1 segment of the ICA resulted in complete loss of left lower limb SEP. Immediately after the procedure, she exhibited mild left lower limb paresis and sensory impairment. Immediate postoperative cone-beam CT revealed contrast enhancement in the right hemisphere, leading to a diagnosis of CIE. On the following day, she developed left hemispatial neglect, along with worsening left hemiparesis and sensory impairment, despite no apparent abnormalities on MRI. The deficits improved with steroid therapy and were resolved by day 6.

Conclusion: Intraoperative SEP monitoring may be useful for the early detection of CIE during aneurysm embolization.

Objective: We report a patient with occlusion of the distal internal carotid artery (ICA), in whom angiography during mechanical thrombectomy revealed a shunt between the ICA and the cavernous sinus.

Case presentation: A 79-year-old man with bile duct cancer, a liver abscess, septic shock, and atrial fibrillation presented to our hospital with sudden disturbance of consciousness, conjugate eye deviation, and right hemiplegia. A cranial CT revealed a hyperdense middle cerebral artery (MCA) and loss of gray-white matter differentiation, suggesting large vessel occlusion. Endovascular therapy was immediately initiated. Left internal carotid angiography indicated occlusion of the distal ICA at the origin of the ophthalmic artery. Injection of contrast medium at a site just proximal to the ICA occlusion depicted the cavernous sinus and inferior petrosal sinus. We withdrew the aspiration catheter to the petrous segment of the ICA and injected contrast medium again. This time, however, neither the cavernous sinus nor the inferior petrosal sinus was visualized. We deployed a stent retriever at the occlusion site and successfully removed the thrombus. The final angiography showed complete recanalization of the affected arterial segment with no sign of a carotid cavernous fistula. The patient was finally discharged on day 73 after endovascular therapy with a cerebral infarction in the territory of the left MCA.

Conclusion: In the present case, angiographic visualization of the cavernous sinus varied depending on the site of contrast medium injection. It appears that the high pressure of the contrast medium generated in the stump of the ICA opened up microvascular shunts between the normal capillaries of the ICA and the cavernous sinus, leading to visualization of the cavernous sinus. Therefore, it is important to be aware that injection of contrast medium into the blind alley of the ICA near the cavernous sinus could result in early visualization of the cavernous sinus.

[This corrects the article DOI: 10.5797/jnet.ra.2023-0054.].

Objective: Reversible cerebral vasospasm syndrome (RCVS) is characterized by multiple reversible convulsions of the cerebral arteries, accompanied by recurrent, thunderclap-like headaches. The prognosis of most patients is favorable; however, extensive cerebral infarction may result in significant disability or mortality in approximately 5% of cases. Endovascular treatment may be a therapeutic option for patients who do not respond to medical therapy. However, there is a paucity of detailed studies addressing this procedure.

Case presentation: A 33-year-old woman presented with severe headache and elevated blood pressure during parturition, resulting in a decreased level of consciousness for 2 days postpartum. Head imaging revealed an intracerebral hemorrhage in the right caudate head nucleus and severe multiple stenoses of the cerebral vessels, leading to a diagnosis of RCVS. Despite treatment with verapamil and magnesium, complete paralysis of both lower limbs, the right upper limb, and aphasia developed on postpartum day 8 (day P8). Nicardipine was injected into the bilateral internal carotid arteries (ICAs) and vertebral arteries, and balloon angioplasty was performed at the tips of the bilateral ICA. Symptoms recurred, and the same nicardipine injection was administered on days P9 and P10. Vasoconstriction gradually improved, no major cerebral infarction occurred, and the patient was able to walk (modified Rankin Scale score, 1) by day P90.

Conclusion: Despite medical treatment, there are cases of extensive cerebral infarction due to strong vasoconstriction, and the postpartum period is a risk factor. Endovascular treatment is an effective option for severe RCVS.

Objective: Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by mutations in the genes encoding transforming growth factor β (TGF-β). LDS is often associated with arterial tortuosity, aortic aneurysm, hypertelorism, and bifid uvula. Patients with LDS are at increased risk for vascular events due to aortic or cerebral aneurysms. We present the 1st reported instance of a carotid-cavernous fistula (CCF) in a patient with LDS.

Case presentation: A 50-year-old male with LDS due to a pathogenic TGFBR2 variant presented with a 9-month history of bilateral tinnitus, right-sided exophthalmos, and conjunctival chemosis. Imaging revealed a direct Barrow type A CCF between the ventral wall of the internal carotid artery and the right cavernous sinus. The patient underwent transarterial embolization of the CCF using coils and 1 vial of ethylene vinyl alcohol copolymer. Postoperatively, the patient showed marked clinical improvement, with the resolution of pulsatile tinnitus and a gradual reduction of right-sided exophthalmos.

Conclusion: This case illustrates the successful endovascular management of a direct carotid-cavernous fistula in a patient with LDS. Careful pre-interventional imaging to rule out aortic aneurysm and meticulous catheter handling are necessary to achieve successful embolization.

Objective: A ruptured aneurysm rarely causes a primary intraventricular hemorrhage. Cases of aneurysms concomitant with internal carotid artery occlusion are occasionally reported; however, no previous studies have described lateral posterior choroidal artery (LPChA)-associated aneurysms with internal carotid artery occlusion.

Case presentation: We experienced a case of intraventricular hemorrhage caused by the rupture of an LPChA aneurysm associated with the collateral circulation of internal carotid artery occlusion. After a detailed preoperative imaging study, the embolization was successfully achieved using n-butyl-2-cyanoacrylate without new neurological deficits.

Conclusion: This case highlights the importance of knowledge of the functional anatomy of collateral anastomosis of the intraventricular choroidal arteries, which allowed safe and successful embolization of the aneurysm.

Thromboembolism is one of the main causes of severe complications in the endovascular treatment of cerebral aneurysms, and antiplatelet therapy (APT) is necessary to prevent such complications. Conversely, prolonged APT has the potential risk of hemorrhagic complications; therefore, the timing of dose reduction or discontinuation is an important aspect of periprocedural APT. However, no clinical evidence of an optimal regimen of APT for cerebral aneurysms exists, and the selection, dosage, duration, or combination of antiplatelets has been dependent on physicians for unruptured or ruptured cerebral aneurysms. Many reports have shown that preoperative APT can reduce ischemic complications without increasing hemorrhagic complications, and some reports have shown that the P2Y12 reaction unit (PRU) value measured using the VerifyNow (Werfen, Barcelona, Spain) system is associated with periprocedural ischemic and hemorrhagic complications. Appropriate dose and duration management adjustments based on the platelet reactivity test, aneurysm morphology, treatment, and patient background may contribute to good outcomes. Although accumulating evidence exists regarding the efficacy of preoperative APT, there is no evidence regarding the optimal duration or discontinuation of APT.

Objective: Direct carotid-cavernous fistula (CCF) is a common neurovascular complication associated with Ehlers-Danlos syndrome (EDS). Nevertheless, reports indicate a significant incidence of treatment-related complications.

Case presentation: We present a case of right CCF in a 28-year-old female with EDS. Femoral artery and vein punctures were performed under ultrasound guidance. We executed transvenous embolization (TVE) of the draining veins and the shunted fistula using a combination of coils and n-butyl-2-cyanoacrylate (NBCA), facilitated by an assisted transarterial balloon. The CCF resolved without any procedural complications.

Conclusion: Utilizing a combination of coils and NBCA in TVE is seen as a safe and efficient method for addressing CCF in patients with EDS. It enables preserving better visualization of the cavernous sinus and adjacent structures, making this approach particularly effective. By keeping a close watch, monitoring for potential high-risk complications, and strategically placing devices between the arterial and venous sides, the arterial puncture profile is reduced, enabling safer endovascular treatment.