Journal of neuroendovascular therapy最新文献

Objective: Treatment of anterior choroidal artery (AChA) aneurysms is frequently associated with ischemic complications. This study aimed to report the outcomes of treatment of unruptured AChA aneurysms in our hospital.

Methods: Between January 2015 and March 2022, 40 patients were treated for an unruptured AChA aneurysm in our hospital. Age, sex, aneurysm size, AChA branching type, treatment, occlusion rate, complications, modified Rankin Scale (mRS) score before surgery and after 90 days, and recurrence were investigated. The branching type was classified as internal carotid artery (ICA), neck, or dome type based on the location of the AChA origin.

Results: The mean age was 61.1 ± 1.9 years; 15 patients were men and 25 were women. The mean aneurysm diameter was 4.4 ± 0.3 mm. The branching type was ICA in four patients, neck in 35, and dome in one. Treatment was surgical clipping in 22 patients and endovascular coil embolization in 18 (14 with stent assistance). Motor-evoked potential (MEP) monitoring was used in all patients of the clipping group and 9 cases of the coiling group. Treatment complications occurred in eight patients (20%). mRS score worsened by more than one point 90 days after treatment in four patients (10%); however, the proportion of patients who experienced this did not significantly differ between the clipping and coiling groups. Although the odds of a thrombotic complication were higher with coiling than clipping, the difference was not significant (odds ratio: 10.2; P = 0.08). The rate of complete occlusion was lower in the coiling group (72.2% vs. 95.3%), but the difference was not significant. The median follow-up was 696 days (range: 99-2053). No aneurysm recurrence or rupture occurred.

Conclusion: AChA branching type is important for treatment decision-making in patients with AChA aneurysms. Rates of complications and occlusion do not significantly differ between clipping and coiling of AChA aneurysms. MEP monitoring may be useful in preventing thrombotic complications during coil embolization.

Objective: Contrast-induced encephalopathy (CIE) is a rare but severe complication that can occur following intravascular treatment of intracranial vascular disease. Although CIE is considered a transient neurological disorder, its natural history, pathophysiology, and risk factors are poorly understood. Contrast leakage (CL) is a more frequently observed adverse event than CIE and can lead to CIE. This retrospective study aimed to elucidate the clinical characteristics of CL and CIE and identify the risk factors for each.

Methods: We retrospectively reviewed the medical records of 61 patients with unruptured intracranial aneurysms who were treated at our institution between January 2019 and May 2023. Risk factors for CIE and CL were identified by Fisher's exact test for univariate analysis of categorical variables and by unpaired t-test for continuous variables. One-way analysis of variance (ANOVA) was conducted, followed by the Tukey-Kramer test for multiple comparisons.

Results: Of the 61 patients, 22 (36%) had CL and 4 (6%) had CIE. Among the clinical characteristics analyzed, older age (p = 0.031), larger aneurysm (p = 0.003), lower serum creatinine (p = 0.026), and use of a distal access catheter (p = 0.030) were significant risk factors for CL. CIE occurred only in CL-positive patients (p = 0.014). Of the 4 patients with CIE, neurological symptoms improved within 3 days in 3 patients, and neurological deficit persisted in 1 patient.

Conclusion: Older age, larger aneurysm, lower serum creatinine, and use of a distal access catheter are risk factors for developing CL, and female sex and greater volume of contrast medium are potential risk factors. No risk factors for developing CIE from CL were identified.

Objective: A Leonis Mova (LM; SB Kawasumi, Kanagawa, Japan), one of the steerable microcatheters, has a remote-controlled flexible catheter tip manipulated with a dial in the hand grip, which enables operators to overcome complicated branching in endovascular surgeries. We report a case of a pituitary tumor in which the LM worked effectively as a distal access catheter (DAC) in tumor embolization.

Case presentation: A female patient in her 70s complained of bitemporal hemianopsia, and an MRI revealed a pituitary tumor that appeared hypervascular. The right internal carotid artery angiography demonstrated a prominent stain from a tumor vessel derived from the meningohypophyseal trunk (MHT). Tumor embolization was scheduled before its removal due to the hypervascularity. In the tumor embolization, the tip of the LM was bent toward the orifice of the right MHT, through which a 1.3F-1.8F 155 cm microcatheter along with a 0.010-inch 200 cm microguidewire was advanced. Locking the LM tip provided good support for the microcatheter and the microguidewire to proceed to the tumor vessel. Successful tumor embolization was achieved with an injection of 0.21 ml of 12.5% n-butyl-cyanoacrylate. Thanks to the tumor embolization, gross total removal of the pituitary tumor was transshenoidally accomplished with the least blood loss. Histopathological diagnosis of pituicytoma was made, and the intraoperative blood loss of 100 ml seemed small for this histology. The patient recovered from the bitemporal hemianopsia and was discharged without a blood transfusion.

Conclusion: This is the first report in which the LM was used and well worked in tumor embolization as a DAC.

Intracranial artery dissections (IADs), although uncommon, are an important cause of cerebral infarction and subarachnoid hemorrhage (SAH). Some IADs can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis. Meanwhile, others can progress to stroke that requires treatment. The incidence of IAD in the posterior circulation is higher than that in the anterior circulation. Anterior circulation dissections are more likely to develop into ischemia and posterior circulation lesions into hemorrhage. The mortality rate after IAD among patients with SAH is 19%-83%. Further, the mortality rate of IAD without SAH is 0%-3%. Patients with SAH commonly undergo surgery or receive neuroendovascular treatment (EVT) to prevent rebleeding. However, the treatment of IADs is empirical in the absence of data from randomized controlled trials. Recently, EVT has emerged and is considered for IADs because of its less invasiveness and perceived low rates of procedure-related morbidity with good efficacy. EVT strategies can be classified into deconstructive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow via the parent vessel) techniques. In particular, the number of reports on reconstructive techniques is increasing. However, a reconstructive technique for ruptured IADs has not yet been established. This review aimed to provide an overview of IADs in the posterior circulation managed with EVT by performing a literature search.

Remarkable advances have been made in the endovascular treatment of intracranial cerebral aneurysms. These advances include various adjunctive techniques, increased indications for endovascular treatment, and improved treatment results. Furthermore, the number of cerebral aneurysm treatments using flow diverters (FDs) is expected to increase. However, the reported long-term rate of branch artery occlusion after FD treatment has been reported is 15.8%. Moreover, the complete aneurysm obliteration rate is low if normal branches arise from an aneurysm neck or dome. Flow diverter placement for ophthalmic artery, posterior communicating artery, and anterior choroidal artery aneurysms is often difficult because these normal branches often arise from the aneurysm neck or dome. Therefore, in many cases, coil embolization, which can occlude the aneurysm while preserving branch vessels, should be selected. Although not yet established, various adjunctive techniques and other endovascular treatments that can be performed safely have been reported. Treatment must be planned after understanding the advantages and disadvantages of each treatment method.

Objective: During cerebral aneurysm embolization of the anterior circulation, the guiding catheter (GC) should be placed as distally as possible in the cervical internal carotid artery (ICA) to secure the maneuverability of the microcatheter and distal access catheter. However, if the shape of the tip of the GC does not appropriately match the course of the ICA, blood stasis might occur. We investigated whether shaping the tip of the GC into an S-shape would allow more stable catheterization to the distal ICA than the conventional GC with an angled tip.

Methods: We included patients with cerebral aneurysms of the anterior circulation who were treated at our institution from April 2019 to April 2021. First, we evaluated the cervical ICA course in these patients through cerebral angiography and classified the courses into type S, type I, and type Z. Then, we focused on the most frequently encountered type-S cervical ICA to investigate the forging effect of the GC tip into an S-shape. We evaluated the lateral view of the carotid angiograms to examine whether the catheter tip reached the foramen magnum (FM) without interrupting ICA blood flow. The effects of age, sex, side, a history of hypertension and smoking, and an S-shape modification of the GC tip on the outcome of GC placement were analyzed.

Results: A total of 67 patients were included in this study. The tip of the GC was placed at the FM in 27 cases. Among these factors, only the S-shape modification was significantly associated with whether the GC could be placed at the level of the FM (p <0.0001).

Conclusion: By forging the tip of the GC into an S-shape, the GC can be safely advanced to the distal part of the cervical ICA, which may contribute to the improved maneuverability of microcatheters.

Objective: Stent retriever (SR) angioplasty is an adjunctive technique for acute large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO). Prolonged SR deployment maintains blood flow distal to the atherosclerotic lesion until the antiplatelet agent has exerted its effect. Although SR angioplasty for ICAD-LVO has been reported, few reports are available on SR angioplasty for medium vessel occlusion stroke due to underlying ICAD (ICAD-MeVO). Here, we describe a case of SR angioplasty for acute occlusion of the left M2 segment of the middle cerebral artery (MCA) due to underlying ICAD.

Case presentation: A 79-year-old man with a history of left MCA M2 segment stenosis presented with motor aphasia and dysarthria. Diffusion-weighted MRI showed no high-signal intensity areas, and MRA showed occlusion of the left MCA M2 segment. The patient was diagnosed with ICAD-MeVO. After performing an MRI, the patient's symptoms progressed to total aphasia. SR angioplasty was performed for the occlusion of the left M2 segment of the MCA. Diffusion-weighted MRI the day after the procedure showed a small area of high-signal intensity exclusively in the left putamen, while MRA confirmed recanalization of the left MCA M2 segment. Aphasia improved after the procedure. No re-occlusion was observed for 90 days, and the modified Rankin Scale score at 90 days was 2.

Conclusion: SR angioplasty appears to be a safe option for managing MCA M2 segment occlusion.

Objective: To report the rare case of a patient with a perianeurysmal cyst following stent-assisted coil embolization of an unruptured vertebral artery aneurysm.

Case presentation: A 63-year-old woman underwent stent-assisted coil embolization for an unruptured vertebral artery aneurysm embedded in the brainstem (pons). Complete occlusion of the aneurysm was successfully achieved. However, subsequent magnetic resonance imaging (MRI) conducted 8 months after the procedure showed perilesional edematous changes surrounding the aneurysm, and at 20 months, cyst formation was observed in the vicinity of the aneurysm. Progressive enlargement of the cyst eventually led to the development of paralysis and dysphagia, necessitating cyst fenestration surgery. Although postoperative reduction in the cyst size was achieved, the patient experienced complications in the form of aspiration pneumonia and bacterial meningitis, which resulted in a life-threatening condition.

Conclusion: Aneurysms embedded in the brain parenchyma should be carefully followed up, recognizing the risk of perianeurysmal cyst formation after coil embolization.

Objective: Recently, the use of the radial artery approach for neuroendovascular treatment has become more frequent. The main advantage of this approach is that there is a low complication risk. However, in the aforementioned case, the 6F guiding sheath proved difficult to remove from the radial artery.

Case presentation: A 60-year-old female patient presented with an unruptured basilar tip aneurysm, which we treated with coil embolization under general anesthesia. We performed paracentesis on the right radial artery and inserted a 6F Axcelguide. The radial artery is bifurcated at the brachial region. We guided the Axcelguide to the right subclavian artery and filled the aneurysm with a coil. After embolization, we attempted to remove the Axcelguide. However, we encountered extreme resistance, and removal proved difficult. We injected verapamil, isosorbide nitrate, nitroglycerin, and papaverine hydrochloride intra-arterially and subcutaneously into the forearm and then performed a brachial plexus block. Unfortunately, the situation remained unchanged. We attempted to slowly remove the catheter with the vascular mass remaining adhered to it. We transected the radial artery in the middle. We could not achieve hemostasis through manual compression and thus injected n-butyl-2-cyanoacrylate intra-arterially. Postoperatively, the patient experienced mild subcutaneous hematoma and pain.

Conclusion: We consider reporting this case valuable because no previous studies have described similar difficulties in removing a 6F guiding sheath from the radial artery.

Objective: Internal carotid artery (ICA) agenesis has been classified into six types: A-F. Type F demonstrates distal reconstitution of the ICA via anastomosis with distal branches of the external carotid artery. Herein, we report the ICA agenesis of type F without rete-like collaterals, which has not been previously reported.

Case presentation: An 80-year-old woman presented with segmental agenesis of the right ICA accompanied by an unruptured intracranial aneurysm. Stent-assisted coil embolization was successfully performed. Digital subtraction angiography showed segmental agenesis of the right ICA from the cervical to the ascending foramen lacerum segment, which was preoperatively supplied with collateral blood flow by a dilated right accessory meningeal artery (AMA) anastomosed with the inferolateral trunk (ILT)-posteromedial branch. Based on the segmental concept, the case was diagnosed with segment 7 (horizontal intracavernous portion until ICA branches off the ILT) agenesis, which may have resulted in secondary regression of the ICA proximal to segment 7. According to the ICA agenesis classification, this was of type F because the case showed collateral flow to the distal ICA via transcranial anastomoses from the AMA without carotid rete-like collaterals.

Conclusion: These findings suggest that the carotid rete-like collaterals did not form because the AMA was first developed during embryonic development.