Journal of neuroendovascular therapy最新文献

Objective: Middle cerebral artery (MCA) aneurysms are difficult to treat with coil embolization (CE) due to their location and shape, but the number of CE-treated MCA has gradually increased as treatment techniques have improved. However, the outcomes of CE for ruptured MCA aneurysms are poorly understood. This study aimed to evaluate the outcomes of CE for ruptured MCA aneurysms.

Methods: We retrospectively analyzed the medical records of patients with aneurysmal subarachnoid hemorrhages (aSAH) that were treated with CE between 2013 and 2020, and compared the differences in outcomes depending on aneurysm location.

Results: A total of 468 patients with aSAH were included: 39 patients had ruptured MCA aneurysms (group M), and 429 had ruptured aneurysms at other sites (group O). There were no significant differences between the background characteristics of the 2 groups. Also, there were no significant intergroup differences in occlusion status, the frequency of complications such as ischemia, hemorrhaging, rebleeding, retreatment, or the modified Rankin Scale score at discharge. However, intracerebral hemorrhage (ICH) removal was required significantly more frequently in group M than in group O (10.3% vs. 0.5%, p = 0.0006). By case-matching analysis, there were no significant differences in these outcomes. All MCA cases that needed removal had more than 36 ml of hematoma volume. Logistic regression analysis showed that the existence of ICH at onset was a poor prognostic factor for ruptured MCA aneurysms.

Conclusion: CE for ruptured MCA aneurysms produced acceptable outcomes in selected cases. However, the indications for CE in patients with ICH should be carefully considered.

Objective: Giant aneurysms of the cavernous segment of the internal carotid artery presenting as acute ischemic stroke (AIS) are rare and often misdiagnosed. Limited treatment experience further complicates management.

Case presentation: A 70-year-old female presented with acute right middle cerebral artery (MCA) occlusion due to a dislodged thrombus from a giant internal carotid aneurysm. Emergency multimodal brain imaging techniques, including CT, CTA, and DSA, were used to clarify the diagnosis. Given the giant aneurysm's interference, cross-circulation thrombectomy via the anterior communicating artery was performed to revascularize the occluded artery. The patient achieved a relatively good outcome due to timely reperfusion.

Conclusion: This case highlights the importance of advanced imaging and innovative surgical techniques in managing complex cerebrovascular conditions, offering insights for future treatment of giant intracranial aneurysms with cerebral embolization.

Objective: This study aimed to determine the status of perioperative antiplatelet therapy in stent-assisted coil embolization (SAC) in Japan.

Methods: The questionnaire consisted of 13 questions and used Google forms, and was sent to institutions where endovascular specialists were employed. The results were analyzed.

Results: The responses from 307 centers indicated that the timing of initiation of antiplatelet therapy was 14 days-1 month before treatment in half of centers, and 7-14 days before treatment in the other half. Platelet function tests were performed at 165 centers (56.2%), of which 136 centers (46.3%) performed these tests for all patients, with the VerifyNow system being the most widely used tool. The duration of postoperative dual antiplatelet therapy was 6, 3, and 12 months in 169 (57.7%), 70 (23.5%), and 42 (14.3%) centers, respectively. The antiplatelet agents used for monotherapy were P2Y12 receptor antagonists or aspirin, with a postoperative period of up to 12 months in 139 centers (47.3%), 24 months in 68 centers (23.1%), and longer than 24 months in 50 centers (17%).

Conclusion: Current antiplatelet therapy for SAC in Japan varies widely among institutions. Moreover, each center has its own empirical rules for SAC. Therefore, the findings of this survey suggest the need to establish guidelines for optimal periprocedural antiplatelet therapy for SAC.

Objective: Marfan's syndrome (MFS) is a systemic connective tissue disorder with autosomal dominant inheritance. Cardiovascular complications of MFS such as aortic root or valve disease and aortic aneurysm or dissection are potential cause of access route problems of mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Here, we report a case of a patient with MFS who underwent MT for AIS.

Case presentation: A 58-year-old woman with MFS presented with a sudden onset of consciousness disturbance and right hemiparesis, and was referred to our hospital. After the infusion of tissue plasminogen activator, CTA showed a type III arch in the aortic arch and severe tortuosity of the thoracoabdominal aorta; thus, angiography was performed using the transbrachial approach. Left common carotid angiogram showed complete recanalization of the left middle cerebral artery. On the sixth day, the patient presented a sudden consciousness disturbance and left hemiparesis. MRA showed right internal carotid artery occlusion. MT was performed by the transbrachial approach, and complete recanalization was achieved on the first pass.

Conclusion: MT via the transbrachial approach is a treatment option that should be considered, especially in MFS, where the transfemoral approach is difficult due to anatomical problems.

Objective: Most large-vessel occlusions (LVOs) amenable to acute recanalization occur in the internal carotid or middle cerebral artery. However, few LVOs with a multivessel disease can be difficult to treat. This study aimed to determine the outcomes of mechanical thrombectomy in patients with both anterior and middle cerebral artery occlusions.

Methods: We retrospectively collected data for patients who had undergone mechanical thrombectomy since January 2016 at Fukushima Medical University and its affiliated institutions (10 institutions). Patients with occluded vessels in the anterior and middle cerebral arteries were selected, and patient background, treatment course, and outcomes were reviewed.

Results: A total of 341 mechanical thrombectomies were performed during the study period. Seven patients had occlusions involving both anterior and middle cerebral arteries. In these seven patients, the median time from onset to imaging, imaging to puncture, and puncture to recanalization was 106, 60, and 74 min, respectively. Only one patient (14%) had a modified Rankin Scale of 0-2 at 90 days.

Conclusion: Comorbid anterior cerebral artery occlusion may worsen the outcome of patients with middle cerebral artery occlusion.

Objective: Complications of mechanical thrombectomy (MT) should be identified and managed because they often worsen clinical outcomes. Here we present a case of post-MT embolization of the artery supplying the oculomotor nerve, which has not previously been reported as a complication of MT.

Case presentation: An 81-year-old woman visited our hospital within 2 hours of the sudden onset of left hemiparesis and impaired awareness. MRA showed right middle cerebral artery (MCA) M1 segment occlusion and a possibly salvageable penumbra. We performed thrombectomy for right MCA occlusion with successful recanalization. In the final angiography view, the marginal tentorial artery was almost invisible. Ten hours after thrombectomy, the patient developed complete right oculomotor nerve palsy. Subsequent MRI showed ischemic lesions, but none in the oculomotor nucleus, and there were no lesions compressing the oculomotor nerve. We presume that embolization of the marginal tentorial artery caused oculomotor nerve palsy. The intracranial middle and distal portions of the oculomotor nerve are supplied by the superior branches of the inferolateral trunk and by the marginal tentorial artery.

Conclusion: Occlusion of the marginal tentorial artery can cause oculomotor nerve palsy, although this has not previously been reported. Our case suggests that neurointerventional surgeons should evaluate patency of branches of the inferolateral trunk and the meningohypophyseal trunk during the procedure of MT.

Objective: Recent studies evaluating plaque protrusion at carotid artery stenting (CAS) using optical coherence tomography showed not a few cases of plaque protrusion when using double-layer micromesh stents. We report a case of symptomatic internal carotid artery (ICA) stenosis with at-risk unstable plaques in which CAS was successfully performed using a stent-in-stent technique by the combined use of a closed-cell stent and a dual-layer micromesh stent.

Case presentation: An 87-year-old Japanese man with dysarthria and right hemiparesis was diagnosed with atheromatous cerebral embolism caused by severe left ICA stenosis on MRI and DSA. MRI with T1-weighted black blood methods showed high intensities in the plaques of the left ICA, suggesting unstable plaque characteristics with intraplaque hemorrhage components. On day 20, CAS was performed. After the pre-stent dilation under proximal and distal protection, a Carotid WALLSTENT was placed to cover the stenotic lesion. Then, a CASPER Rx was placed from the proximal left ICA to the common carotid artery to cover the Carotid WALLSTENT. Although visible plaque debris was recognized in the aspirated blood, the debris became invisible after aspiration of 1300 mL. Postoperative angiography showed enough dilation of the left ICA, with no plaque protrusion or acute stent thrombosis. The patient had an uneventful postoperative course and was discharged without any neurological sequelae.

Conclusion: The present case suggests that the combined stent-in-stent technique using a closed-cell stent and a micromesh stent can be considered as one of the treatment strategies for preventing plaque protrusion and procedural ischemic complications in patients with high-risk carotid plaques.

Objective: Plaque protrusion (PP) during carotid artery stenting (CAS) is considered to be associated with periprocedural ischemic stroke. A new double-layer micromesh stent, the CASPER stent (CS), was approved for use in Japan in 2020. The expectation is that this micromesh stent system will reduce the risk of PP, but we report a case of PP during CAS despite the use of a CS.

Case presentation: An 87-year-old man presented with left hemiparesis. MRI showed right brain infarction and angiography showed right internal carotid artery stenosis with thrombus. Follow-up angiography after medical treatment showed that thrombus disappeared. We therefore performed CAS for right internal carotid artery stenosis with unstable plaque. CAS was performed under local anesthesia with Mo.Ma Ultra and FilterWire EZ protection using a CS placed to sufficiently cover the stenotic region. Conservative post-dilatation was then performed. Intravascular ultrasonography (IVUS) after post-dilatation showed the presence of PP. A second CS was then added using the stent-in-stent technique. No postoperative neurological abnormalities were found and the patient was discharged without postoperative complications. No stroke or restenosis has been observed as of 16 months after CAS.

Conclusion: PP can occur even when CAS is performed using the CS for carotid artery stenosis with unstable plaque. The importance of checking for PP using IVUS is suggested.

Objective: This is a report on the usefulness of 3D fusion imaging with susceptibility-weighted imaging (SWI) as preoperative imaging for mechanical thrombectomy (MT) for acute ischemic stroke (AIS).

Case presentations: Among 17 cases of patients who underwent MT in AIS between March 2021 and April 2022, 14 patients who underwent MRI with SWI (shortened SWI for stroke) and 3D T2-weighted sampling perfection with application-optimized contrasts using different flip angle evolution were targeted in the study. Three cases with motion artifacts due to body movement were excluded from the images.After imaging, 3D fusion images were constructed to visualize thrombi and occluded vessels. SWI for stroke obtained thrombus information in 11 of the 14 cases (78.5%) and 3D images of the thrombi could be created in all 11 cases. 3D fusion images could be created in nine of the 14 cases (64.2%).

Conclusion: 3D fusion images, using SWI for stroke, can visualize thrombi and occluded vessels and may be effectively used as preoperative images for MT.