Journal of neuroendovascular therapy最新文献

Objective: Traumatic carotid-cavernous fistula (TCCF) is a rare neurovascular condition that occurs after blunt head trauma. This condition accounts for approximately 4% of traumatic cerebrovascular injuries. Various symptoms can be observed in TCCF, and aggressive treatment is frequently required. Herein, we reviewed the treatment of TCCF in our hospital.

Methods: We retrospectively reviewed patients with TCCF between December 2021 and May 2023. The physical findings, clinical images, and surgical details of patients were investigated.

Results: Three men and 1 woman were included. Only 1 case was diagnosed with CCF using initial 3D-CTA; the other 3 were diagnosed after admission using DSA. All patients received endovascular treatment; 2 were initially treated with transarterial embolization, and the other 2 were treated with transvenous embolization, although 1 case of transarterial embolization required additional treatment with transvenous embolization. Complete occlusion was achieved in all cases. Two of the cases were accompanied by skull base fractures, both of which were middle fossa fractures.

Conclusion: TCCF is caused by direct injury to the internal carotid artery and can be accompanied by skull fractures or vessel wall damage as a result of shear force. We should suspect TCCF, especially when a skull base fracture is detected, even if the initial 3D-CTA shows no evidence of TCCF. Treatment for TCCF is mainly endovascular; however, the specific treatment approach should be determined for each case based on various factors, including vessel anatomy.

Objective: Treatment of infectious aneurysms is challenging because of the fragility of the vessel walls. Surgical trapping and endovascular parent artery occlusion are the treatments of choice for medically intractable infectious aneurysms. Here, we describe a patient with an infectious aneurysm at the extracranial petrous segment of the internal carotid artery that was secondary to exudative otitis media; it was successfully treated with reconstructive endovascular interventions using a flow redirection endoluminal device (FRED).

Case presentation: A 57-year-old man was administered antibiotics for exudative otitis media. After 6 months, the patient underwent CT screening, which revealed destruction of the petrous bone and a pseudoaneurysm at the petrous segment of the left internal carotid artery. Catheter angiography, including a balloon occlusion test, revealed a 47-mm wide-necked pseudoaneurysm at the distal cervical segment of the left internal carotid artery with poor collateral blood supply to the left internal carotid artery. We performed reconstructive endovascular treatment using a FRED. A follow-up catheter angiogram after 6 months confirmed a minor neck remnant of the aneurysm.

Conclusion: Flow diversion may be a useful treatment approach for extracranial infectious aneurysms, despite concerns about incomplete obliteration of the aneurysm and the persistent risk of re-rupture before complete obliteration.

Objective: In medically refractory idiopathic intracranial hypertension (IIH), venous sinus stenosis (VSS) stenting has been an effective treatment modality. Among patients who experience recurrent symptoms and develop new stenosis, the optimal treatment strategy is unknown. The aim of this study was to investigate the role of rescue re-stenting in patients with recurrence after prior successful stenting.

Methods: This was a single center, retrospective review from a prospectively maintained IIH registry. Between 2012 and 2023, patients who underwent interventions for confirmed IIH and angiographically demonstrable VSS were included. The cohort was divided into those who underwent a single stenting procedure (single stent group) and those who underwent re-stenting due to recurrence of symptoms and new angiographic stenosis (re-stent group).

Results: Ninety seven patients were included: 87 in the single stent group and 10 in the re-stent group, with a median age of 32 (interquartile range 26-38). 94% were female. Both groups had similar baseline demographic and clinical characteristics. There was similar improvement in papilledema and tinnitus. Headache improvement was greater in the single stent group at 6 weeks (88.4% vs. 60.0%, p = 0.04, single vs. re-stent group), but similar at 6 months post-procedure. For visual disturbances, there was similar improvement at 6 weeks, but greater improvement in the single stent group at 6 months post-procedure (86.8% vs. 75.0%, p = 0.04, single vs. re-stent group). None of the re-stented patients required rescue ventriculoperitoneal shunt placement.

Conclusion: Re-stenting among IIH patients with recurrent symptoms after initial successful VSS stenting is feasible with similar efficacy in improving symptoms.

Objective: As a solution to the shortage of and overwork among physicians, task shifting and task sharing have been proposed for health-care professionals. This study aimed to investigate the role of nurse practitioners (NPs) in neurovascular interventions and evaluate the validity of task shifting in our institute.

Methods: Medical records from 684 neurovascular intervention cases from 2020 to 2023 were retrospectively reviewed, and the tasks performed by NPs were investigated. Additionally, the procedure times between cases in which NPs acted as the first assistant alongside a physician (NP + physician group) and those in which 2 physicians performed the procedure (physician + physician group) were compared.

Results: The main tasks performed by NPs included preoperative checks, assistance during the procedure, postoperative care, the initial handling of complications, and inputting orders. No significant differences in procedure times were found between the NP + physician and physician + physician groups.

Conclusion: NPs showed potential for task shifting in perioperative neurovascular interventions, particularly in assisting, providing care, inputting orders, and initially handling complications. However, further discussions and improvements are needed regarding task shifting in emergency cases and work arrangements for NPs.

Objective: To assess the efficacy of mechanical thrombectomy (MT) for cerebral venous sinus thrombosis associated with Ewing sarcoma invasion into the venous sinus.

Case presentation: A 48-year-old woman presented to our hospital with left hemifacial paralysis. The patient had undergone surgical treatment for left subclavian Ewing sarcoma 24 years ago. Furthermore, the patient had undergone tumor resection for very late metastasis in the left occipital bone and mastoid air cells 3 years prior to her admission. As the Ewing sarcoma had extended to the left transverse sinus, the sinus was resected during craniotomy. The tumor remained in the mastoid air cells, and radiotherapy was administered. On admission to our hospital, FLAIR revealed hyper-intensities in the straight sinus and the superior sagittal sinus. Magnetic resonance venography revealed no signal in the posterior part of the superior sagittal sinus and the bilateral transverse sinuses. The patient was diagnosed with cerebral venous sinus thrombosis, and anticoagulation therapy was administered. However, the swelling and pain on the left side of the face worsened, and intraocular pressure (IOP) increased. Therefore, an MT was performed. After endovascular treatment, the patient's facial swelling and pain were reduced, and IOP returned to normal. Pathological examination of the captured thrombus revealed tumor cells, suggesting venous sinus invasion of Ewing sarcoma.

Conclusion: Although it was a palliative treatment, MT was effective in confirming the diagnosis of tumor invasion into the venous sinus and improving the patient's quality of life.

Objective: Computed tomography (CT) and magnetic resonance imaging of cerebral perfusion are useful in determining the indication of mechanical thrombectomy (MT) for acute ischemic stroke. RAPID (iSchemaView, Menlo Park, CA, USA) is the most common software for analyzing brain perfusion images worldwide, but various other software are also available. The optimal threshold value for each software is different, and each has its characteristics. This study investigated the relationship between the quantitative evaluation of ischemic core volume (ICV) and the Alberta Stroke Program Early CT Score (ASPECTS) using CT Perfusion 4D (GE Healthcare Inc., Milwaukee, WI, USA), a software used in our hospital.

Methods: Among patients who underwent MT between April 2015 and February 2023, those with modified Rankin Scale: 0-2, obstruction by embolic mechanism, and thrombolysis in cerebral infarction: 2b or higher were selected retrospectively. Patients with middle cerebral artery M1 segment (M1) and internal carotid artery (ICA) occlusions (90 and 46 patients) were included. We quantitatively analyzed ICV at relative cerebral blood flow (rCBF) <20% and cerebral blood volume (CBV) <1 mL/100 g and evaluated the relationship with ASPECTS scores in 3 groups: M1 + ICA, M1, and ICA occlusion groups.

Results: The median ICV was rCBF <20%: 44.7 cm³ and CBV <1 mL/100 g: 34.6 cm³, and there was no statistically significant difference between the 2 groups (p = 0.23). There was a negative correlation between ICV and ASPECTS scores in each occlusion group in all groups.

Conclusion: The quantitative evaluation of ICV at rCBF <20% and CBV <1 mL/100 g was negatively correlated with the ASPECTS score in GE's CT Perfusion imaging analysis software.

In the field of abdominal and pelvic surgery, endoscopic procedures have increasingly utilized robotic surgery, including the da Vinci system (Intuitive Surgical, Sunnyvale, CA, USA). Unlike robotic surgery in these fields, endovascular treatment involves simple movements such as pushing and pulling or twisting catheters and wires, allowing for the creation of relatively straightforward robotic systems that can replicate these endovascular procedures. Recently, there have been clinical applications of this technology in coronary arteries. However, when applying it to cerebral vessels, which have significant curvature and fragility, it is essential to develop a system that can adequately assess and reflect the physical stress on the vessel wall. Furthermore, remote surgery (telesurgery) performed by specialists is one of the most sought-after applications of robotics, but issues remain due to poor communication environments, leading to delays in operation and control difficulties. Additionally, there are ethical concerns regarding the responsibility for adverse events related to robotic surgery, highlighting the urgent need for the establishment of guidelines.

Objective: Herein, we present a novel flow reversal technique using dual-balloon inflation that can provide enhanced catheter stability and reliable embolic protection for percutaneous antegrade stenting in a patient with right common carotid artery (CCA) stenosis.

Case presentation: A 75-year-old female patient with post-radiation right CCA stenosis initially underwent stenting using distal filter protection, which resulted in transient left upper limb paralysis caused by embolic infarction. After restenosis at 6 months, retreatment was performed using dual-balloon occlusion with the 9-F balloon guiding catheter in the innominate artery and the 8-F balloon guiding catheter in the right subclavian artery. Intraoperative ultrasonography confirmed a successful flow reversal, and debris was captured from the aspirated blood. The patient was discharged without neurological deficits, and postoperative imaging showed no new ischemic lesions.

Conclusion: The novel flow reversal technique using dual-balloon inflation can be effective and safe for treating right CCA stenosis by achieving both reliable embolic protection and improved catheter stability.

Objective: This report describes the creation of a freestanding cerebrovascular model with an attached Luer valve device and a bridge.

Case presentation: A left internal carotid artery aneurysm was discovered during a detailed examination of headaches in a 70-year-old woman. A vascular lumen model was created for the pretreatment simulation. The addition of a male Luer valve and bridge to the vascular lumen model created using the multistep vascular wall thickness method facilitated lumen washing, support material removal, self-support, and compatibility with medical devices.

Conclusion: By adding Luer valves and struts and creating cerebral vascular lumen models with appropriate vessel wall thicknesses, we can enhance their efficiency, strength, and utility in preoperative simulations.

Objective: Formation of an aneurysm at the anastomosis site is a rare complication of superficial temporal artery-middle cerebral artery (STA-MCA) bypass for moyamoya disease (MMD). All 5 previously reported cases were treated with craniotomy, and no case of endovascular treatment has been reported to date. Here, we report a case in which endovascular treatment was performed for an anastomotic aneurysm that developed after STA-MCA bypass surgery for MMD.

Case presentation: A 46-year-old woman with no relevant medical history developed a cerebral hemorrhage and was diagnosed with MMD. Bilateral STA-MCA bypass was performed to prevent recurrence of bleeding, and a de novo aneurysm was found at the right anastomosis site 1 year after the surgery. After a 2-year follow-up period, the size of the aneurysm and the diameter of the STA increased; therefore, treatment was initiated. Endovascular treatment was performed using the double-catheter technique. After coil embolization, the aneurysm was no longer visible, and no complications were observed.

Conclusion: Anastomotic aneurysms after STA-MCA bypass can be safely and effectively treated with endovascular therapy.