Journal of neuroendovascular therapy最新文献

Objective: The Woven EndoBridge (WEB), an intrasaccular device, is a new alternative to coils for the endovascular treatment of wide-neck bifurcation aneurysms. Selection of the correct size of the device is of utmost importance for successful treatment outcomes. We present a case of an unruptured cerebellar artery aneurysm that was successfully treated with WEB implantation, guided by a 3D silicone model for preoperative evaluation.

Case presentation: A 67-year-old woman with no family history of cerebral aneurysms was diagnosed with an unruptured basilar-superior cerebellar artery (BA-SCA) aneurysm. The patient's aneurysm was wide-necked with a dome of 8.1 mm, a neck of 6.5 mm, a height of 6.9 mm, and a volume of 287 mm³. In the preoperative simulation with 3D printed models, the WEB 9 × 4 mm device successfully preserved the SCA. Therefore, it was selected for treatment. Although the aneurysm had an angle of nearly 90° to the BA artery, the preoperative evaluation made it easy to guide the microcatheter and place the WEB device. The postoperative course was favorable and no new neurological symptoms were noted. Cerebral angiography performed 6 months after the procedure confirmed complete occlusion of the aneurysm.

Conclusion: Preoperative simulation with 3D printed models can help to plan device size selection and implantation position, thereby predicting intraoperative microcatheter behavior in advance.

Objective: Mechanical thrombectomy (MT) for acute ischemic stroke usually requires blind procedures when endovascular devices are advanced into the occluded vessels. Therefore, the visualization of occluded vessels could potentially achieve safer procedures, shorter procedural time, and progression of the reperfusion rate. We report on the usefulness of a novel technique in which a 3D roadmap of occluded vessels was created from a rapid 3D proton density-weighted (PDW) variable refocusing flip angle and turbo spin echo (VRFA-TSE) method.

Case presentation: 3D PDW VRFA-TSE imaging was performed in addition to routine MRI for 2 patients with middle cerebral artery occlusion. With the adjustments to the imaging parameters, we were able to perform 3D PDW imaging in less than 1 minute. Subsequently, a 3D image of the occluded vessels was constructed from these images. To create a 3D roadmap, the 3D PDW images were positioned with cone beam CT images obtained before MT using 3D-3D fusion. Because a neurological technician performed the imaging processing while doctors and nurses prepared for MT, practical loss time was approximately 2 minutes. MT was performed with reference to the 3D roadmap, and the occluded lesion was recanalized without complications in both patients. The 3D roadmap of the occluded vessels was well-matched with the recanalized vessels.

Conclusion: A 3D roadmap created from rapid 3D PDW imaging is a useful assistance technique for MT that allows the visualization of occluded vessels.

Optimal platelet inhibition is critical in patients with carotid and intracranial artery stenosis undergoing carotid artery stenting (CAS) and intracranial artery stenting (ICS). Many reports have highlighted the importance of dual antiplatelet therapy (DAPT) in reducing adverse neurological outcomes without a significant increase in bleeding complications during CAS. DAPT has commonly used CAS and ICS, typically with aspirin and clopidogrel, but clopidogrel resistance occurs in approximately 20% of Japanese and other Asian populations. One solution to clopidogrel resistance is using adjunctive cilostazol to suppress the frequency of stroke events and in-stent restenosis after CAS. Other antiplatelet agents such as prasugrel, ticagrelor, cangrelor, and glycoprotein (GP) IIb/IIIa inhibitors are under investigation. The duration of DAPT after CAS remains controversial, as a longer duration of DAPT after CAS is associated with lower rates of readmission for stroke, but increased risk of hemorrhagic complications. Regarding antithrombotic therapy in CAS with concomitant atrial fibrillation, the use of direct oral anticoagulants plus a P2Y12 inhibitor may be suggested for the optimal safety and efficacy of antithrombotic management. For emergent CAS in acute ischemic stroke (AIS), intraprocedural DAPT loading and GP IIb/IIIa inhibitors, as necessary, may improve stent patency without increasing the risk of intracranial hemorrhage. In ICS, aggressive antiplatelet therapy based on an assessment of platelet aggregation is also important to improve clinical outcomes. In addition, rescue stenting for AIS caused by intracranial atherosclerotic stenosis-related large vessel occlusion is gaining attention. GP IIb/IIIa inhibitors have shown promise, but are not approved in Japan. In conclusion, DAPT is essential for the perioperative management of CAS and ICS. Specific perioperative antithrombotic management remains unclear, but the potential benefits of antithrombotic agents must be weighed against the corresponding increased risk of bleeding complications.

This review discusses the use of N-butyl cyanoacrylate (NBCA) in various neuroendovascular treatments. Despite the increase in the ONYX, NBCA continues to have significant usage. It is particularly useful for the treatment of arteriovenous malformations (AVM) and dural arteriovenous fistulas (dAVFs). Comparative studies have suggested that ONYX and NBCA are equally effective and safe for the treatment of AVM. However, the choice between the two depends on specific situations, such as the characteristics of the feeding arteries. NBCA is recommended for tortuous feeders, high-flow fistulous feeders, and feeders with a short margin of reflux, owing to the procedural risks posed by ONYX. The use of NBCA is also prominent in dAVF embolization. While achieving total occlusion solely with NBCA can be challenging, NBCA adheres to the vessel wall and encourages thrombus formation, aiding in fistula obliteration. In addition to AVM and dAVF, NBCA is used to treat chronic subdural hematoma and craniofacial vascular injuries. Embolization using NBCA is beneficial because of its deep penetration into the target tissue. For craniofacial injuries, NBCA embolization provides secure hemostasis within a short time. Neuroendovascular physicians should understand the characteristics of NBCA as a liquid embolic material and have expertise in the technical aspects of NBCA embolization, even in the ONYX era.

Brain arteriovenous malformations (bAVMs) are uncommon vascular lesions found in young individuals exhibiting diverse clinical manifestations ranging from asymptomatic to spontaneous intracranial hemorrhage, seizures, or headaches. Despite improvements in endovascular tools and methods, standalone transarterial embolization seldom achieves success rates surpassing 50%, even when employing ethylene vinyl alcohol copolymers. Transvenous embolization (TVE) emerges as a promising option, especially for bAVMs situated distally or inaccessible through arterial routes. Despite the possibility of achieving high angiographic cure rates, concerns regarding hemorrhagic complications persist, limiting its adoption. This review article outlines the indications and methodology of TVE, discusses complications, and highlights the essential expertise needed for the safe execution of TVE along with strategies to mitigate associated risks. Clinical results reveal promising outcomes in terms of obliteration rates and favorable neurological results, although challenges persist, particularly regarding device accessibility and risk management. Despite these challenges, TVE remains a valuable alternative for managing bAVMs, particularly for cases resistant to surgical intervention, emphasizing the significance of careful patient selection and procedural expertise.

Objective: This study aimed to investigate the difference in outcomes after emergent stenting with antiplatelet therapy for large vessel occlusion (LVO) stroke in patients with and without prior intravenous tissue plasminogen activator (IV tPA).

Methods: Patients who arrived at our hospital within 4.5 h of symptom onset and underwent endovascular therapy (EVT) for LVO between January 2015 and March 2023 were analyzed retrospectively. Patients were included if they underwent stenting for atherosclerotic lesions or arterial dissection with antiplatelet therapy during EVT. The safety and clinical outcomes were compared between patients who received IV tPA before EVT (IV tPA group) and those who did not (no-IV tPA group). The primary outcome was symptomatic intracranial hemorrhage (SICH) within 48 h of EVT.

Results: Overall, 54 patients were included in the analysis, with a median age of 72 years (interquartile range [IQR]: 53-74); 41 (76%) were women. The median pre-stroke modified Rankin Scale (mRS) score was 0 (IQR: 0-2), and the median National Institutes of Health Stroke Scale (NIHSS) score was 7 (IQR: 1-21). These patients underwent emergent stenting with antiplatelet therapy during EVT, with stenting performed in the cervical carotid artery and intracranial artery in 38 and 16 patients, respectively. Thirty-one of 54 patients received IV tPA before EVT. Sex, age, NIHSS score on admission, or Alberta Stroke Program Early Computed Tomographic Score on non-contrast CT did not differ significantly between the IV tPA and no-IV tPA groups. Final modified thrombolysis in cerebral infarction scores ≥2b were achieved more frequently in the IV tPA group than in the no-IV tPA group (97% vs. 87%; p = 0.30). SICH (13% vs. 0%; p = 0.13) and any intracranial hemorrhage (ICH) (29% vs. 8.7%; p = 0.09) occurred more frequently in the IV tPA group than in the no-IV tPA group. The rate of achieving mRS scores of 0-2 at 3 months after stroke onset was lower in the IV tPA group [11 (35%) vs. 13 (57%); p = 0.17].

Conclusion: Among patients who received emergent stenting with antiplatelet therapy, successful reperfusion was achieved more frequently in the IV tPA group than in the no-IV tPA group, although the former exhibited a higher SICH rate and worse functional outcomes. These findings suggest that prior IV tPA administration may increase the risk of hemorrhagic complications in cases requiring emergent stenting with antiplatelet therapy.

Objective: Basilar artery perforating aneurysms (BAPAs) represent an infrequent clinical finding, typically manifesting as subarachnoid hemorrhage (SAH). Consensus on the optimal management of this rare entity is lacking. We report a single-center case series of 11 patients diagnosed with BAPAs, providing a detailed description of their clinical presentation, management course, and follow-up.

Methods: A retrospective review of our institutional aneurysm database was performed, encompassing cases treated between January 2008 and 2024. Inclusion criteria required aneurysm localization to the middle or upper 3rd of the basilar artery.

Results: All cases presented with diffuse SAH, with 80% exhibiting a perimesencephalic cisternal bleeding pattern. Notably, in most cases, aneurysms were detected upon repeat angiography, performed approximately 10 days after the initial angiographic study. A conservative management strategy was employed, resulting in spontaneous aneurysm exclusion in 80% of the cohort. No instances of rebleeding were observed during the follow-up period.

Conclusion: Conservative management demonstrated favorable functional outcomes in our case series, marked by a high rate of spontaneous thrombosis. These findings suggest that conservative management is an effective and potentially preferred treatment strategy for this rare pathology, mitigating perioperative risks associated with surgical or endovascular interventions.

Objective: Shortening prehospital time and door-to-puncture (DTP) time are important to achieve better outcomes in patients with acute stroke. To reduce treatment delays, particularly DTP time and prehospital delays, our core hospital in the Saitama Stroke Network (SSN) implemented a series of interventions aimed at enhancing collaboration with emergency medical services (EMS) personnel and optimizing in-hospital workflows.

Methods: A revised prehospital flowchart was co-developed with the EMS to shorten on-scene time and streamline information transmission using the Cincinnati Prehospital Stroke Scale and essential clinical indicators. Simultaneously, the in-hospital stroke treatment algorithm was modified: CT was omitted, MRI was prioritized, and patients were transferred directly from the imaging suite to the operating room. Intravenous recombinant tissue-type plasminogen activator (rt-PA) was administered in the operating room. Simulation training for hospital staff was conducted bimonthly to reinforce the new protocol. We retrospectively analyzed changes in time metrics and patient volumes before (Group A, January 3, 2019, to January 3, 2020) and after (Group B, January 4, 2020, to January 4, 2021) these interventions.

Results: Among 66 patients undergoing mechanical thrombectomy (MT), DTP time significantly decreased in Group B (p <0.001), with notable improvements in door-to-imaging and imaging-to-operating room intervals. However, prehospital times showed no significant change. The number of MT procedures increased by 54%, and SSN transports rose by 43% from Groups A to B. The rates of successful recanalization (thrombolysis in cerebral infarction score ≥2b) and rt-PA administration increased, but without significant differences.

Conclusion: Although we could not shorten prehospital time sufficiently, DTP time was significantly shortened by our new algorithm and simulation training, and the numbers of acute stroke patients and MT were increased significantly through collaboration with the EMS. Further collaboration with the EMS remains an important challenge going forward.

Objective: Tandem occlusions in acute ischemic stroke are usually atherothrombotic; however, in rare cases, they may result from simultaneous emboli at both proximal and distal sites. Embolic tandem occlusions pose challenges for endovascular therapy because single-stent retrievers (SRs) or aspiration approaches often require multiple passes. This report describes a novel technique that uses serially aligned SRs for en bloc retrieval.

Case presentation: A 90-year-old woman with atrial fibrillation presented with a National Institutes of Health Stroke Scale (NIHSS) score of 22. Imaging revealed an embolic tandem occlusion of the intracranial internal carotid artery (ICA) and the M1 segment of the middle cerebral artery (MCA), with a large penumbra and no ischemic core. A mechanical thrombectomy was performed. Using a 0.074-inch inner diameter distal access catheter, a microcatheter was guided into the M2 inferior trunk. An SR (4 × 40 mm) was deployed across the M2 trunk from the M1 thrombus, followed by the deployment of another SR (6 × 37 mm) across the ICA thrombus. This "Railroad Technique," in which 2 SRs are deployed in a straight, serial alignment, enabled simultaneous capture and en bloc retrieval of both thrombi in a single pass, resulting in recanalization of the ICA and M1. A 2nd pass with an SR and aspiration catheter resulted in modified thrombolysis in cerebral infarction (mTICI) 2b reperfusion. The patient recovered rapidly.

Conclusion: The Railroad Technique may be a feasible option for embolic tandem occlusions with large thrombus volumes and anatomically distant lesions.

Objective: Moyamoya disease and dural arteriovenous fistulas (dAVFs) are both rare conditions, and their coexistence is extremely uncommon. The causal relationship between moyamoya disease and cavernous sinus dAVFs (CS-dAVFs) remains unclear. We report a successfully treated case of CS-dAVF in a patient with moyamoya disease, focusing on vascular structural changes and potential pathophysiological associations.

Case presentation: A 69-year-old man with a history of moyamoya disease presented with progressive left ocular symptoms. Imaging studies, including 3D-DSA, revealed a CS-dAVF supplied by multiple feeders and draining into the superior ophthalmic and angular veins. Compared to previous imaging, the progression of moyamoya disease was evident, with worsening middle cerebral artery stenosis and increased collateral vessels. Superselective transvenous embolization was performed under general anesthesia. Microcatheters were navigated into the affected venous structures, and coil embolization successfully obliterated the shunt. Postoperatively, the patient had significant symptomatic improvement, with no moyamoya-related complications, and was discharged on postoperative day 4.

Conclusion: To our knowledge, this is the first report of a successfully treated CS-dAVF in a patient with moyamoya disease. Superselective transvenous embolization was successfully performed, which led to a favorable outcome despite the presence of moyamoya disease.