Journal of neuroendovascular therapy最新文献

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.

Objective: Duplication of extracranial cerebral arteries is a rare anatomical variant, most commonly observed in the vertebral artery. However, duplication of the cervical internal carotid artery (ICA) is extremely rare. We present a unique case of a patient diagnosed with a right facial artery aneurysm, in whom a right duplicated ICA, ipsilateral persistent stapedial artery (PSA), and contralateral aberrant ICA were incidentally identified.

Case presentation: A 56-year-old woman presented with a painless mass in the right lower jaw. Physical examination revealed a round, pulsatile mass. Contrast-enhanced CT demonstrated a 25 mm saccular aneurysm originating from the right facial artery, along with a right duplicated ICA and a left aberrant ICA. The lateral limb of the right duplicated ICA and the left aberrant ICA were seen traversing the tympanic cavity and entering the carotid canal. The absence of the right foramen spinosum indicated the presence of a PSA. Angiography confirmed the duplicated ICA, aberrant ICA, and PSA. The lateral limb of the right duplicated ICA gave rise to the occipital artery and a small branch, the PSA, which entered the middle cranial fossa. The facial artery aneurysm was successfully embolized. Follow-up MR angiography showed stable occlusion of the aneurysm, with the duplicated ICA giving off both the PSA from the lateral limb and a pharyngeal branch from the medial limb.

Conclusion: This case provides valuable insights into the development of the cervical arterial system during the fetal period, particularly the collateral pathways connecting the third arch to the dorsal aorta.

Objective: Although vagal paragangliomas (VPs) and carotid body paragangliomas (CBPs) are both neck paragangliomas, they have different surgical risks and clinical courses. In this report, we investigated the feeding arteries of VPs compared with CBPs, with an aim to better differentiate these tumors and improve our understanding of their angioarchitecture.

Methods: We conducted a retrospective analysis of angiography data from 3 cases of VPs and 10 tumors from 9 cases of CBP. For each case, we evaluated the level of the vertebral body corresponding to the upper margin of the tumor, the tumor size, the arterial supply of the tumor, the topological relationship between the external carotid artery and internal carotid artery and the tumor, the details of preoperative embolization, and the incidence of postoperative neurological deficits.

Results: In all 3 cases of VPs, the blood supply originated from the occipital, vertebral, and ascending pharyngeal arteries. By contrast, among the 10 CBP tumors, 3 were supplied by the occipital artery, 1 was supplied by the vertebral artery, and all 10 were fed by the ascending pharyngeal artery. VPs, when compared to CBPs, exhibited larger tumor sizes, a higher positioning of the upper margin of the tumor, and a lack of splaying of the internal and external carotid arteries, compressing both forward. Additionally, preoperative embolization was frequently performed in cases of VPs. Furthermore, the postoperative occurrence of complications such as hoarseness and vocal cord paralysis was also higher.

Conclusion: VPs originate from the inferior ganglion of the vagus nerve, which is chiefly nourished by the vertebral artery. This original arterial distribution may explain the angioarchitecture observed in this study. This study may facilitate the better understanding of the VP angioarchitecture and safe and efficient embolization for them.

Objective: Hematoma expansion in acute epidural hematomas occurred in 11.2%-32% of patients treated conservatively at initial presentation and required craniotomy. Middle meningeal artery (MMA) embolization has been reported to be effective in preventing hematoma expansion. We report a case of an asymptomatic acute epidural hematoma in which CTA was used to identify the source of bleeding. Embolization of the MMA was performed to prevent hematoma expansion.

Case presentation: A 30-year-old male patient was admitted to the emergency department following a collision with a car while riding his motorcycle. The patient exhibited clear consciousness and no neurological deficits. A head CT scan revealed a right parietal and temporal bone fracture, and an acute epidural hematoma directly below the fracture site. The hematoma was small, and the patient was treated conservatively. Three hours later, a follow-up head CT scan revealed an enlarged hematoma. This hematoma was found near the transverse sinus. To identify the source of the bleeding, a CTA was performed, which revealed extravasation into the hematoma from an area distant from the transverse sinus. We performed embolization of the MMA. The postoperative course was good with no postoperative hematoma expansion.

Conclusion: CTA for acute epidural hematoma without neurological symptoms is a useful diagnostic tool that can identify patients at high risk for hematoma expansion. If the findings indicate the need for intervention, MMA embolization is a treatment option that may reduce the risk of hematoma expansion and craniotomy.

Objective: Carotid endarterectomy (CEA) is a standard treatment for atherosclerotic carotid stenosis. Perioperative symptomatic restenosis or reocclusion of the carotid artery following CEA is a rare but serious complication that typically necessitates intervention. The efficacy and safety profile of emergent endovascular therapy (EVT) as an alternative to repeat CEA in the treatment of acute perioperative neurological decline remain unknown.

Methods: All patients undergoing CEA in the Department of Neurosurgery at a single comprehensive stroke center from 2015 to 2024 were reviewed. Patients who underwent EVT for acute perioperative neurological deficits were included in our series. A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify articles relevant to the endovascular management of acute neurological deficits following CEA.

Results: Four patients from our institutional cohort met the inclusion criteria. An additional 39 patients were identified from the literature review in 11 source articles, which yielded a total of 43 patients. CEA was performed for symptomatic lesions in 28 (28/32, 87.5%) patients. Abnormal angiographic findings were reported for all patients. Thrombus accumulation in or distal to the operated internal carotid artery (ICA) (26/43, 60.5%) and dissection flaps (15/43, 34.9%) were the most common findings. Five (11.6%) patients had tandem cervical ICA and intracranial occlusions, of which thrombectomy of the intracranial lesion was successfully performed on 3 patients. All patients except for 1 (42/43, 97.6%) underwent technically successful endovascular stenting. Following EVT, 76.7% (33/43) of patients had no persisting neurological deficits. Nine (20.9%) patients were found to have new cerebral infarcts on post-EVT imaging. In-hospital mortality was reported for 6 patients (14%), 4 of whom were found to have tandem cervical ICA and intracranial occlusions.

Conclusion: EVT is likely a technically viable alternative treatment for patients with perioperative acute neurologic deficits after CEA. However, most of the literature available comes from case series, thereby limiting the quality of evidence. Improved reporting of standard stroke outcome measures may help to inform the implementation of EVT and repeat CEA for acute ischemic symptoms after CEA.

Objective: During the perioperative period of carotid artery stenting (CAS), severe aortic stenosis (AS) is associated with a risk of serious complications, such as cardiac arrest. There is no consensus regarding the order of treatment for patients with severe AS concomitant with proximal carotid artery stenosis. We herein report a case in which CAS following transcatheter aortic valve implantation for severe AS was safely performed in an older high-risk patient.

Case presentation: An 84-year-old woman presented with severe aortic stenosis that required treatment. Magnetic resonance angiography revealed severe left proximal internal carotid stenosis. Cerebral blood flow measurements revealed a normal cerebral perfusion. An uneventful transcatheter aortic valve implantation for severe aortic stenosis was followed by carotid stenting at a 2-month interval.

Conclusion: Staged treatment may be a safe and effective strategy in high-risk patients with concomitant severe AS and carotid stenosis. In cases with a normal cerebral blood flow, CAS following transcatheter aortic valve implantation can be a reasonable option, especially in older patients with multiple comorbidities.

Objective: The implantation of stents in the cerebral arteries for aneurism exclusions requires the administration of dual antiplatelet therapy. This medication increases the haemorrhage risk, while some patients develop a phenomenon called "high on-treatment platelet reactivity," exposing to the material thrombosis. The focus on the platelet function monitoring in this context is key to the success of this procedure, allowing for identification of the different population of patients for the adjustment of the prescription for which antiplatelet therapy to use, to get the best balance between the prevention of material thrombosis and haemorrhage risk. This study focuses on the use of platelet function monitoring with Multiplate (Roche, Boulogne-Billancourt, France), in the context of a prescription of clopidogrel and its possible replacement by ticagrelor for resistant patients.

Methods: The study is an observational retrospective cohort monocentric study. Patients were sampled for a Multiplate analysis with no antiplatelets treatment, then the day before the procedure, a new Multiplate analysis is proceeded with after 5 days of clopidogrel and aspirin. If adenosine diphosphate (ADP) test was above 300 area under the curve on Multiplate, it was decided to introduce ticagrelor. The primary endpoint was the occurrence of thromboembolic or haemorrhagic events during the first 30 days postoperatively.

Results: 104 patients treated electively with a stent for an intracranial aneurysm were included from January 2016 to June 2020; 77 patients were classified as responder to clopidogrel and 27 had to be switched from clopidogrel to ticagrelor; 9 patients under clopidogrel (8.6%) had an ischaemic event and 1 under ticagrelor (1%). No patient had a haemorrhagic event under clopidogrel and 3 under ticagrelor (2.8%). Comparing clopidogrel and ticagrelor group regarding ischemic or haemorrhagic event endpoints, the difference was not statistically significant: (p = 0.37), but statistically significant regarding fatal event (p = 0.02) in disfavour of ticagrelor.

Conclusion: The use of platelet function monitoring makes it possible to determine the therapeutic effectiveness of P2Y12 inhibitors, and thus to provide the most appropriate antiplatelets treatment for the patient when an intracranial stent is placed.

Interventional and therapeutic neuroradiology offers minimally invasive treatments for neurological disorders, and the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) plays a crucial role in advancing this field globally. This article discusses WFITN's mission to promote education, research, and collaboration among practitioners, establish clinical standards, and embrace technological innovations. It highlights the Federation Assembly's role in governance and policy-making, as well as initiatives like mentorship programs aimed at empowering women in neurointerventional radiology. Facing challenges such as rapid technological changes and healthcare disparities, WFITN is committed to expanding its global impact and fostering an inclusive, innovative community to enhance patient outcomes worldwide.