Journal of neuroendovascular therapy最新文献

Objective: Fenestrated basilar artery aneurysms (fBA-ANs) typically arise at the proximal bifurcation of the fenestration limb. It is reported that endovascular treatment with conventional coil embolization or balloon-assisted embolization techniques is often challenging and associated with a high complication rate, especially for wide-neck fBA-ANs. We present a case of fBA-AN successfully treated with stent-assisted coil (SAC) embolization using a novel one-and-a-half-lap approach with an open-cell stent, ensuring reliable neck coverage while preserving parent artery patency.

Case presentation: A 33-year-old man with a history of an unruptured fBA-AN, previously treated with coil embolization via the double-catheter technique 6 years ago, presented with coil compaction and aneurysm recurrence. DSA revealed an fBA-AN measuring 8.7 mm in diameter, requiring retreatment. Under general anesthesia, SAC was performed using a one-and-a-half-lap approach. A Neuroform Atlas stent (Stryker Neurovascular, Fremont, CA, USA) was deployed via a 2.4 Fr microcatheter, positioned in a clockwise direction from the left loop fenestration to the right loop across the aneurysm neck, followed by coil embolization. Postoperatively, the patient remained free of ischemic complications, and follow-up imaging showed no recurrence of the fBA-AN.

Conclusion: This case demonstrates the efficacy of SAC with a one-and-a-half-lap approach using an open-cell stent for the treatment of complex fBA-ANs. This technique provides a viable treatment option for wide-neck fBA-ANs, ensuring durable aneurysm occlusion while maintaining parent artery patency.

Objective: Left ventricular systolic dysfunction has traditionally been considered an unfavorable prognostic factor in stroke. However, chronic hypoperfusion due to this dysfunction may improve cerebral collateral flow, potentially serving as a compensatory mechanism during ischemic stroke. This study aimed to investigate the effects of left ventricular systolic dysfunction on outcomes after mechanical thrombectomy (MT), with a focus on cerebral collateral flow.

Methods: This retrospective cohort study included 94 consecutive patients with acute ischemic stroke who underwent MT between April 2017 and July 2022. Patients were divided into 2 groups based on their left ventricular ejection fraction (EF): the reduced EF group (EF ≤40%) and the preserved EF group (EF >40%). We evaluated post-treatment stroke volume, clinical outcomes, length of hospital stay, and the relationship between EF and cerebral collateral flow.

Results: The reduced and preserved EF groups consisted of 11 (12%) and 83 (88%) patients, respectively. No significant differences were observed in post-treatment stroke volume (13 vs. 12 cm³, p = 0.779), hospital stay duration (23 vs. 22 days, p = 0.634), or favorable clinical outcomes at discharge (36% vs. 43%, p = 0.754) between the 2 groups. The odds ratio for favorable outcomes at discharge, adjusted using inverse probability of treatment weighting, was 0.693 (95% confidence interval: 0.176-2.732, p = 0.600) for the reduced EF group compared with the preserved EF group. Cerebral collateral flow developed better in the reduced EF group (56% vs. 13%, p = 0.008).

Conclusion: Left ventricular systolic dysfunction did not significantly worsen outcomes after MT. Chronic cerebral hypoperfusion due to left ventricular systolic dysfunction may promote the development of cerebral collaterals, potentially enhancing resistance to ischemic events.

Objective: The distal transradial approach has been one of the options for endovascular neurointervention because of the low risk of puncture site complications. However, the conventional and distal transradial artery approaches frequently cause cannulation-induced vasospasms, which can usually be prevented by vasodilators. The aim was to evaluate the effects of local infiltration using a puncture site cocktail of lidocaine mixed with nitroglycerin on puncture success and vasospasm for distal transradial cerebral angiography.

Methods: A total of 85 consecutive patients who underwent cerebral angiography via distal radial artery puncture between February 2024 and December 2024 were included. Of these patients, 28 patients were excluded due to irregularities. The remaining 57 patients were eligible for this retrospective study and were divided into 2 groups: (1) underwent local anesthesia with 1% lidocaine (n = 23, Lidocaine group); and (2) puncture site cocktail of 1% lidocaine mixed with nitroglycerin (n = 34, Cocktail group). In both groups, patients' characteristics and procedure results were retrospectively assessed. In addition, in all patients, the correlation between the number of punctures and distal radial artery diameter, and the cutoff values of distal radial artery diameters after local anesthesia for 1st puncture success were also assessed.

Results: Patient background characteristics showed no significant differences between the groups. In the procedure results, the mean diameter of the distal radial artery before local anesthesia was significantly smaller in the Cocktail group (2.1 vs 1.7 mm, p <0.05). The mean dilatation rate of the distal radial artery was significantly greater in the Cocktail group than in the Lidocaine group (1.3 vs 1.1, p <0.05); thus, there was no difference in the mean diameter after local anesthesia. The 1st puncture success rate and the mean number of punctures were not significantly different between the 2 groups. The rate of cannulation-induced distal flow arrest was significantly lower in the Cocktail group (47.8% vs 20.6%, p <0.05). Puncture site complications and radial artery occlusions were not observed in either group. There was a negative correlation between distal radial artery diameter after local anesthesia and the number of punctures (r = -0.53, 95% CI: -0.69 to -0.31, p <0.001). The cutoff value for the diameter of the distal radial artery was 1.9 mm.

Conclusion: The puncture site cocktail significantly increases the diameter of the distal radial artery, which may be related to the reduction of cannulation-induced vasospasm without periprocedural complications in cases with a small-diameter distal radial artery.

Objective: Carotid artery stenting (CAS) has been reported to be a safe and effective option for treating carotid atherosclerotic disease. However, reports and studies from resource-limited countries are scarce. The published data support the use of embolic protection devices (EPDs) to reduce periprocedural stroke. This study aimed to evaluate the outcomes of CAS procedures without EPDs in Yemen, one of the lowest-income countries.

Methods: This is a retrospective cohort study regarding CAS for symptomatic carotid artery stenosis that was conducted at the stroke center of Borg Al-Atiba and American Modern Hospital during the period from March 2023 to March 2025. All patients with symptomatic carotid artery stenosis were included in the study. CAS procedures were performed by a single interventional neurologist. The primary outcomes included a 30-day periprocedural mortality, stroke, myocardial infarction, or arrhythmia. Any other complications were considered secondary outcomes.

Results: A total of 62 patients (53 males) were included in this study, with a mean age of 60.2 ± 9.7 years. All patients had symptomatic carotid artery stenosis. The technical success rate was 100%. No perioperative cerebral infarctions were observed. One patient developed transient dysarthria, but diffusion-weighted-MRI was negative. Significant bradycardia occurred in 2 patients and responded immediately to atropine. Three patients developed mild local hematoma, and 1 patient had a femoral pseudoaneurysm. Closed-cell Carotid WALLSTENT (Boston Scientific, Marlborough, MA, USA) was used as a single stent in all patients.

Conclusion: CAS conducted by a trained interventional neurologist without EPDs demonstrates a low complication rate, and it is an effective and safe option in countries with limited resources.

Objective: Flow diverter (FD) stents are a promising treatment option for complex intracranial aneurysms. However, rapid hemodynamic changes, thrombus formation, and complex morphologies can increase rupture risk and pose technical challenges. To address these concerns, a "staged treatment" with initial coil embolization followed by delayed FD placement has been introduced. This study aimed to evaluate its clinical outcomes, safety, and technical feasibility, including in anatomically challenging aneurysms.

Methods: A retrospective analysis was conducted on 11 patients with intracranial aneurysms who underwent initial coil embolization followed by FD placement at our institution between 2018 and 2024. The data collected included aneurysm characteristics, number of coils used, initial volume embolization ratio (VER), interval between coil embolization and FD placement, and procedure-related complications.

Results: Of the 11 patients, 10 were female. Nine aneurysms were large (>10 mm) and 2 were giant (>25 mm). The median initial VER was 18% and the median interval between coil embolization and FD placement was 79 days. All the FD procedures were technically successful, even in aneurysms for which direct distal navigation was expected to be difficult. No permanent complications or delayed ruptures occurred during the follow-up. At the 12-month follow-up DSA, 81.8% of the patients achieved complete occlusion (O'Kelly-Marotta [OKM] grade D), and all cases were graded as OKM C or higher. All patients had favorable clinical outcomes, with modified Rankin Scale scores of 0 or 1.

Conclusion: Staged FD treatment appears to be a safe and effective therapeutic option for treating large, ruptured, or morphologically complex intracranial aneurysms. This approach may serve as a valuable alternative in cases in which primary FD deployment poses a high procedural risk. Moreover, the use of coils in the initial stage may offer a mechanical scaffold that facilitates a more stable and safer FD delivery. Nevertheless, further studies are warranted to determine the optimal coil packing density and timing of the FD placement.

Objective: Flow diverter placement across the ophthalmic artery carries a reported visual-impairment risk of about 1%, yet oculomotor nerve palsy following treatment of small paraclinoid aneurysms without mass effect has not been described. Our objective was to present a case of a transient oculomotor palsy following a flow diverter treatment for 6 and 2.5 mm paraclinoid aneurysms.

Case presentation: A 57-year-old woman underwent flow diverter treatment for two left paraclinoid aneurysms measuring 6 and 2.5 mm. On the fifth post-operative day, she experienced blurred vision, mild left ptosis, and restricted adduction and elevation of the left eye, while pupillary function remained intact. The diagnosis of left pupil-sparing oculomotor palsy was made. Conservative management led to full resolution of symptoms within three months. Follow-up 3D rotational angiography demonstrated occlusion at the origin of the inferolateral trunk of the left internal carotid artery.

Conclusion: Oculomotor nerve palsy caused by flow diverter coverage of small internal carotid artery branches supplying the cranial nerves may be an under-recognized complication and warrants clinical attention. A review of the literature suggested an approximately 3% incidence of this complication, and we discussed the pathomechanism of the cranial nerve palsy caused by flow diverter treatment.

Objective: Arterial spin labeling (ASL) is a noninvasive MRI technique used to evaluate cerebral perfusion. Arterial transit artifact (ATA), which appears as high-signal areas proximal to vessel occlusion, may provide important diagnostic information, particularly when conventional angiographic visualization is limited. We present two cases of posterior cerebral artery (PCA) occlusion in which ATA detection via ASL played a critical role in guiding endovascular treatment.

Case presentation: Case 1 involved a woman in her 70s who presented with right-sided numbness and visual field loss. MRA did not clearly delineate the left PCA; however, ASL revealed an ATA in the P3-4 territory distal to the angiographically confirmed P2 occlusion. CT perfusion confirmed hypoperfusion, and thrombectomy resulted in complete visual recovery. Case 2 involved a man in his 40s who experienced sudden-onset blindness. MRA indicated bilateral PCA occlusion, and ASL showed bilateral ATA(s). Following intravenous recombinant tissue-type plasminogen activator administration and left PCA thrombectomy, partial visual improvement was observed. On postoperative day 3, ASL again revealed an ATA in the right P3 segment, suggesting reocclusion. Emergency thrombectomy led to visual restoration.

Conclusion: These cases highlight the utility of ASL imaging and ATA detection in diagnosing PCA occlusion and monitoring treatment response. ASL provides a noninvasive, contrast-free complement to MRA in the acute stroke setting, particularly for the posterior circulation, where visualization is often limited. ATA may serve as a valuable imaging biomarker for identifying occlusion and reocclusion, aiding clinical decision-making.

Objective: Reports on embolization of the feeding arteries for vestibular schwannomas are limited, and studies addressing the tumor volume reduction effect of embolization are similarly scarce. Here, we present a case of a patient with vestibular schwannoma and associated ventricular enlargement, in which preoperative embolization led to substantial tumor volume reduction and subsequent improvement in ventricular enlargement.

Case presentation: The patient was a 32-year-old man presenting with hearing loss, headache, nausea, unsteadiness, and loss of appetite. MRI displayed a left vestibular schwannoma with a maximum diameter of 38 mm and associated ventricular enlargement. Angiography displayed a hypervascular vestibular schwannoma with feeders from the left anterior inferior cerebellar artery (AICA) and the petrosal branch of the middle meningeal artery (MMA). Embolization was performed using 25% N-butyl cyanoacrylate for the AICA and 500-700-μm Embosphere microspheres diluted 60 times for the MMA. Symptomatic improvement was observed 2 days after the procedure. MRI conducted 4 days after the procedure showed a 19.8% reduction in tumor volume and mild ventricular shrinkage. The patient underwent tumor resection 7 days post-embolization and had a favorable postoperative course.

Conclusion: Although the tumor volume reduction effect of preoperative embolization does not always lead to an improvement in ventricular enlargement, our present case demonstrates that preoperative embolization can contribute to the improvement of ventricular enlargement through its volume reduction effect.

Objective: Anterior condylar (AC) arteriovenous fistulas (AVFs) can form intraosseous shunted pouches, and recent reports have suggested the involvement of the jugular tubercle venous complex (JTVC). Transvenous embolization (TVE) via the AC vein (ACV) is considered the 1st-line treatment. This paper reports a case of an intraosseous AC-AVF successfully treated with TVE via a strategic detour through the posterior condylar vein (PCV).

Case presentation: A 60-year-old woman was suspected of having a dural AVF during the examination for pulsatile tinnitus. Detailed preoperative imaging studies using 3D rotational angiography (3D-RA) and cone-beam CT (CBCT) led to the diagnosis of an intraosseous AC-AVF. We were unable to navigate the catheter through a potentially existing direct pathway to the intraosseous shunted pouch, as it was not visualized on intraoperative angiography. Finally, we were able to navigate by tracing a unique drainage detour involving the PCV visualized on angiography and perform selective TVE. Postoperatively, the shunt completely disappeared, and the pulsatile tinnitus resolved.

Conclusion: Detailed preoperative imaging studies using 3D-RA and CBCT, as well as the use of a thin intermediate catheter, may have enabled the unique approach. In intraosseous shunts, guiding through the visualized drainage route, even when it involves a detour, may represent the most reasonable primary strategy.

In recent years, artificial intelligence (AI) has made remarkable progress. In the near future, AI will become an indispensable technology in daily clinical practice in the field of neuroendovascular therapy. Clinicians who understand the information processing and limitations of AI will create new and comfortable working styles. This article introduces current applications of AI in the field of neuroendovascular therapy and presents a vision for its future directions.