Journal of cerebrovascular and endovascular neurosurgery最新文献

Y-configuration stent deployment strategies for aneurysms with complex configurationare well recognized, with and without subsequent coil placement. Delivery of flow diverters in this configuration has no precedent in the literature and may be a viable alternative when feasible. A case is presented in which this configuration for a complex anterior cerebral artery aneurysm was achieved, with subsequent successful aneurysm closure.

Objective: In practice, variability in clinical decisions among clinicians can exist and may be acceptable. However, from the patient's standpoint, particularly for those with potentially life-threatening conditions such as unruptured intracranial aneurysms (UIAs), this variability can be confusing and concerning. In this study, the levels of interobserver agreement in clinical decisions among three endovascular neurosurgeons working at the same hospital were analyzed using a newly developed grade of recommendation (GOR) system.

Methods: A total of 161 consecutive patients with 202 UIAs were included in this study. The GOR system consists of six grades, representing various clinicians' recommendations, including treatment or no-treatment. The three observers reviewed the medical records and digital subtraction angiography images, and then assigned the corresponding GORs for each aneurysm. Interobserver agreement was analyzed using Fleiss' kappa values.

Results: The overall Fleiss' kappa among three observers was 0.52, indicating a moderate level of interobserver agreement. The agreement was relatively high for grades 1 and 5. It was the lowest for grade 3. When GORs were classified as treatment, middle and no-treatment groups, the overall kappa value was 0.84, indicating almost perfect.

Conclusions: This study shows that the level of interobserver agreement was very high for treatment versus no-treatment decisions, but moderate regarding the strength of the recommendations. Further studies are needed to clarify the detailed reasons for the similarities and differences in clinicians' recommendations.

Objective: This study compared clinical and cosmetic outcomes of cranioplasty using customized three-dimensional (3-D) printed implants versus autologous bone in patients with aneurysmal subarachnoid hemorrhage (aSAH) after decompressive craniectomy (DC).

Methods: We retrospectively reviewed 50 patients who underwent cranioplasty after DC for aSAH between July 2018 and December 2023. Patients were divided into the three-dimensional cranioplasty(3-DC, n=26) and autologous bone cranioplasty (AC, n=24) groups. Demographics, aneurysm characteristics, surgical parameters, morphometric analysis of defect coverage, complications, and functional outcomes assessed by the modified Rankin Scale (mRS) were compared.

Results: A total of 54 hemispheres underwent cranioplasty. Compared with AC, the 3-DC group had larger defects but achieved higher coverage (96.7% vs. 93.4%, p=0.044) and smaller residual defects (338.7±274.2 mm² vs. 528.5±331.3 mm², p=0.049). Complication rates were lower in 3-DC (9 cases) than AC (15 cases, p=0.0994). Wound dehiscence and fluid collection were more frequent with 3-DC, while bone flap resorption and epidural abscess occurred only with AC. Revision surgery was required in six patients, five initially treated with autologous bone. Neurological outcomes (mRS) were maintained or improved in both groups.

Conclusions: In aSAH patients undergoing cranioplasty after DC, customized 3-D printed implants achieved significantly better anatomical restoration and showed a numerical trend toward fewer complications compared with autologous bone. While AC remains feasible, its risks of resorption and infection often necessitate revision. 3-D printed implants may be considered a reasonable alternative, particularly in aSAH patients at higher risk of complications.

Background: Kissing middle cerebral artery bifurcation aneurysms (KMCBA) are rare vascular lesions. Their complex morphology and limited surgical experience may predispose patients to devastating complications.

Cases: Among 100 patients who underwent microsurgical clipping for cerebral aneurysms between May 2022 and April 2025, two were diagnosed with unruptured KMCBA. In Case 1, the two aneurysm sacs of a left KMCBA were clipped separately using interlocking and fenestrated clips without premature rupture. In Case 2, both aneurysm sacs of a right KMCBA were clipped simultaneously with a long J-shaped clip. Postoperatively, the patient developed left hemiparesis due to clip-induced encroachment of the superior trunk of M2. Revision clipping with a shorter L-shaped clip restored flow, and the patient was discharged with a modified Rankin scale (mRS) score of 4.

Conclusions: Successful microsurgical clipping of KMCBA requires meticulous surgical strategies to avoid parent artery encroachment, including separate clipping of each aneurysm neck whenever feasible, appropriate clip selection, and the use of multimodal intraoperative anatomical and physiological monitoring.

Objective: Saccular aneurysms of the basilar artery (BA) trunk are a significant challenge in neurosurgery due to their rarity and the complexity of surgical approaches. This study examines the efficacy and outcomes of microsurgical treatment for these aneurysms, highlighting the advantages over endovascular methods in terms of occlusion rates and complication management.

Methods: A retrospective review of 23 patients with BA trunk aneurysms treated microsurgically at the Moscow Regional Clinical Research Institute from June 2019 to April 2024 was conducted. Patient demographics, aneurysm characteristics, surgical techniques, and postoperative outcomes were analyzed.

Results: The study group included 16 women and 7 men, with an average age of 51.2 years. Notably, 19 of 23 patients (82.6%) presented with subarachnoid hemorrhage (SAH), while 4 had unruptured aneurysms (2 asymptomatic, 2 with mass effect). Aneurysms were predominantly located at the origin of the superior cerebellar artery (SCA). Surgical approaches varied based on aneurysm location, with most utilizing the orbito-pterional approach. Complete occlusion was achieved in all cases and was maintained over the follow-up period without signs of recanalization. Complications included transient oculomotor nerve dysfunction in 5 patients, with a substantial recovery rate. Favorable outcomes (mRS 0-2) were achieved in 87% of patients, including most SAH cases, highlighting the safety and effectiveness of treatment.

Conclusions: Microsurgical treatment of BA trunk aneurysms provides a reliable occlusion with a low rate of complications and excellent clinical outcomes. This series supports microsurgery as a preferred option for managing these challenging aneurysms, particularly when located at the SCA origin.

Carotid webs are endoluminal shelf-like projections caused by fibrous dysplasia observed along the dorsal carotid bulb of the internal carotid artery (ICA). Symptomatic lesions have historically been treated with endarterectomy or stent placement and there is little data to support treating a patient with medical management alone. An asymptomatic contralateral carotid web may be discovered during stroke work-up. In this study, we evaluate the safety and efficacy of staged bilateral carotid artery stenting for bilateral carotid webs. We report three cases: the first patient presented with recurrent transient ischemic attacks attributable to an ipsilateral ICA with associated carotid web and the other two presented with right middle cerebral artery strokes requiring emergent endovascular mechanical thrombectomy. Bilateral carotid webs were identified, with the ipsilateral lesion considered the likely embolic source. All three patients underwent successful carotid stenting of their symptomatic carotid webs followed by staged contralateral stenting of their asymptomatic webs. All patients were premedicated with a dual antiplatelet regimen of aspirin and clopidogrel. There was no clinical history of recurrent stroke/transient ischemic attack (TIA) or death peri-procedurally or in follow-up. Bilateral carotid web stenting is a safe and effective treatment in patients presenting with symptomatic carotid webs with associated contralateral lesions.

Dural arteriovenous fistulas (dAVFs) are uncommon intracranial vascular shunts that typically cause hemorrhage when retrograde cortical venous drainage and diffuse venous hypertension are present. Venous aneurysms are usually considered a sequela of sustained venous hypertension; however, localized focal hemodynamic stress may also contribute to aneurysm formation and rupture. We report a rare case of a 51-year-old woman who presented with acute expressive aphasia and dense right hemiparesis. Imaging revealed a large left temporoparietal intracerebral hemorrhage with subarachnoid extension. Digital subtraction angiography demonstrated a left temporal dAVF supplied by the middle meningeal artery and draining via the veins of Trolard and Labbé into the superior sagittal sinus. A discrete saccular venous aneurysm was identified at a sharply angulated and stenotic draining segment, suggesting localized venous hypertension without diffuse angiographic congestion. Transarterial embolization using Onyx-18 achieved complete obliteration of the fistula and aneurysm. At one-month follow-up, the patient showed complete recovery of aphasia and marked motor improvement. This case illustrates that focal venous hypertension, even without diffuse angiographic congestion, can result in aneurysm formation and rupture. Early angiographic assessment and endovascular intervention remain critical for favorable outcomes.

Alagille syndrome (ALGS), also known as arteriohepatic dysplasia, is a rare multisystem vascular disorder affecting brain, liver, heart, ophthalmic and skeletal systems. Moyamoya syndrome is a rare arteriopathy due to an underlying cause that can lead to ischemic and hemorrhagic strokes. Here, we report a rare case of ALGS in a patient with congenital narrowing of bilateral internal carotid arteries (ICA) with superimposed intracranial arteriopathy and associated moyamoya syndrome. A 34-year-old female presented with progressively worsening intermittent right eye visual blurriness, associated headache, and dizziness. Digital subtraction angiogram findings were consistent with the bilateral intracranial steno-occlusive disease at the ICA terminus with moyamoya collaterals at the skull base; bilateral posterior communicating arteries supplied the bilateral middle cerebral arteries, and the left ophthalmic artery supplied the distal right anterior cerebral artery. Her right-sided vision abnormalities were highly concerning for branch retinal artery occlusion based on fundoscopic exam. She continued antiplatelet therapy and was scheduled for an ophthalmology follow-up as an outpatient. The patient was monitored in outpatient stroke clinic with surveillance scans. Due to patient preference and the absence of further strokes on preventive medications, the initial plan of external carotid artery to ICA bypass was deferred. Early identification of moyamoya syndrome and initiation of secondary stroke preventive therapy in symptomatic patients can reduce the incidence of ischemic strokes. This is an important consideration for patients transitioning from pediatric to adult neurologists, as the latter may not be as familiar with managing this condition.

Objective: We aimed to investigate the predictors of aneurysm occlusion following flow diversion treatment for unruptured intracranial aneurysms (UIA) using the Surpass Evolve (SE) stent.

Methods: The radiological and clinical outcomes of UIAs treated using SE stent at a single tertiary hospital were reviewed retrospectively. We categorized radiological outcome into the poor (O'Kelly-Marotta [OKM] grade A-B) and favorable occlusion group (OKM grade C-D). Univariate and multivariate analyses were conducted to identify risk factors associated with poor occlusion.

Results: A total of 68 unruptured intracranial aneurysms in 52 patients were treated in our institution from December 2019 to July 2024. At last radiological follow-up (mean 17.5±10.1 months), the overall favorable occlusion rate was 79.4% (n=52). Multivariate analysis showed larger aneurysm (p=0.011, OR=0.89, 95% CI [0.81-0.98]) and presence of incorporated branch (p=0.007, OR=8.26, 95% CI [1.78-38.28]) were associated with independent factors for poor occlusion, respectively. Procedural mortality and morbidity were 0% (n=0) and 1.9% (n=1). One patient presented with delayed ischemic stroke (1.9%, n=1) without permanent neurological deficit.

Conclusions: Treatment for UIAs using the Surpass Evolve flow-diverting stent might be feasible for efficacy and safety. In this study, larger size of aneurysm and branch incorporated aneurysm were associated with poor occlusion after flow-diversion using SE stent.

The adhesion of arteries to aneurysm domes can pose significant technical challenges during surgical clipping. Dissection of these vessels carries a risk of iatrogenic wall damage and subsequent complications. We present the case of a 67-year-old woman with three unruptured intracranial aneurysms. Following successful coil embolization of a right posterior communicating artery aneurysm, surgical clipping was planned for the remaining left middle cerebral artery and anterior choroidal artery aneurysms. Intraoperatively, the M2 inferior division was found to be densely adherent to an aneurysm located at the bifurcation of the M2 superior division. After temporary clipping of the parent artery, careful dissection was performed, and the aneurysm was successfully clipped. Postoperatively, the patient failed to regain consciousness. A computed tomography scan revealed diffuse subarachnoid hemorrhage, and subsequent angiography confirmed active contrast extravasation from the dissected M2 inferior division. The family declined reoperation, and the patient subsequently expired after brain death was declared. This case illustrates that in instances of strong arterial adhesion, extreme caution is warranted during dissection. Even without evident intraoperative bleeding, subtle vessel wall injury can lead to fatal delayed rupture. Meticulous inspection and, when necessary, reinforcement of dissected arterial segments is crucial to prevent such devastating outcomes.