Journal of cerebrovascular and endovascular neurosurgery最新文献

Spontaneous scalp arteriovenous malformations (AVMs) are often present at birth but are usually noticed when they cause aesthetic problems in adulthood. Concerning treatment; there has been a shift towards endovascular treatment alone or in combination with surgical resection. In developing countries, endovascular options might not be readily available. We hereby report a case of a large spontaneous scalp AVM managed successfully via surgical excision only. A 35-year-old man presented with a large pulsating mass located in the occipital region of the scalp. This mass had been present from birth and had been growing over the years. Computed tomography (CT) scan and CT-angiography showed an occipital, contrast-enhancing mass, mostly lateralized to the right and fed by the right occipital artery. The patient did not benefit from digital subtraction angiography or pre-operative embolization. An indication for surgical excision was made. The first step was geared at controlling hemorrhage which was only partially effective due to another feeder that was missed on the CT-angiography. The second step involved dissecting and de-vascularizing the lesion. Complete excision of the AVM was achieved along with excision of the adjacent galea. Management of large scalp AVMs is possible even in resource strained environments. Knowledge of the behavior of feeders regarding lateral or midline disease, coupled with meticulous interpretation of available imaging, is essential in planning surgery. Intra- operative bleeding can be controlled by early temporary clipping or ligation of the main feeders and then one can proceed with the surgical resection.

Stent-assisted coiling is an essential technique for managing wide-neck intracranial aneurysms. However, complications such as stent dislodgement can pose significant challenges, potentially compromising procedural success and patient outcomes. We present the case of a 73-year-old woman with an unruptured basilar tip aneurysm who experienced intra-procedural stent dislodgement into the target aneurysm during a Y-stent-assisted coiling attempt. Recognizing the instability of the displaced stent and the risk of further complications, we employed a modified "waffle cone technique" using a Solitaire AB stent to successfully secure the aneurysm while preserving parent vessel patency. This case highlights the importance of prompt recognition and innovative problem-solving strategies in managing stent-related complications during neuro-interventions. The rescue waffle cone technique represents a viable alternative for addressing complex stent dislodgement scenarios and improving patient outcomes.

This study presents the rare case of an intraosseous dural arteriovenous fistula (DAVF) draining into the diploic veins in the left frontal bone with high-flow feeder, successfully treated with transarterial Onyx embolization. A 59-year-old male exhibited mild right hemiparalysis and aphasia without prior head trauma, surgery, or venous sinus thrombosis. Imaging identified DAVF, fed by the bilateral superficial temporal arteries, left middle meningeal artery, and left occipital artery, draining retrogradely solely through the diploic veins into the superior sagittal sinus, causing cortical venous reflux (CVR). Treatment involved Onyx embolization under flow control, preventing Onyx (Medtronic, Irvine, CA, USA) migration and achieving complete DAVF occlusion, resolving the neurological deficits. This case highlights the clinical significance of diagnosing and managing DAVF draining exclusively into the diploic veins, emphasizing the effectiveness of Onyx embolization in such cases.

Objective: Intravenous tissue plasminogen activator (IV t-PA) is commonly used as bridging therapy before mechanical thrombectomy (MT) in acute ischemic stroke. However, in practice, some patients undergo MT only after IV t-PA has been fully administered. This study aimed to compare clinical and radiological outcomes of MT only versus IV t-PA followed by MT within 4.5 hours of symptom onset.

Methods: We retrospectively reviewed 190 patients with acute large artery occlusion treated with MT between January 2018 and December 2020. After excluding 53 patients ineligible for IV t-PA. A total of 137 patients were enrolled and categorized into two groups: MT only (n=82, 59.8%) and post-IV t-PA MT (n=55, 40.2%). The primary outcome was successful recanalization; the secondary outcome was a good clinical outcome at 90 days (3-month modified Rankin Scale (mRS) score of 0-2).

Results: The successful recanalization rates did not significantly differ between the MT-only and post-IV t-PA MT groups (92.7% vs. 89.1%, p=0.466). Good outcomes at 90 days were not statistically different between both groups (58.5% vs. 61.8%, p=0.701). Multivariable analysis identified baseline National Institutes of Health Stroke Scale (NIHSS) score (adjusted odds ratio (OR) 0.873; 95% confidence intervals (CI), 0.806-0.946; p<0.001) and door-to-puncture time (adjusted OR 0.987; 95% CI, 0.978-0.997; p=0.009) as independent predictors of outcome.

Conclusions: In our study, MT alone yielded comparable outcomes to IV t-PA followed by MT in patients treated within 4.5 hours. Direct MT may be a reasonable treatment strategy.

Objective: A ruptured blood blister-like aneurysm (BBA) of the supraclinoid internal carotid artery is a rare but surgically challenging vascular disease. Numerous endovascular approaches have been reported, but optimal management remains controversial. This study aimed to report on our experience and assess the safety and efficacy of our treatment strategy.

Methods: The treatment strategy basically involves stent-assisted coiling using semi-jailing technique followed by stent overlap with Neuroform Atlas stents. Angiographic results (modified Raymond scale), clinical outcomes (modified Rankin Scale), and technical feasibility were evaluated.

Results: A total of ten patients with ruptured BBAs were treated via this technique (8 women; mean age, 45.4 years). Procedures were successfully applied without any procedure-related symptomatic complications except one thromboembolism. The immediate angiographic results were complete occlusion in 6 aneurysms, residual neck in 1 aneurysm, and residual sac in 3 aneurysms. Early complementary treatment was required in one. Follow-up angiograms (mean, 9.6 months), which were available in 8 patients, showed complete resolution of BBAs in all, except one who was retreated with a flow diverter. At the end of the observation period (mean, 41.0 months), all patients had excellent clinical outcomes (modified Rankin Scale 0-1), except two with initial poor grade subarachnoid hemorrhage.

Conclusions: Double stent-assisted coiling using Neuroform Atlas stents offers a feasible and practical reconstructive option for ruptured BBAs, particularly in healthcare systems where flow diverters are not approved for acute-phase use.

Objective: To assess the safety and performance of the Cereglide 71 aspiration catheter, launched in February 2024, by analyzing adverse events from the Manufacturer and User Facility Device Experience (MAUDE) database.

Methods: Reports from the MAUDE database (February 2024 onward) were analyzed using Microsoft Excel and Jamovi, with 36 reports reviewed-27 device-related and 14 patient-related.

Results: The most common device-related issues were cracks (8 occurrences), material bending (6), and deformation/stretching (5). Adverse events included thromboembolism (4 cases), intracranial hemorrhage (2), carotid-cavernous fistula (2), and cerebral vasospasm (2). The most common indication was middle cerebral artery stroke (9 cases).

Conclusions: This study highlights the importance of post-market surveillance to improve patient outcomes, identifying key complications that require careful consideration in clinical practice. This is the first report on complications related to the Cereglide 71 aspiration catheter from the FDA MAUDE database.

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.