Journal of cerebrovascular and endovascular neurosurgery最新文献

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.

Middle meningeal arteriovenous fistulas (MMAVFs) are known as rare diseases, often associated with head trauma, with idiopathic cases being exceedingly uncommon. Here, we present a clinical case of spontaneous and simultaneous bilateral MMAVFs in a 37-year-old woman. She presented with persistent pulsatile tinnitus but no history of head trauma. Bilateral MMAVFs were identified via Time-of-Flight Magnetic Resonance Angiography. Subsequent digital subtraction angiography revealed a fistula between the middle meningeal artery (MMA) and middle meningeal vein (MMV) without definite intracranial venous reflux. We had planned coil embolization via a trans-arterial approach for both sides. Remarkably, after six days, the right-sided MMAVF observed in the previous external carotid artery (ECA) angiogram disappeared spontaneously. The left-sided MMAVF was successfully treated with coil embolization, achieving complete obliteration of fistula flow. Postoperatively, the patient's pulsatile tinnitus disappeared, and she was discharged without medication. There are a few possible mechanisms of spontaneous MMAVFs, such as middle meningeal artery aneurysm and trivial head trauma. Trans-arterial embolization with coils appears to be an effective and safe treatment option for complete obliteration of fistula flow.

Central nervous system (CNS) aspergillosis is a life-threatening infection primarily affecting immunocompromised patients and may lead to severe cerebral infarction through vascular invasion. However, there is limited data on the treatment options for aspergillosis-induced cerebral infarction especially surgical treatments such as superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery. Herein, we present a case of cerebral infarction in a 59-year-old male with progressive right eye ptosis. Specifically, he had ipsilateral MCA stenosis originating from paranasal sinusitis due to invasive aspergillosis. After 3 months, the patient was readmitted due to worsening cerebral infarction and complete internal carotid artery (ICA) occlusion. Conservative treatment failed to improve cerebral perfusion, leading to gradual neurological decline. Consequently, STA-MCA bypass was performed to stabilise the patient. Postoperative imaging revealed a patent bypass graft and an enhanced cerebral perfusion. Although the patient experienced persistent left-sided hemiparesis, his overall neurological condition remained stable for 1 year, with a Glasgow Coma Scale score of 15. STA-MCA bypass should be considered a potential treatment option for patients with aspergillosis-induced vasculitis resulting in cerebral infarction secondary to total ICA occlusion.

Introduction: Dural arteriovenous fistulae (dAVFs) can lead to subarachnoid hemorrhage and other devastating complications. A rare subtype of dAVFs is those located in the anterior condylar confluence adjacent to the hypoglossal canal. These dAVFs can be difficult to treat, with some electing to utilize endovascular approaches for these lesions. There is a need to further assess the safety and efficacy of this approach.

Case description: All patients that underwent endovascular treatment of dAVFs affecting the anterior condylar confluence at our center were included. Pre-treatment factors including anatomy and presentation were recorded, as were follow-up data including angiographic cure and clinical or technical complications. Three patients were included in this study. Presenting symptoms included ocular hyperemia, proptosis, auditory symptoms (whooshing, tinnitus), and Cranial Nerve 6 palsy. Both transarterial and transvenous embolization were employed in select cases, with Onyx HD-500 and coils both used as embolic materials. No clinical or technical complications were reported in these patients, and patients were asymptomatic at final follow-up without recurrence or regrowth of their dAVF.

Conclusions: Treatment of dAVFs located in the anterior condylar confluence can be achieved endovascularly using both transarterial and transvenous approaches.

The irony of life is that in the complex world of neurosurgery, where the skilled mind of the neurosurgeon navigates the delicate terrain of cerebral aneurysm, the same mind can be affected by the very thing it treats. Sometimes the healer becomes the one in need of healing. This predicament highlights the reality of existence that vulnerability transcends professional boundaries, and any individual can become a target.

We present a case of a meningo-meningeal arteriovenous fistula (MMAVF) discovered immediately following middle meningeal artery (MMA) microparticle embolization for the treatment of an acute subdural hematoma (SDH). An elderly patient presented with an SDH found during stroke workup. MMA embolization was elected due to his need for therapeutic anticoagulation. During the procedure, multiple MMAVFs appeared after microparticle embolization of the distal MMA branches. We aborted further microparticle embolization and performed coil embolization of the MMA trunk with cessation of flow. No clinical complication was noted postoperatively and no post-procedure hemorrhage was seen. Review of literature suggests that this phenomenon may be associated with microparticle embolization. We hypothesize the cause to be vessel rupture due to barotrauma during manual injection via the microcatheter. As MMA embolization becomes more common, this complication may become more recognized.

Endovascular therapy is the current gold standard treatment for the management of acute ischemic stroke from large vessel occlusion. Despite this, the presence of severe vascular tortuosity and cervical carotid loops can hinder the success of the procedure. We present a case of an 83-year-old female presenting with acute ischemic stroke and extreme tortuosity including common carotid artery and internal carotid artery consecutive loops, as well as a tandem common carotid artery bifurcation thrombus with an M1 segment occlusion. Subsequently, relevant literature is reviewed regarding the technical management of complex thrombectomy cases. The endovascular procedure involved navigating through extreme vascular tortuosity using multiple endovascular tools for optimal reperfusion using delivery devices to facilitate the procedure. Challenges such as vasospasm and straightening of an internal carotid artery loop occurred during the procedure. However, successful thrombectomy was performed using adequate procedural techniques discussed.

Objective: Tortuosity in blood vessels is a common angiographic feature that plays a crucial role in hemodynamics and is implicated in systemic diseases such as arterial hypertension and diabetes mellitus. Although studies exist on the relationship between vessel tortuosity and intracranial aneurysms, standard imaging modalities and parameters representing vessel tortuosity are controversial. This study compared vessel tortuosity based on angle measurements using magnetic resonance angiography (MRA) and digital subtraction angiography (DSA).

Methods: A retrospective analysis of 85 patients with 63 males (75.3%) with unruptured anterior circulation aneurysms between December 2021 and December 2022 was conducted using MRA and DSA. The vessel angles of several segments in the carotid siphon, internal carotid artery bifurcation, and the inflow angles to intracranial aneurysms were measured to evaluate the discrepancy between MRA and DSA.

Results: No significant difference was observed in vessel and inflow angles between MRA and DSA, except the internal carotid artery-middle cerebral artery (ICA-MCA) angle, which shows a significant difference (MRA; 50.26˚ (interquartile range (IQR), 33.49-70.57), DSA; 50.75˚ (IQR, 34.91-62.24), p-value=0.035). Conclusions: We found a discrepancy between MRA and DSA in measuring the ICA-MCA angle. Further studies are required to address observed discrepancies between imaging modalities and improve the accuracy of hemodynamic analysis in clinical settings.