Journal of cerebrovascular and endovascular neurosurgery最新文献

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.

Fahr's disease is an uncommon condition characterized by a gradual decline in cognitive, psychiatric, and motor functions, linked to idiopathic calcification in the basal ganglia, typically inherited in an autosomal dominant fashion. Acute presentation is most often as a seizure disorder; however, we present a case of an acute presentation in which the cause of the deterioration was an aneurysmal subarachnoid haemorrhage. The association between Fahr's disease and intracranial aneurysms is exceedingly rare, with only five cases documented in the literature to date. This report represents the sixth such case. Furthermore, all previously reported aneurysms were confined to the anterior circulation; thus, this is the first documented instance of Fahr's disease presenting with an aneurysm in the posterior circulation. The case here presented to the emergency service with the complaint of severe headache. Computed tomography (CT) of the head showed bilateral basal ganglia calcification and subarachnoid haemorrhage. Digital subtraction angiography (DSA) revealed a basilar tip aneurysm. The aneurysm was treated with Neqstent assisted coiling via jailing technique. Intraoperative aneurysmal haemorrhage occurred just after inserting the first coil. Heparin was reversed, blood pressure decreased and aneurysm was packed with further coils till the bleeding stopped. External ventricular drainage was performed to address subarachnoid hemorrhage (SAH) and intraventricular hemorrhage. The exact mechanisms underlying Fahr's disease are not fully understood, but it is believed to play a role in the development of aneurysms due to mineral deposits in blood vessels. For patients experiencing unexplained recurrent episodes of loss of consciousness, brain computed tomography angiography (CTA) should be performed to rule out an aneurysm, even if they have a known diagnosis of Fahr's disease, to prevent misattributing these episodes to epilepsy. Additionally, vessel wall magnetic resonance imaging (MRI) should be conducted preoperatively in cases of aneurysms linked to Fahr's disease or vasculitis to improve management planning.

Objective: The management of highly vascularized tumors in the brain, head, and neck regions poses significant challenges. This review aims to provide practical insights into using preoperative embolization to improve surgical outcomes and guide healthcare centers with limited expertise in this technique.

Methods: A literature review was conducted using PubMed, Scopus, and Web of Science databases with keywords related to preoperative embolization and highly vascularized tumors, detailing its definition, indications, diagnostic considerations, procedural aspects, clinical and surgical implications, and associated complications. The findings are supported by data from 309 patients with brain, head, and neck tumors treated with preoperative embolization at Hospital Clínica Kennedy in Guayaquil, Ecuador, from 2015 to 2023. Cases without embolization or those below the clavicular border were excluded. Illustrations and photographs, based on the authors' surgical experience, are included with informed consent.

Results: Preoperative embolization has proven effective in reducing morbidity, enhancing surgical outcomes, and palliating symptoms in inoperable cases by decreasing tumor size. While complications are rare, they can be minimized with careful planning. Despite its efficacy, the lack of randomized controlled trials due to the rarity of hypervascular tumors limits the ability to establish standardized practices. Conclusions: Preoperative embolization is a valuable tool in managing highly vascularized tumors. However, further research and uniform reporting are essential to optimize outcomes and develop clear guidelines for this critical procedure.

Objective: Treatment failure usually occurs within 24 hours after mechanical thrombectomy (MT) for acute intracranial atherosclerotic steno-occlusion (ICAS) and is an unexpected event that adversely influences the clinical outcome. We retrospectively evaluated the factors influencing reocclusion after MT plus rescue treatment in acute ICAS patients with successful recanalization.

Methods: From January 2013 to December 2020, 60 patients with ICAS who underwent MT plus rescue treatment with successful recanalization were included in our study. We classified the patients into a patency group (n=47, 78.3%) and a reocclusion group (n=13, 21.7%) based on CT angiography data obtained the day after MT plus rescue treatment.

Results: Intravenous tissue plasminogen activator (IV t-PA) in the patency group (n=18/47 (38.3%)) significantly differed from that in the reocclusion group (n=1/13 (7.7%)) (p=0.045). The number of thrombectomy attempts in the reocclusion group was significantly greater than that in the patency group (median [interquartile range], 2 [1-3] vs. 1 [0-1.5], p=0.004). According to the univariate logistic regression analysis, the only prognostic factor for reocclusion was the number of thrombectomy attempts (odds ratio (OR), 1.655 [1.046-2.619], p=0.032). Conclusions: In our study of ICAS patients who achieved successful recanalization after MT plus rescue treatment, the number of thrombectomy attempts was an independent prognostic factor for reocclusion after MT. Accordingly, for highly suspicious ICAS lesions, additional attempts at the MT should be carefully performed to prevent reocclusion.

Objective: To investigate the possibility of using coils as a standalone treatment for middle meningeal artery embolization.

Methods: Four patients (3 females, 1 male, median age 77.5) with bilateral subdural hematomas were treated with bilateral MMA embolization. One hematoma of each patient was treated with coils and PVA, and the other was treated exclusively with coils. New or resolved symptoms, radiographic imaging demonstrating hematoma change, and complications were recorded and compared between the two treatment modalities. Minimum follow-up time was three months.

Results: All patients demonstrated symptomatic and radiographic improvement at three month follow-up. None of the patients in this cohort received surgical evacuation of the hematoma prior to or after embolization. One patient had previously been treated for hydrocephalus with a VP shunt. There were no postoperative complications. In the hematomas treated with a combination of coils and particles, three showed complete resolution with one showing interval improvement on imaging. All hematomas treated with coils alone demonstrated complete resolution after three months. Conclusions: Middle meningeal artery embolization with coils alone has demonstrated noninferior results to embolization with a combination of particle embolisate and coils in this small cohort.

Objective: The stent-assisted coiling (SAC) is a well-known procedure for wide neck intracranial aneurysms. To date, the impact of the semi-jailing technique (SJT) on outcomes in patients with SAC remains unknown. This study aims to evaluate the efficacy and safety of SAC using open- or closed-cell stents in patients with unruptured intracranial aneurysms.

Methods: The data of patients treated with SAC between December 2013 and May 2022 was retrospectively investigated. Clinical, aneurysmal, outcomes were compared between patients with and without SJT. The primary outcome was 1-year complete occlusion defined as the Raymond-Roy occlusion classification class I. Safety outcomes included permanent deficits and mortality. Subgroup analysis was also performed regarding open-cell or closed-cell stents.

Results: Among 320 patients with SAC, 220 patients undertook SJT (68.8%). The median age of patients was 61.0 years (interquartile range, 50.3-71.0 years) and 73 were male (22.8%). 1-year complete occlusion was obtained in 221 patients (69.1%). Permanent deficits and mortality were observed in 3 (0.9%) and 1 (0.3%) patient, respectively. Compared to non-SJT, SJT was significantly related to 1-year complete occlusion (73.2% vs. 60.0%, adjusted odds ratio 1.85, 95% confidence interval 1.11-3.09, p=0.02). Safety outcomes showed no significant difference between SJT and non-SJT. Conclusions: The results of this study showed the efficacy and safety of SJT in unruptured intracranial aneurysm patients treated with SAC.

Foix-Alajouanine syndrome is an extremely rare yet important differential diagnosis for subacute lower limb weakness in middle-aged to elderly adults. Current understanding of the pathophysiology of this disease, along with recent publications on successful endovascular interventions, has shifted the perspective and clinical approach for its management. Nonetheless, neurosurgical pathways for clinical treatment are still preferred over endovascular embolization. Here, we present the case of a 63-year-old male who developed a rapidly progressing thoracic medullary syndrome over a 6-month period, compromising motor function, sphincter control, and sensory function in the lower extremities. The patient was diagnosed with venous congestive myelopathy secondary to a dural arteriovenous fistula and underwent endovascular embolization using hyper-selective catheterization. Over an 8-month period, the patient experienced successful recovery of both motor and sensory functions. This case supports the use of minimally invasive techniques for the treatment of dural arteriovenous fistulae with spinal involvement.

Vertebral artery dural arteriovenous fistulae (VADAVF) are a rare entity. We present a patient who experienced pre-syncopal symptoms and was found to have a VADAVF between the posterior meningeal artery and a cortical vein draining into the sigmoid sinus. The patient initially underwent surgical intervention, which failed to obliterate the shunt. Endovascular treatment with use of a flow diverter provided definitive disconnection of the shunt.