Journal of cerebrovascular and endovascular neurosurgery最新文献

Objective: Acute vertebrobasilar occlusion can led to a fatal outcome, but lack of established procedures poses many difficulties in its management. Although mechanical thrombectomy (MT) has shown positive outcomes recently, high reocclusion rate remains a hurdle. This study is to share experience and to review technical challenges of rescue angioplasty and/or stenting (RAS) for refractory occlusions after MT in posterior circulation ischemic stroke (PCIS).

Methods: Out of 494 patients with acute ischemic stroke from January 2014 to December 2022 in a Hospital, PCIS was identified in 50 patients. 2 extracranial vertebral artery occlusion patients were excluded. For 48 patients, MT was applied as the primary treatment. RAS was done for reocclusion after MT in 15 patients. We evaluated patient characteristics and clinical course, emphasizing the technical aspects of treatment.

Results: Compared to those without rescue procedures, RAS group had a higher percentage of large artery atherosclerosis as an etiology (p<0.001), long segment occlusions (p=0.03), and was more likely to involve posterior inferior cerebellar artery (p=0.007). There was no difference in functional outcome at 6 months between these two groups. Reopening could not achieve (N=2, 13.3%) and procedural complication rate (iatrogenic rupture) is 6.7% in RAS group. Rescue procedures were complicated with dissection, plaque rupture and migration, device damage, and misplacement of the balloon/stent. Avoiding these traps, finding true lumen, and reconstructing the flow by connecting the proximal and distal normal were the keys to the successful RAS.

Conclusions: RAS could be inevitable during endovascular treatment for PCIS and being aware of possible events and technical strategies would navigate interventionists to successful recanalization and the better outcomes.

Objective: This study aimed to evaluate the prognosis of patients with subarachnoid hemorrhage after anterior communicating artery (Acom) artery aneurysm rupture who underwent endovascular treatment according to inflammatory markers.

Methods: A retrospective assessment of medical data revealed 223 consecutive patients who received endovascular Acom artery aneurysmal subarachnoid hemorrhage (SAH) therapy. The study comprised 80 patients, excluding those who had microsurgery following endovascular treatment, those who had diagnostic angiography, patients with ruptured aneurysms at other locations, and those who needed extra surgery. The patients' preoperative electronic medical records were used to collect values of white blood cell (WBC), neutrophil, lymphocyte, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), and CRP/lymphocyte ratio (CLR).

Results: The study divided patients into two groups based on their modified Rankin Scale (mRS) scores: Group 1 (71.2%) had 57 patients on a scale of 0-2 and Group 2 (28.8%) had 23 patients on a scale of 3-6. Inflammatory markers such as WBC, neutrophils, lymphocytes, CRP, NLR, and CLR levels were higher in Group 2 than in Group 1.

Conclusions: Our study evaluated the impact of inflammatory markers (WBC, neutrophils, lymphocytes, CRP, NLR, and CLR) on the prognosis of patients with intracerebral aneurysmal hemorrhage treated endovascularly. Our results indicated that these parameters aligned in their ability to predict the severity of the neurological condition.

Objective: Stent-assisted coil embolization (SAC) is an effective method of treating intracranial aneurysms. The aim of the study was to assess the safety and efficacy of the new ACCERO stent for the treatment of cerebral aneurysms.

Methods: It was a retrospective, single-center study. Nine ruptured and 41 unruptured cerebral aneurysms were treated using the ACCERO stent between February 2021 and December 2023. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical outcomes were analyzed. Follow-up was conducted with magnetic resonance angiography (MRA) or Digital subtraction angiography (DSA) was performed 6 to 12 months after the procedure.

Results: The ACCERO stent deployment was attempted in 51 cases, with replacement by the Neuroform Atlas stent in 1 case. Successful stent deployment was achieved in 50 cases, and appropriate wall apposition to the parent artery. The average clinical follow-up period was 17.1 months. Intimal hyperplasia was observed in 1 case, but no other clinical complications related to the stent occurred. Favorable clinical outcomes were observed in 92% of patients (46/50), including those with subarachnoid hemorrhage. Immediate favorable angiographic outcomes and complete occlusion were achieved in 90% (45/50) and 74% (37/50) of cases, respectively. Among the 45 patients who had imaging follow-up, favorable angiographic outcomes and complete occlusion were observed in 93.3% (43/45) and 82.2% (37/45) of cases, respectively.

Conclusions: The ACCERO stent is a braided-type stent that requires more attention than stents, such as the Neuroform Atlas or Enterprise stents. However, since the struts of the stent are fully visible, it can be more useful in treating challenging aneurysms once the user becomes familiar with its use.

Intro: There is a growing preference among neurointerventionalists for transradial access (TRA) over transfemoral access (TFA) due to improved patient satisfaction, recovery time and reduced access site complication, but using balloon guide catheters (BGCs) in the radial artery remains a challenge. We report our experience in successfully using the 0.087" inner diameter Walrus BGC without a sheath via the radial artery for non-emergent neurointerventions.

Objective: Describe the technique for safely accessing the radial artery using the sheathless Walrus balloon guide catheter.

Methods: A retrospective chart review of thirteen consecutive patients who underwent intervention with radial artery access with a sheathless Walrus BGC was performed.

Results: All twelve procedures were performed successfully with no instances of conversion from TRA to TFA. There were no significant procedural or access site complications. The mean radial diameter was 2.51 mm.

Conclusions: The Walrus 0.087" ID BGC is an effective tool that can safely be used via the radial artery using a sheathless approach, which helps to maximize the size of the catheter that can be used. This is the first instance of our knowledge of this technique being utilized for neurointerventions and therefore could be used to expand the indications for TRA for a wider range of procedures.

Objective: This study aims at spotlighting different lines of management of aggressive vertebral hemangioma (VH) through a retrospective analysis of single center experience.

Methods: Patients diagnosed with aggressive VHs in a tertiary referral center were reviewed from 2014 through 2024. Data of patients who met the inclusion criteria were analyzed. Patients of all ages, both sexes, and all varieties of clinical presentation were included, only patients who underwent at least one intervention were included.

Results: The study included nine patients, comprising six females and three males, with a mean age of 29.3 years (ranging from 14 to 46). Six patients underwent Trans-arterial embolization (TAE), of whom five underwent further surgical procedures, while one patient found TAE to be sufficient as a stand-alone management technique. Eight patients underwent surgical management, five of whom were pre-operatively embolized.

Conclusions: Aggressive VHs are rare, and their management is challenging. Most cases require a multi-modal management, especially when presented with neurological deficit. Pre-operative embolization and/or vertebroplasty are safe and useful tools to decrease intra-operative bleeding of such a vascular pathology in cases undergoing open surgical procedures.

Background: Endovascular treatment of intracranial aneurysms (IAs) provides less invasiveness and lower morbidity than microsurgical clipping, albeit with a long-term recurrence rate estimated at 20%. We present our single-center experience and a literature review concerning surgical clipping of recurrent previously coiled aneurysms.

Methods: Retrospective analysis of nine (9) patients' data and final clinical/angiographic outcomes, who underwent surgical clipping of IAs in our center following initial endovascular treatment, over a 12-year period (2010-2022). Regarding the literature review, data were extracted from 48 studies including 969 patients with 976 aneurysms.

Results: 9 patients (5 males - 4 females) were included in the study with a mean age of 49 years. Subarachnoid hemorrhage was the initial presentation in 78% of patients. Aneurysms' most common location was the middle cerebral artery bifurcation (5/9) followed by the anterior communicating artery (3/9) and the internal carotid artery bifurcation (1/9). Indications for surgery were coil loosening, coil compaction, sac regrowth, and residual neck. Procedure-related morbidity and mortality were zero whereas complete aneurysm occlusion was achieved after surgical clipping in all cases (100%). All patients had minimal symptoms or were asymptomatic (mRS 0-1) at the final follow-up.

Conclusions: Surgical clipping seems a feasible and safe technique for selected cases of recurrent previously coiled intracranial aneurysms. A universally accepted recurrence classification system and a guideline template for the management of such cases are needed.

Objective: In this study, changes in treatment methods and patient prognosis were analyzed using a Korean nationwide medical insurance information database.

Methods: Patients with subarachnoid hemorrhage who received surgical treatment for cerebral aneurysm from 2005 to 2020 were included. The specific surgery type was classified using the surgical code and according to whether stents were used. Yearly trends in mortality rates and poor prognosis, using tracheostomy as proxy, were analyzed by a simple regression analysis. A multistep logistic regression analysis was performed to evaluate the risk factors of mortality and poor prognosis.

Results: Overall, 83,587 patients were included. Females were predominant (64.5%). Microsurgical clip usage rate decreased by approximately two-thirds from 78.8% in 2005 to 24.4% in 2020. Contrarily, endovascular treatment proportion gradually increased, and stent-assisted coil embolization rate surpassed microsurgical clip usage rate in 2020 (24.6% vs. 24.4%). In the multivariate analysis, endovascular treatment correlated positively with 3-month mortality (hazard ratio [HR]: 1.13, 95% confidence interval [CI]: 1.07-1.19, P<0.0001), although correlated negatively with poor prognosis (tracheostomy) (HR: 0.93, 95% CI: 0.89-0.98, P=0.0050).

Conclusions: According to the treatment trend analysis, during the 16 years studied, for patients with subarachnoid hemorrhage due to ruptured cerebral aneurysm, the endovascular treatment rate increased rapidly and stent-assisted coil embolization rate surpassed that of microsurgical clip ligation. Diversification of treatment methods has led to a decrease in mortality and improved prognosis.

Aneurysms of the pineal region are rare and theoretically could arise from the medial posterior choroidal artery (MPChoA) or lateral posterior choroidal arteries (LPChoA). A 64-year-old lady with subarachnoid haemorrhage (SAH) and intraventricular haemorrhage (IVH) due to a ruptured MPChoA aneurysm was treated with microsurgical aneurysm excision via an occipital interhemispheric approach. This case demonstrates the importance of being mindful of rare aneurysm locations when initial vascular imaging in SAH appears normal.

Complex aneurysms are a therapeutic challenge in contemporary neurosurgery. Several microsurgical and endovascular techniques have been proposed for their treatment. The picket fence clipping technique uses fenestrated clips, that are stacked not to reconstruct the neck of the aneurysm, but to create a duct to normalize the cerebral flow by reconstructing the dome. We present four illustrative cases using the picket fence clipping technique. The aneurysms considered were of different locations (ICA, MCA, AComA), of large or giant size with wide necks, in which clipping attempt with a conventional technique was not possible, so that the use of non-conventional clipping techniques had to be applied with favorable results. In our experience we found this technique useful in large and giant, wide-necked aneurysms by reconstructing the parent vessel according to the concept of the ideal closure line in these previously unreported locations, thereby restoring normal cerebral circulation. The use of non-conventional techniques for clipping complex aneurysms can be used alone or in combination for adequate treatment, preserving cerebral circulation without compromising adequate exclusion of the aneurysm. The Picket fence technique is a feasible clipping technique that can be used as a less morbid option in large and giant aneurysms with wide necks.