Objective: We evaluated outcomes after mechanical thrombectomy for intracranial internal carotid artery occlusion (ICO) in comparison with middle cerebral artery occlusion (MCO), and evaluated its pathophysiology and future problems.
Methods: A retrospective study was performed in 28 patients (14 patients with intracranial ICO and 14 with MCO) who underwent mechanical thrombectomy using the Penumbra System, TrevoProvue, or Solitaire FR in 2014 and 2015. Assessment was performed mainly using the modified Rankin scale after 30 days and at the time of discharge.
Results: The interval from onset to arrival at the hospital (onset to door) and the findings of imaging techniques did not differ between the groups with intracranial ICO or MCO, but the National Institutes of Health Stroke Scale (NIHSS) score on hospital arrival was higher in the former group (21 vs 16, p = 0.028). The favorable recanalization rate was 78% in each group. However, the rates of favorable outcomes were 14.3% and 42.9%, and the mortality rates were 29% and 7.1% in the group with internal carotid artery cerebral artery occlusion and that with MCO, respectively, showing poor outcomes in the former (p = 0.04).
Conclusion: In the patients with intracranial ICO, although favorable recanalization was achieved by mechanical thrombectomy, the functional outcome was poor. These results suggest more rapid progression of neurological deficits in the patients with intracranial ICO than those with MCO and the need for even earlier favorable recanalization in the former.
Objectives: Manual shaping of a straight microcatheter is required when guiding or retention of a microcatheter with a pre-shaped tip is difficult. According to the manufacturer’s instructions, it is recommended that the microcatheter be shaped by steaming “for 30s” and “25 mm away from the steam source”. However, insufficient shaping and blunting can occasionally occur during the procedure. In this technical note, we present the optimal conditions of shaping for a microcatheter system.
Methods: In this study, we used a hot air gun (BOSCH, Gerlingen, Germany) as the shaping source and a Headway microcatheter (Microvention, CA, USA; Terumo, Tokyo, Japan). After measuring the difference between the preset and the actual temperature value, shaping was performed at different temperatures (preset temperature of 110°C–140°C) and time intervals (30s–120s).
Results: The actual temperature was constant at 20°C below the preset temperature, at a distance of 2.5 cm from the hot air outlet. We performed shaping at a preset temperature of 110°C–140°C (i.e., 90°C–120°C actual temperature) for 30s–120s. Because the Headway microcatheter could not tolerate preset temperature higher than 130°C (i.e., actual temperature of 110°C), the distal tip fluffed, bubbled, and perforated. We examined the durability under each condition, comparing the shape just after mandrel removal, after micro-guidewire manipulation, and after stretching in a vascular model. The highest moldability and durability were achieved at a time interval of 90s–120s, and a preset temperature of 120°C (i.e., 100°C actual temperature).
Conclusion: The Headway microcatheter showed the best performance at a heating time of 90s and a preset temperature of 120°C (i.e., 100°C actual temperature) in hot air gun shaping, although the optimal temperature and time interval may vary with the used microcatheter, depending on each instrument structure and materials.
Purpose: We retrospectively examined the results of coil embolization for 28 cerebral tiny aneurysms (<3 mm), 73 small cerebral aneurysms (3–4 mm) and associated complications.
Subjects and Methods: From a total of 418 patients who underwent coil embolization of cerebral aneurysms (n = 433) between January 2008 and August 2015, we analyzed 28 cerebral tiny aneurysms (6.5%) and 73 small aneurysms (16.9%). The type of procedure, results of embolization, and complications were compared.
Results: For 23 (82.1%) of the 28 tiny aneurysms and 52 (71.2%) of the 73 small aneurysms, embolization was performed using a simple technique. Embolization resulted in complete obliteration (CO) and neck remnant (NR) in 26 (92.9%) of the 28 tiny aneurysms, and CO + NR was achieved in 62 (84.9%) of the 73 small aneurysms. Treatment was discontinued for one tiny aneurysm and one small aneurysm. Intraoperative rupture occurred in one tiny aneurysm and three small aneurysms. Thromboembolism was observed in one tiny aneurysm and one small aneurysm. Morbidity was encountered in one tiny aneurysm (thromboembolism), and mortality was associated with another tiny aneurysm (intraoperative rupture).
Conclusion: The results of coil embolization for tiny aneurysms were similar to those of small aneurysms. Coil embolization-related complications and prognosis were also considered to be similar.
Purpose: Recent studies demonstrated the efficacy of acute-phase thrombectomy for acute major artery occlusion in anterior circulation. However, its efficacy in posterior circulation has not been verified. We examined acute-phase thrombectomy involving posterior circulation in our hospital.
Methods: The subjects were 15 patients who underwent acute-phase thrombectomy involving posterior circulation in our hospital between July 2010 and July 2015. The mean age was 74.6 years. The mean baseline National Institute of Health Stroke Scale (NIHSS) score was 24.6 points. For preoperative evaluation, MRI was performed in 13 patients, and perfusion CT in 1. The type of cerebral infarction was evaluated as cardiac embolism in nine patients (60%), atherothrombotic infarction in two (13%), and others in four (27%). A Merci, Penumbra, or stent retriever was used as a first-choice device. Nine patients were treated with several devices.
Results: In all patients, a Thrombolysis in Cerebral Infarction (TICI) score of 2B or higher was achieved. Eight patients (53%) showed a TICI score of 3. An improvement of the NIHSS score after 24 hours was achieved in 13 patients (87%), but three patients (20%) showed an mRS score of 0–2 on discharge. The mortality rate was 0% (n = 0). There was a correlation between a high signal intensity of the brain stem on MRI Diffusion Weighted Image (DWI) and the outcome.
Conclusion: Acute-phase thrombectomy was useful for relieving symptoms and reducing the mortality rate. Furthermore, the outcome was correlated with a high signal intensity of the brain stem on DWI.
Objective: To report on unusual veins traversing the petromastoid part of the temporal bone (petrosal bone) and to discuss their embryological origins.
Methods: Unusual veins traversing the petrosal bone were incidentally found on CTA, MRI, or conventional angiography in four cases. We have evaluated the course of these veins in detail and have reviewed the previous descriptions in the literatures about similar venous variations as well as the osseous and venous embryology around the petrosal bone.
Results: In all cases, the vein was anteriorly connected to the dural venous sinus around the foramen ovale and entered the petrosal bone through the facial hiatus. With regard to the subsequent running course and its exit from the petrosal bone, the vein crossed the petrous internal carotid artery, exited the petrosal bone into the petroclival fissure, and entered the inferior petrosal sinus in two cases. In one case, the vein exited the petrosal bone through the stylomastoid foramen after running the entire length of the facial canal. In the remaining case, the vein ascended in the petrosal bone along its anterior aspect and emptied into the superior petrosal sinus. The running course of these veins may correspond to the course of the embryonic primary head sinus and its tributaries.
Conclusion: Here we report on rare venous channels in the petrosal bone. We also believe that these veins may be remnants of the embryonic primary head sinus, based on their course in the petrosal bone and the embryological development of the veins in the region.
Purpose: Transvenous sinus packing with coils has been widely accepted as a curative treatment method for dural arteriovenous fistulas (DAVFs) with sinus occlusion. Some technical reports have described using luminal angioplasty or stent placement to reconstruct antegrade venous drainage. In addition, recent anatomical considerations of the parasinuses have enabled us to achieve selective embolization of the shunted venous pouch. Here, we report the technical results from five cases of DAVF with sinus occlusion treated by selective transvenous embolization combined with balloon sinoplasty (STVEBS).
Materials and Methods: Five consecutive patients who underwent STVEBS between March 2009 and March 2015 in our institution were retrospectively reviewed. All of the patients were males and were between 68 and 83 years of age. Three patients had a DAVF at the transverse sinus (TS) with ipsilateral sigmoid sinus (SS) or jugular vein (JV) occlusion. One patient had concurrent DAVFs at the right SS and left TS with left transverse sigmoid sinus (TSS) occlusion and a history of right JV ligation. The last patient had an isolated DAVF at the superior sagittal sinus.
Results: In three of the five cases, the fistula was completely obliterated by selective embolization, and antegrade sinus flow was successfully reconstructed by sinoplasty. The remaining two patients showed recanalization of DAVFs at the occluded sinus, and the sinus reopened after balloon angioplasty. These patients were subsequently treated with sinus packing. In all five patients, angiography showed complete obliteration of the DAVF. No complications occurred, and clinical symptoms improved. No recurrence was observed in any patient during the follow-up period, which ranged from 7 to 79 months, and the reconstructed sinus was patent at the last follow-up in all three patients who had undergone successful STVEBS.
Conclusion: STVEBS can obliterate DAVFs with re-establishing the antegrade sinus flow and would be an effective and safe treatment method for cases of DAVF with sinus occlusion.
Purpose: We report on a patient who underwent transvenous target embolization of a small, direct carotid-cavernous fistula (CCF).
Case: A 74-year-old female without a history of trauma was referred to our department. Tinnitus and ocular symptoms initially occurred as symptoms of a right, direct CCF. Anterograde blood flow at the peripheries of the anterior and middle cerebral arteries was maintained, and an Allcock test confirmed a fistula connecting from the C3 region of the internal carotid artery to the cavernous sinus. Transvenous target embolization of the fistula was performed while protecting the internal carotid artery using a balloon. The use of only a single coil led to the disappearance of the shunt.
Conclusion: In some patients, a small, direct CCF can be cured by target embolization. It is important to predict the size of a fistula and clearly visualize the fistulous site in the process of diagnosis.
Objective: We report a patient with symptomatic right carotid artery dissection due to extension from aortic dissection who underwent stenting via the right brachial artery approach.
Case: A 61-year-old male underwent emergency operation for Stanford A type aortic dissection, but developed cerebral infarction due to extension of the dissection to the right carotid artery after the operation, and underwent stenting via the right brachial artery approach for the prevention of recurrence. A 6-Fr Simmons type Axcelguide was inserted, and stenting was performed with two Carotid Wallstents in conjunction with the Filterwire EZ. He showed a favorable postoperative course and was discharged home.
Conclusion: When extension of dissection to the right subclavian artery is absent, stenting using the right radial artery approach should be considered as a safe procedure.
Objective: Authors describe our experience of transbrachial coil embolization for posterior circulation aneurysms by using a 4 French (Fr.) guiding sheath.
Case Presentations: We retrospectively evaluated the technical feasibility, access site complications, and concomitant use of adjunctive techniques on transbrachial coil embolization from April to July 2015.
Results: Three patients underwent transbrachial coil embolization for a posterior circulation aneurysm using a 4 Fr. guiding sheath. The patients’ average age was 78.7 years (range 74–87 years). Two patients had a ruptured aneurysm (two aneurysms), and one had an unruptured aneurysm. The site of the aneurysms included a right vertebral artery-posterior inferior cerebellar artery bifurcation, basilar bifurcation, and basilar artery-left superior cerebellar artery bifurcation. All procedures were successfully performed using the brachial approach and balloon neck remodeling technique. No periprocedural or access site complications were observed.
Conclusion: Transbrachial coil embolization of a posterior circulation aneurysm may be a useful alternative method, especially in elderly patients with an undesirable arterial anatomy for a transfemoral approach. Additionally, the 4 Fr. guiding sheath is a useful device for this approach, as it enables the adjunctive techniques and minimizes the brachial puncture size.
Purpose: Reconstructed three-dimensional (3-D) images are essential for cerebral endovascular treatment. Conventional reconstructed 3-D images are no more than planar images projected onto a monitor. In this study, we prepared 3-D stereoscopic images before cerebral endovascular treatment, and conducted preoperative simulation to examine their usefulness (the subjects were six cases with cerebral aneurysms and eight with arteriovenous shunts).
Case Presentations: Case 6: The patient was a 60-year-old male with an unruptured paraclinoid aneurysm. Case 8: The patient was a 64-year-old male with a spinal dural arteriovenous fistula. To prepare 3-D stereoscopic images, 3-D stereoscopic image-converting Work Station/a 3-D monitor was used. The first surgeon performed a preoperative simulation using 3-D stereoscopic images. Subsequently, usual cerebral endovascular treatment was conducted, and the usefulness of 3-D stereoscopic images was evaluated with free comments after surgery.
Conclusion: The application of 3-D stereoscopic images for cerebral endovascular treatment was useful for recognition of spatial orientation. In particular, it was highly assessed in arteriovenous shunt disease patients with a complex vascular structure. Therefore, 3-D stereoscopic images may be appropriate for training for non-skilled specialists in cerebral endovascular treatment and student education.