Objective: The effectiveness of mechanical thrombectomy using the Penumbra system (PS) for acute ischemic stroke due to large vessel occlusion was evaluated.Subjects: The subjects were 43 patients (mean age: 76.6 years, 24 females) with cerebral infarction who underwent mechanical thrombectomy using the PS between January 2012 and December 2015. Grade 2b or 3 according to the Thrombolysis in Cerebral Infarction (TICI) scale was defined as successful recanalization, and a modified Rankin scale (mRS) score of 0–2 at discharge or 3 months after the onset was defined as a favorable outcome.Results: The median time from stroke onset to hospital arrival was 63 min, time from hospital arrival to the initiation of recombinant tissue plasminogen activator was 61 min, time from stroke onset to recanalization was 263 min, and time from groin puncture to recanalization was 73 min. Successful recanalization was achieved in 62.8%, and favorable outcomes were obtained in 30.2%. Treatment-related complications were observed in 14.0%. The factors predictive of a favorable outcome were Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomographic Score (DWI-ASPECTS) on MRI and time from groin puncture to recanalization, and those predictive of successful recanalization was the time from stroke onset to groin puncture. Concerning the procedure, the time needed for the procedure was shortened, and the recanalization rate was improved, in comparison with before the introduction of ADAPT. Comparison of three generations, i.e., 1st generation, MAX series, and 5MAX-ACE, showed shortening of the time needed for the procedure and improvements in the recanalization rate and outcome with the development of the device.Conclusion: In mechanical thrombectomy using the PS, the extent of ischemia and time needed for the procedure affected the outcome, and upgrades of the device and introduction of ADAPT were suggested to be involved in the improvements in the recanalization rate and outcome.
Objective: Permanent therapeutic occlusion of the carotid artery is one of the treatment options for patients with a large/giant internal carotid artery aneurysm or tumor involving the neck or skull base. Balloon test occlusion (BTO) is performed to predict the tolerance of parent artery occlusion (PAO). The authors combined various modalities to improve the sensitivity of BTO. The purpose of this study is to present the efficacy of the multimodal BTO.Methods: Between January 2008 and September 2014, a total of 50 patients (internal carotid aneurysms: 39, neck or skull base tumor: 8, others: 3; mean 58.4 years, range 7–81 years; 10 men and 40 women) underwent multimodal BTO. Tolerance of PAO was evaluated by the algorithm with various assessment modalities including neurological symptoms with/without induced hypotension, findings of angiogram (collateral flow, venous phase laterality), perfusion CT, and stump pressure. Clinical data of patients with BTO were analyzed retrospectively. Procedures were performed in the angio/CT combination suite. BTO was performed in the usual fashion and when the patient passed the immediate test occlusion, perfusion CT was performed. Subsequently, the angiogram under balloon inflation followed. If the patient did not show neurological symptoms for 20 min, hypotension was induced by intravenous injection of the vasodilator. Neurological symptoms were then checked for more than 30 min.Results: By multimodal assessment of BTO, 33 patients were considered tolerable, six were partially tolerable, and 11 were intolerable. Thirteen of 33 patients with predictive tolerance underwent PAO without bypass, and all but one showed no hemodynamic ischemia postoperatively. Three of six patients with predictive partial tolerance were treated by PAO with extracranial-intracranial bypass, and they experienced no hemodynamic ischemia. In contrast, one with predictive partial tolerance treated by PAO without bypass developed ischemic events as feared.Conclusions: The multimodal BTO is helpful to evaluate the tolerance of PAO and is a reliable predictor of postoperative ischemic events. It reduces risks and increases treatment safety for permanent therapeutic occlusion of the carotid artery.
Objective: Vac-Lok cushions are widely used in the field of radiation therapy to fix a body in place. We introduced this device during neuroendovascular therapy and evaluated its utility in comparison with a conventional device.Methods: We conducted questionnaire surveys regarding post-procedural headache among patients and regarding advantages and disadvantages of the new fixation device among radiation technologists and neurosurgeons. We measured the contact pressures of volunteers’ heads to compare stress on the head between the two devices.Results: Contact pressure significantly decreased using the new device. Furthermore, complaints regarding post-procedural headache sharply declined after introducing the new device. The new device also reduces respiratory motion artifacts and allows the head to be positioned at any angle we want.Conclusion: The Vac-Lok cushion is extremely useful for fixing the head in place during neuroendovascular therapy.
Objective: The preparation of transient ischemic stroke models in monkeys has been highly invasive, and consistent preparation of an infarct area has been difficult. We attempted the preparation of a model by applying a neuroendovascular technique for humans.Methods: Using the Macaca fuscate, a 5 Fr sheath was placed in the right femoral artery under general anesthesia, a 5 Fr catheter was placed in the right internal carotid artery (ICA) via a bovine arch, a 4 Fr catheter was concentrically placed distally to the bifurcation of the posterior communicating artery (Pcom A), and a balloon catheter conventionally used for the prevention of distal embolism was guided to the origin of the M1 segment of the middle cerebral artery in a triple co-axial manner. Under antithrombotic treatment by heparinization, balloon occlusion was performed for 2 h, and neurological and histological evaluations were carried out 48 h after reperfusion.Results: Left hemiplegia was observed after the procedure, and ischemic changes were histopathologically confirmed around the head of the caudate nucleus located in the border zone of the territory of the occluded vessel.Conclusion: Less invasive and highly consistent transient ischemic stroke models may be prepared by an endovascular approach.
Objective: We describe successful stentings for treatment of bilateral jugular bulb stenosis and occlusion in a case of dural arteriovenous fistulas (d-AVFs) of bilateral transverse sinuses.Case Presentations: A 71-year-old woman presented with rapidly progressive cognitive impairment as well as consciousness disturbance, and cerebral angiography demonstrated d-AVFs of bilateral transverse sinuses, right jugular bulb occlusion, and left jugular bulb stenosis accompanied by marked intracranial venous congestion. The symptoms were temporarily alleviated after transarterial and transvenous embolization, but recurred one year later. Curative embolization was thought to be difficult, and stenting for stenosis/occlusion of the bilateral jugular bulbs, which were considered to be causing her symptoms, was performed and resulted in improvements in the condition.Conclusion: Stent for treating sinus stenosis/occlusion accompanying d-AVF is effective to improve venous congestion and hypertension.
Objective: We report a case of the growing acute epidural hematoma treated by embolization of the middle meningeal artery.Case Presentations: An 18-year-old man was admitted with head trauma sustained in a traffic accident. Initial CT revealed a linear fracture and a small epidural hematoma in the left frontal region. As the hematoma was small and neurological deficits were absent, it was treated conservatively. A second CT assessment 3 h later showed that the hematoma had enlarged and external carotid angiography showed extravasation from the frontal branch of the middle meningeal artery. Embolization of the middle meningeal artery gradually decreased the hematoma.Conclusion: Embolization of the middle meningeal artery effectively treated a small acute epidural hematoma.
Objective: A novel mechanical thrombectomy device for acute ischemic stroke has provided a favorable outcome. However, it is not well known that delayed stenotic change of the affected arterial wall can be caused by device scratching.Case Presentations: A 73-year-old male presented with a symptomatic left middle cerebral artery (MCA) occlusion. The patient was recovered without any sequelae after stent-using mechanical thrombectomy. During follow-up in the outpatient department, magnetic resonance angiography and imaging revealed a progressive diffuse severe MCA stenosis and leukoencephalopathy. A hundred and eight days after the stent assisted procedure, the patient received percutaneous transluminal balloon-angioplasty, because of the resistance to any medical treatment and minor ischemic symptom.Conclusion: The authors state that close observation of both vascular lumen and wall is mandatory after mechanical thrombectomy and postoperative symptomatic stenosis may occur as in this case.
Objective: In this report, three patients with cervical internal carotid artery dissection (cICAD) successfully treated with stenting are presented, and the relevant literature is discussed.Case Presentations: Case 1: A 47-year-old man developed dysarthria, right facial palsy, right paresthesia, and left photophobia lasting for half an hour. MRI showed no new infarction, but angiography demonstrated a severe high cervical internal carotid artery (ICA) stenosis with a false lumen. He underwent stenting on the 9th day, and the lesion disappeared completely. His postoperative course was uneventful, and no recurrence has been observed to date. Case 2: A 34-year-old man noted episodes of mild headache and a transient left visual field defect and was brought to the hospital by ambulance. Initial diffusion-weighted MRI showed left ICA occlusion. Although his symptoms improved with iv rt-PA, global aphasia and right hemiparesis occurred after 4 h. Since his emergent DSA showed left cICAD with nearly complete occlusion, he underwent stenting. His symptoms improved dramatically, and he recovered fully in 3 months. Case 3: A 63-year-old man developed two transient episodes of mild right hemiparesis. Due to his recurrent symptoms, DSA was performed, and dissection was found at left cervical ICA of C1 level. Endovascular intervention with a stent was conducted, and no recurrence has been observed to date.Conclusion: Endovascular intervention using stent may play an important role in patients with cICAD having severe stenosis or recurrent ischemic stroke.
Objective: We report two cases of unruptured intracranial aneurysms treated with the coil embolization using T-stenting technique.Case Presentations: Case 1 was a 49-year-old woman with wide-neck basilar tip aneurysm (10.8 mm × 9.8 mm × 8.9 mm) riding on the origin of the bilateral posterior cerebral arteries. Case 2 was an 84-year-old woman with left internal carotid artery-posterior communicating artery aneurysm (16.8 mm × 13.5 mm × 12.6 mm) and the ipsilateral posterior communicating artery (Pcom) was branched from the dome of the aneurysm. Both cases were treated with coil embolization using the T-stenting technique without any neurological deficits.Conclusion: Although the T-stenting technique is accompanied by a difficulty on the occasion of stent placement in comparison with the Y-stenting technique, such a technique has a potential benefit to reduce the risk of thrombotic complications.
Objective: A case of carotid artery stent placement performed by exposing and directly puncturing the femoral artery through a small surgical incision is reported.Case Presentations: In this patient, who had undergone multiple bypass surgeries for arteriosclerosis obliterans of the bilateral lower extremities, the inguinal region was scarred and atrophied, and percutaneous puncturing of the femoral artery was difficult. In addition, the possible area of device insertion was limited to a short segment of the left femoral artery. Also, as stenting through the right brachial artery was difficult due to flexion contracture of the elbow as a sequela of cerebral infarction, stent placement was performed by surgically exposing and puncturing the femoral artery under local anesthesia.Conclusion: This stenting method was useful as it could be performed similarly to the usual percutaneous stenting procedure under local anesthesia with limited physical and psychological burden to the patient.
Objective: Focusing on the effect of oily contrast medium as an embolic agent, we performed embolization of meningioma. Its usefulness is reported.Case Presentations: A flow guide catheter was advanced through the feeding blood vessel to the tumor as close as possible, and 1.0 mL–2.0 mL of undiluted oily contrast medium was injected. The contrast medium did not flow out, and it was retained in the tumor. The proximal portion was then embolized with 33%–40% N-butyl cyanoacrylate (NBCA). On pathological examination of the excised specimen, the embolized blood vessel and tumor necrosis were noted, showing time-course progression of necrosis and softening.Conclusion: This method is superior in visibility and injection control because of the use of oily contrast medium. The flow guide microcatheter is easy to guide close to a tumor and insert into thin and tortuous blood vessels. So this is applicable for skull base tumors, showing its usefulness.
Objective: Four microcatheters were compared, and the properties of new microcatheters that are designed to be more shapable (Headway 17 and Excelsior XT 17) were evaluated.Case Presentations: After the tips of the catheters were shaped into one, two, and three spiral rounds about 4 mm in diameter, they were allowed to stand in physiologic saline at 37°C, and changes in the shape between immediately after and 10 min after shaping were compared. There was no difference in the shape among the catheters immediately after shaping, but the initial shape was better retained in Headway 17 and XT 17 after 10 min.Conclusion: Headway 17 and XT 17 had higher shape consistency than Excelsior SL 10 and Echelon 10, and better retained their original shape.