Purpose: The laterocavernous sinus (LCS) is a normal variation of the venous sinus bordered by the dura mater lateral to the cavernous sinus (CS) and one of the major drainage route of the superficial middle cerebral vein (SMCV). In this study, we evaluated the angiographic findings and the procedure and results of transvenous embolization (TVE) in patients with a cavernous sinus dural arteriovenous fistula (CSDAVF) involving the LCS, and discussed technical tips and pit fall in treatment. In 27 patients with a CSDAVF who underwent TVE between January 2007 and October 2015, we evaluated their three-dimensional digital subtraction angiography/digital angiography (3D-DSA/DA) and selective arteriography about the presence or absence of a shunt to the LCS. Subsequently, in patients with a shunt to the LCS, the angiographic findings and the procedure and results of TVE were evaluated.
Results: A shunt to the LCS was observed in four patients (14.8%). In all the four patients, there were multiple shunted pouches of the CS and LCS, and the feeders to the LCS were the artery of the foramen rotundum, middle meningeal artery, and accessory meningeal artery. Reflux to the SMCV and/or uncal vein (UV) via the LCS was present in all the patients. The LCS was connected to the CS at a dorsal site in two patients and at a lateral site in two patients. In all the patients, embolization was performed by advancing a microcatheter to the LCS, but insertion into the LCS was time-consuming in the patients with CS-LCS connection at a dorsal site. The symptoms disappeared without complications in all the patients.
Conclusion: Microcatheter insertion into the LCS is sometimes difficult in patients with CS-LCS connection at a dorsal site, requiring careful attention. In patients with a shunt to the LCS, since embolization of the CS alone can result in Borden type 3 in which cortical venous reflux remains, it is necessary to be careful.
Objective: To report the clinical outcomes of carotid artery stenting (CAS) using the FilterWire EZ (FWEZ) Embolic Protection System.
Methods: In 262 consecutive patients who underwent CAS using FWEZ from May 2010 to December 31, 2015, major adverse events (MAEs) including stroke, myocardial infarction, and death that occurred between 30 days and 1 year after the procedure and findings on diffusion-weighted imaging (DWI) were evaluated.
Results: Ischemic stroke was observed after CAS using FWEZ in four patients (1.53%), but the neurological symptoms disappeared within 30 days in all those patients. No cerebral hemorrhage, myocardial infarction, or death occurred within 30 days after CAS. New DWI lesions were observed in 53 patients (20.2%): ipsilateral hemisphere alone in 38 patients (14.5%), contralateral hemisphere alone in 5 patients (1.9%), and both hemispheres in 10 patients (3.82%). They were significantly related to age, smoking within 1 year, and prolonged post-procedural hypotension. In 235 patients who could be followed up, no ipsilateral stroke was noted between 31 days and 1 year after CAS. Non-ipsilateral strokes were observed in three patients (1.28%): contralateral cerebral infarction in one patient (0.43%), contralateral cerebral hemorrhage in one patient (0.43%), and death due to subarachnoid hemorrhage in one patient (0.43%). Other events included non-traumatic acute subdural hematoma in one patient (0.43%), myocardial infarction in six patients (2.55%), and death in seven patients (2.98%). No 50% or severer stenosis was observed within 1 year.
Conclusion: The clinical outcomes and DWI-positive rates between 30 days and 1 year after CAS using FWEZ were favorable. CAS using FWEZ is a simple procedure and is considered effective for the treatment of carotid stenosis considered.
Purpose: This study investigated the efficacy of endovascular therapy for occlusion of the second segment (M2) of the middle cerebral artery (MCA) in patients who were ineligible for intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA).
Materials and Methods: The subjects were 29 patients with M2 occlusion who were admitted between December 2010 and July 2015. In total, 21 patients were assigned to medical therapy and 8 received endovascular therapy.
Results: We compared background factors and the outcome between the two groups. We also assessed the impact of endovascular therapy on the outcome by multivariate analysis. After 90 days, the mean modified Rankin Scale (mRS) score was significantly lower in the endovascular therapy group than in the medical therapy group (1.62 ± 0.50 vs. 3.00 ± 0.31, P = 0.02). Multivariate analysis showed that the age (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.61–0.99, P = 0.04), the National Institutes of Health Stroke Scale (NIHSS) score on admission (OR: 0.58, 95% CI: 0.27–0.83, P <0.01), and endovascular therapy (OR: 160, 95% CI: 1.28–985,014, P = 0.03) were independent predictors of an mRS score ≤2 after 90 days.
Conclusion: Endovascular therapy is effective for M2 occlusion in patients showing diffusion-weighted imaging/CT perfusion mismatch who are ineligible for intravenous thrombolysis.
Purpose: We report a patient with an occipital artery aneurysm below the scalp associated with a transverse-sigmoid sinus dural arteriovenous fistula (dAVF).
Case: An 84-year-old male noticed a painless pulsatile mass measuring 2 cm in the left occipital region. Computed tomography (CT) 6 years before did not confirm any subcutaneous mass. An inquiry was conducted, but there was no history of occipital trauma. Cerebral angiography revealed a left transverse-sigmoid sinus dAVF. The dilated left occipital artery was a major feeding blood vessel, and aneurysm formation was partially observed. There was no marked change in the aneurysmal shape 6 months after diagnosis.
Conclusion: Vascular wall stress related to an increase in blood flow and the fragility of the perivascular supporting tissue may have been involved in the pathogenesis.
Objective: We describe a successful clot retrieval therapy of cerebral embolism while on a ventricular assist device (VAD) in a pediatric patient.
Case Presentations: A 15-year-old boy underwent an intracorporeal type left VAD placement as a bridge to heart transplantation for severe heart failure related to dilated cardiomyopathy. Eight months later, he suddenly presented with right hemiparesis and dysarthria. A head computed tomography (CT) scan demonstrated a hyperdense sign in the left middle cerebral artery (MCA), and cerebral angiography revealed occlusion of the left MCA M1 distal segment. Mechanical thrombectomy with a stent clot retrieval device achieved complete recanalization. His symptoms rapidly improved and disappeared.
Conclusion: Clot retrieval therapy may be useful for treating a pediatric patient with cerebral embolism related to VAD therapy.
Purpose: We report a patient in whom basi-parallel anatomical scanning (BPAS) confirmed the enlargement of ischemia-onset-type vertebral artery dissection in a short period and its reduction after internal trapping.
Case: A 44-year-old male consulted the Emergency Outpatient Unit with sudden posterior cervical pain and gait disorder. Magnetic resonance imaging (MRI) revealed vertebral artery dissection-related bulbar infarction, and he was admitted. MRI and Magnetic resonance angiography (MRA) were performed every 2 months at the outpatient clinic, showing a serial increase in the dissected lumen. Internal trapping was conducted. Postoperative MRI, MRA, and BPAS confirmed a serial reduction in the outer diameter of the dissected lumen.
Conclusion: BPAS is useful for evaluating the progression of vertebral artery dissection and healing process after internal trapping.
Objective: We report a case of dissecting aneurysm of the basilar artery that showed repeated rupture and regrowth but was successfully occluded by “sandwich” placement of a coil between two stents.
Case Presentation: The patient was a 41-year-old man. He had subarachnoid hemorrhage (SAH) due to rupture of dissecting aneurysm of the basilar artery 4.5 years before, and a temporary cure was achieved by stent-assisted coil embolization. However, he had SAH again from de novo dissecting aneurysm of the basilar trunk, and, despite repeated treatment by multiple stent-assisted embolization, the aneurysm was recanalized due to coil compaction, and a fourth treatment became necessary. Since it was difficult to insert a microcatheter by the trans-cell approach through three layers of stents, we placed a coil by sandwiching it between two layers of stents in front of the inflow and achieved complete occlusion of the aneurysm.
Conclusion: This “coil sandwich technique” is expected to be useful as an option for the treatment of recurrence after stent-assisted coil embolization.
Objective: We report a new microcatheter shaping method that makes consistent and safe microcatheter navigation into cerebral aneurysms possible for coil embolization even in lesions difficult to catheterize.
Case Presentation: The patient was an 83-year-old woman who had been followed-up for unruptured aneurysm of the internal carotid-anterior choroidal bifurcation. Endovascular treatment was performed because a bleb tended to enlarge. A straight microcatheter was guided to the parent artery about 5 mm distal to the target aneurysmal neck. The whole catheter was pressed against the wall of the parent artery, and this state was maintained for about 3 minutes. When the catheter was retrieved out of the body, the 3D shape memorized by the catheter was in agreement with the 3D morphology of the parent artery on 3D-DSA. Two sites of the catheter were steam-shaped, and the catheter tip was further steam-shaped into a shape that is more likely to be stabilized in the aneurysm using a mandrel. The microcatheter could be guided into the aneurysm simply by pulling it from a point distal to the aneurysm. Satisfactory coiling could be achieved. The microcatheter could be guided into the aneurysm by simply pulling it from a point distal to the aneurysm in all five patients to whom this technique was applied (one patient with ruptured and four patients with unruptured aneurysms).
Conclusion: This method was extremely effective in not only aneurysms to which the microcatheter was difficult to guide, but also those in which advancing a Guidewire into the aneurysm in advance was dangerous.