Objective: Thin-walled regions of cerebral aneurysms are areas of risk for rupture, particularly during surgical procedures. Prediction of thin-walled regions before surgery can lead to safer treatment, avoiding interactions with thin-walled regions. It is considered that blood flow influences aneurysm wall thickness reduction. The objective of this study was to establish a parameter to accurately identify thin-walled regions using computational fluid dynamics (CFD) analysis.
Methods: The surgical field was photographed during craniotomy in 50 patients with unruptured middle cerebral artery aneurysms and red regions of the aneurysm wall were compared with the color of the parent vessel and defined as a thin-walled region. CFD analysis was performed and the distribution map of wall shear stress divergence (WSSD*) was compared to the surgical image of the cerebral aneurysms.
Results: The WSSDmax region and thin-walled region were coinciding in 41 (82.0%) of the 50 patients. There was a significant difference (P = 0.00022) between the patients with and without coincidence between the WSSDmax and thin-walled regions, and the threshold, sensitivity, specificity, and area under the curve (AUC) on receiver operating characteristic (ROC) analysis of WSSDmax were 0.230, 0.900, 0.875, and 0.883, respectively.
Conclusion: High-WSSD regions tended to be coinciding with thin-walled regions, suggesting that WSSDmax is useful to identify thin-walled regions of cerebral aneurysms.
Objective: Antiplatelet drugs are frequently used to prevent ischemic complications of endovascular therapy, but patients who showed poor responses to these drugs have been reported. We have adjusted antiplatelet drugs based on platelet aggregation activity before endovascular therapy. The objective of this study was to investigate the association between platelet aggregation test-based modification of antiplatelet drugs and perioperative complications.
Methods: In this study, we enrolled 146 patients who received elective endovascular therapy between October 2015 and December 2016. All patients received administration of aspirin 100 mg and clopidogrel 75 mg from 2 weeks before endovascular therapy and platelet aggregation activity was measured 1–2 days before the procedure. Cilostazol was additionally administered to patients who poorly responded to aspirin, or the drug was switched to prasugrel in patients who poorly responded to clopidogrel. Thereafter, platelet aggregation activity was re-tested on the following morning.
Results: On the initial test, 52 (35.6%) and 57 (39.0%) patients showed poor responses to aspirin and clopidogrel, respectively, and these rates were higher than those previously reported. After antiplatelet drug modification, 31 (21.2%) and 20 (13.7%) patients showed poor responses to aspirin and clopidogrel, respectively, showing significant decreases (p = 0.012 and <0.0001, respectively). Perioperative ischemic complication developed in five patients (3.4%), being lower than that (4.6%) previously reported.
Conclusion: The rate of patients with poor responses to antiplatelet drugs on the platelet aggregation test was higher than those previously reported, but their responses were improved by drug modification. Platelet aggregation test-based drug modification may be effective to prevent perioperative complications and further investigation is necessary.
Objective: For patients with tandem occlusion (TO), it is controversial whether an antegrade approach or retrograde approach should be undertaken. Here, we report our strategy for treating patients with TO by simultaneous approach. First, a microcatheter was advanced to the distal occlusion site along with a microwire. Second, a stent retriever (SR) was deployed as an anchor at the distal lesion, and percutaneous transluminal angioplasty (PTA) was performed at the proximal lesion using push wire of SR. After that, the microwire was removed and PTA balloon as well as the guiding catheter (GC) was advanced along the wire of SR. Finally, the SR was withdrawn with clot.
Case Presentations: Cases 1 and 2, who were confirmed as TO, were treated by the method described above. We could re-perfuse successfully. These two cases had favorable outcomes, indicating a modified Rankin scale 2 at the time of discharge.
Conclusion: Our therapeutic strategy for TO might be useful for early reperfusion of a distal occlusion site and associated with favorable outcome.
Objective: A rare case of enlargement of asymptomatic dissecting aneurysm after its initial treatment with stent-assisted coiling with parent artery occlusion for the ruptured contra lateral side is reported.
Case Presentation: A 52-year-old male patient presented with a subarachnoid hemorrhage resulting from a bilateral vertebral artery dissecting aneurysms. The patient was treated within 24 hours of the hemorrhage to prevent re-rupture by parent artery occlusion of the right vertebral artery and stent-assisted coiling of the left side. A 6-month follow-up showed an enlargement of the left side dissecting aneurysm. A second treatment was done to the left side also using stent-assisted coiling. The patient was discharged with no neurological deficit.
Conclusion: To our knowledge, parent artery occlusion for ruptured vertebral artery dissecting aneurysms (VADA) may cause contra lateral VADA enlargement even after its initial treatment by stent-assisted coil embolization in the same setting.
Objective: We report a case of ruptured large thrombosed true posterior communicating artery (PCoA) aneurysm and consider its treatment.
Case Presentation: A 71-year-old male patient had a left ruptured large thrombosed true PCoA aneurysm (maximum diameter 23 mm) with a small neck. Intra-aneurysmal coil embolization via the internal carotid artery was performed to preserve the premammillary artery (PMA). The adjunctive technique could not be used because the diameter of the PCoA was 1.5 mm. The result was a neck remnant and the aneurysm was recanalized. After 14 months, similar treatment was performed, and the aneurysm was recanalized again. The acute and twisted angle of the PCoA origin and the thinness of the PCoA were considered as factors for incomplete embolization. Because the distance between the origin of the PMA and aneurysmal neck was 5 mm, short-segment internal trapping of the aneurysm was performed 13 months after the second embolization. As a result, the PMA was no longer visualized on DSA; however, he had no neurologic deficit. The aneurysm remained obliterated after 7 months.
Conclusion: Making a tight intra-aneurysmal coil embolization of a large thrombosed true PCoA aneurysm is difficult. If there is a certain distance between the PMA and the aneurysm neck, short-segment internal trapping might be useful to treat it.
Objective: We report a first case of stent-assisted coiling for the left vertebral artery aneurysm via the left distal radial approach.
Case Presentation: The patient was a 47-year-old male with unruptured left vertebral artery aneurysm. Transfemoral approach was infeasible because of the history of thoracoabdominal aortic dissection, the left distal radial approach was selected. Distal radial artery in the left anatomical snuffbox was punctured and a 4 Fr guiding sheath was introduced to the left vertebral artery, followed by successful coil embolization with stent.
Conclusion: The left distal radial approach via the anatomical snuffbox is a feasible method for left vertebral artery lesions.