Objective: We pathologically examined thrombi collected by mechanical thrombectomy in Embolic Stroke of Undetermined Source (ESUS).
Methods: We examined the thrombi of acute ischemic stroke patients who underwent mechanical thrombectomy from January 2017 to June 2018. We histopathologically investigated the thrombi in ESUS patients, and performed a comparison with the thrombi of cardioembolic stroke.
Results: Mechanical thrombectomy was performed in 35 patients, and the thrombus were obtained from five patients diagnosed as ESUS.
The thrombus in one patient consisted of neutrophils and nuclear crush cells not only the red blood cells, and another one was included atheroma which was different from the typical clot in one patient. In the 25 cardioembolic stroke patients in this study, the thrombi were all constructed of fibrin, red blood cells, and platelets.
Conclusion: In this pathological study, a difference was recognized in the clot components of ESUS. The results suggest that a pathological examination of thrombi obtained by mechanical thrombectomy is useful because there is a possibility that we can recognize the etiology of ESUS, and choose the best treatment for prevention of recurrence of stroke.
Objective: The usefulness of endovascular treatment for cavernous sinus (CS)-dural arteriovenous fistula (dAVF) has been established. As the first choice of endovascular intervention for CS-dAVF, transvenous embolization (TVE) is generally performed, and the inferior petrosal sinus (IPS) is usually selected as the main access route to the affected CS because of its accessibility. However, the angiographical pattern of the CS varies among individuals. In some cases, it is difficult to access the affected CS via the ipsilateral IPS because of thrombosis, hypoplasia, or aplasia. Therefore, in some cases, alternative venous access routes are needed for TVE.
Methods: A retrospective study was performed with 27 patients diagnosed with intracranial dAVF who underwent endovascular embolization at our institution. Among these, the data of nine patients with CS-dAVF treated by endovascular intervention were analyzed retrospectively in this study. We reviewed the endovascular access routes for CS-dAVF treatment based on anatomical and embryological considerations.
Results: The most common complaint was diplopia, followed by exophthalmos and chemosis. There was no hemorrhagic onset. Cortical venous reflux (CVR) was recognized angiographically in six patients. The IPS on the affected side was angiographically occluded in four patients. TVE was attempted first in all patients. In five patients where the ipsilateral IPS was patent, TVE was successfully performed via the ipsilateral IPS. In four patients where the ipsilateral IPS was occluded, microcatheter access to the affected CS via the ipsilateral IPS was unsuccessful. The following alternative approach routes were selected: the superficial temporal vein, facial vein, direct puncture of the superficial middle cerebral vein (SMCV), and ascending pharyngeal artery (APA) for transarterial intravenous embolization (TAIV). The CS-dAVF had disappeared in all patients at the final follow-up examination. In the case of difficult access, compartment formations of the intracavernous sinus were recognized. Compartment formation due to the anatomical and embryological differences of the intracavernous structure may have influenced the ability of the catheter to reach the affected shunted pouch.
Conclusions: In cases where the approach via the ipsilateral IPS was difficult, alternative access routes were effective for the required embolization. It is extremely important to fully understand the angioarchitecture, location of the shunted pouch, and compartments of the CS for successful endovascular treatment. Anatomical and developmental CS considerations may be useful for better access route selection.
Objective: A rare case of parent artery stenosis and visual disturbance after balloon-assisted coil embolization for an unruptured cerebral aneurysm is reported.
Case Presentation: A 63-year-old woman underwent successful coil embolization of an incidental cerebral aneurysm using a balloon-assisted technique. The aneurysm was located in the right internal carotid artery. Her treatment course was uneventful, and she was discharged without any neurological deficits. Follow-up angiography after 9 months showed severe parent artery stenosis without aneurysm recurrence. However, she had a visual disturbance, and MRI showed edema around the treated aneurysm at the same time. Judging from the results of several metal patch tests, the platinum coils caused this pathology, and oral steroids and antihistamines were administered. This treatment improved her parent artery stenosis, but her visual disturbance persisted.
Conclusion: Although parent artery stenosis after coil embolization using balloon-assisted technique of a cerebral aneurysm in the chronic phase is rare, we should consider the possibility of metal allergy.
Objective: The authors report a rare case of symptomatic cerebral arteriovenous malformation (AVM) manifesting as trigeminal neuralgia (TGN) that was successfully treated by a multimodal treatment.
Case Presentation: A 68-year-old man presented with right TGN. The symptom progressed with lancinating pain. Brain MRI showed a right temporal lobe AVM with a maximum diameter of approximately 50 mm. A right ectatic tortuous vertebral artery (VA) compressed the root of the right trigeminal nerve. The TGN completely disappeared after the 4th embolization. After the 6th embolization, excision was performed. No recurrence of TGN was observed in the 6 months after its excision.
Conclusion: The present case suggested that treatment of nidus may improve AVM-induced TGN. Embolization was considered to be an effective modality, especially in multimodal treatment for high-grade AVM.
Objective: The objectives of treating dural arteriovenous fistula (dAVF) are to achieve complete occlusion of the arteriovenous (AV) shunt and restoration of anterograde venous flow. We report a patient with complex dAVF who was managed by double overinflated balloon protection of the torcula and percutaneous transluminal angioplasty (PTA) for the occluded venous sinus.
Case Presentation: A 62-year-old woman was admitted with gradually worsening nausea and vomiting, as well as progressive memory disturbance and left hemiparesis. Head MRI/MRA demonstrated a dAVF involving the region from the right sigmoid sinus (SS) to transverse sinus (TS) along with occlusion of the left TS and right proximal SS. There was associated dilatation of the right TS, torcula, and superior sagittal sinus (SSS). The intracranial venous circulation was impaired, with venous reflux draining into the deep cerebral veins as well as the cortical veins. Transarterial embolization (TAE) and transvenous embolization (TVE) were performed with double overinflated balloon protection of the torcula, and shunt flow was completely abolished. The occluded sinus was recanalized by PTA. Her symptoms gradually improved after treatment.
Conclusion: In this patient, double overinflated balloon protection was effective for maintaining the torcula.
Objective: We report a case of cavernous sinus dural arteriovenous fistula (CSdAVF) associated with Klippel-Trenaunay syndrome (KTS).
Case Presentation: A 58-year-old woman was diagnosed with KTS with port-wine stain, overgrowth of tissues and bones, and venous malformation on the left upper limb. She was admitted to our hospital with the primary complain of ptosis and diplopia due to left oculomotor palsy, and her cerebral angiography revealed CSdAVF with retrograde leptomeningeal venous drainage. The shunt point was located at the posteromedial part of the left cavernous sinus (CS) on the angiogram. An enlarged subclavian vein and giant varix was detected in the left upper limb, and abnormality of the coagulation-fibrinolysis system caused by localized intravascular coagulation was confirmed. We performed transvenous coil embolization, and the symptoms improved after a few weeks with no new neurological deficits. However, the activation of coagulation-fibrinolysis system continued even after the surgery.
Conclusion: The formation of dAVF occurrence in this case is unclear. If genetic abnormalities that cause angiogenesis are involved in KTS, follow-up is important in the future.