Objective: Long-term clinical outcomes including delayed rupture of unruptured intracranial aneurysms (UIAs) after coil embolization (CE) remain unclear. The purpose of this study was to evaluate the precise timing of re-treatment for recanalized UIAs before rupture.
Methods: From February 2012 to June 2020, a total of 197 patients with 207 UIAs underwent CE in our institution and were followed up for more than 6 months. The follow-up period, as well as morphological changes from treatment to recanalization, regrowth, and rupture, was retrospectively analyzed. Delayed rupture was defined as a rupture that occurred more than 1 month after CE.
Results: The average length of follow-up was 48.7 months. Three of 207 UIAs (1.45%) ruptured after CE. The aneurysm locations were the middle cerebral artery (MCA), anterior communicating artery (AcomA), and internal carotid artery–posterior communicating artery (ICA–Pcomm). The annual rupture rate after CE was 0.36%. Immediately after the first CE, treated aneurysms were graded according to the Modified Raymond–Roy Classification with class II for MCA aneurysms and class IIIb for AcomA and ICA–Pcomm aneurysms. The ICA–Pcomm aneurysm was treated with two additional CEs and was finally graded as class I. In all cases, DSA or MRA before aneurysm rupture showed recanalization and regrowth of aneurysms. The average periods from final embolization to regrowth and from regrowth to rupture were 54.3 months (±16.8) and 2.3 months (±0.9), respectively.
Conclusion: UIAs with recanalization and regrowth after CE should undergo re-treatment as early as possible.
Objective: This study aimed to use optical frequency domain imaging (OFDI) to evaluate the efficacy of post-dilatation (PD) after stent placement for unstable plaques during carotid artery stenting (CAS) using a double-layer stent.
Methods: Twelve unstable carotid plaque lesions diagnosed by MRI were evaluated using OFDI during CAS. The pre-procedural minimum lumen diameter was 1.6 ± 0.7 mm. Each lesion was pre-dilated with balloon catheters (diameter, 5.3 ± 0.5 mm), and a double-layer stent was deployed. PD was performed with balloon catheters of the same size as those used for pre-dilatation. Cross-sectional OFDI images within the stented segment were evaluated at 1-mm intervals for a 20-mm segment, including the most stenotic lesion. Slice rates for the presence of in-stent plaque protrusion (PP) and plaque between the double-layer lumen were calculated.
Results: No procedural complications occurred with the use of an embolic protection device. Compared to after stent placement, slice rates for any PP (44 ± 19% to 62 ± 22%, P <0.05) and plaque between the double-layer lumen (79 ± 16% to 91 ± 34%, P <0.05) were significantly increased after PD; slice rates for >500 μm PP (7.5 ± 14% to 0%, P <0.05) were significantly decreased. Visible debris were captured in 50% of lesions.
Conclusion: PD after double-layer carotid stent placement decreases in-stent large PP. Double-layer construction contributed to the prevention of large PP, as the PP may have been crushed into debris by PD.
Objective: Unlike in older adults, ischemic stroke in young patients occurs secondary to preexisting conditions. Infective endocarditis (IE) is among the most important causes of stroke in young adults and has a severe prognosis. There are few reports of mechanical thrombectomy (MT) for IE-induced large-vessel occlusion (LVO). This paper reports a case of acute IE-induced LVO in a young patient who was successfully treated with MT.
Case Presentation: An 18-year-old woman presented to our hospital with severe headache, high fever, and left fingertip pain. She was admitted to the Department of Neurology for conservative treatment of suspected meningitis. On day 2 of admission, she developed acute left hemiparesis, left hemispatial neglect, and dysarthria. MRA showed occlusion of the right M1 segment of the middle cerebral artery, and the patient immediately underwent MT. After a single pass, we achieved thrombolysis in cerebral infarction 2b. A white clot was diagnosed as a vegetation on pathological examination. As transesophageal echocardiography showed a vegetation on the mitral valve, the patient was diagnosed with IE and underwent cardiovascular surgery. The patient recovered well and underwent additional treatment and rehabilitation.
Conclusion: Although rare, IE-induced septic emboli may occur in young patients with LVO, necessitating MT and pathological diagnosis of the clot.
Objective: Owing to the limited time since the introduction of the PulseRider (PR), inconsequential or rare complications that clinicians should be aware of remain unreported yet. Here, we report a rare complication of incomplete detachment.
Case Presentation: A 50-year-old male underwent PR-assisted coil embolization for a basilar tip aneurysm. Coiling was completed, and the detachment procedure was performed using a detachment machine; the success signal was observed. The delivery microcatheter was subsequently advanced back up to the proximal markers, and no reapproximation of the proximal markers, which indicates successful detachment, was observed. However, only one of the proximal markers returned to the microcatheter, and incomplete detachment of only one leg was detected. Ultimately, electrical detachment was not possible, and physical separation by tension was achieved.
Conclusion: Our case report presents a rare case of a detachment problem in the PR. The PR could not be detached, although the signal revealed successful detachment. Therefore, careful withdrawal of the delivery wire by checking not only the proximal markers but also the behavior of the entire PR and coil complex is important.
Objective: A case of cerebral venous sinus thrombosis (CVST) during pregnancy effectively recanalized by endovascular mechanical thrombectomy with the combined use of an aspiration catheter and a stent retriever is reported.
Case Presentation: A 27-year-old woman at eight weeks’ gestation developed sudden onset of right hemiparalysis and seizures and was referred to our hospital. Her National Institutes of Health Stroke Scale score on admission was 23. On MRI, diffusion-weighted imaging showed a hyperintensity area in the left frontal lobe, and T2* imaging showed hemorrhagic infarction in the same area. MR venography showed obstruction of the anterior two-thirds of the superior sagittal sinus (SSS). Anticoagulant therapy with heparin was started, but since the venous return was expected to be severely impaired, mechanical thrombectomy by endovascular surgery was selected, hoping to resolve symptoms early. Using a large-bore aspiration catheter in combination with a stent retriever, it was possible to safely guide the aspiration catheter into the anterior half of the SSS. The use of a large-bore aspiration catheter enabled retrieval of a large amount of thrombus in a short time, and complete recanalization was achieved. The patient’s hemiplegia and aphasia improved significantly within a week after the procedure, and she was discharged without sequelae.
Conclusion: Mechanical endovascular therapy of CVST performed with a combination of a large-bore aspiration catheter and a stent retriever should be considered particularly for patients with severe neurological symptoms or intracranial hemorrhage and for those who do not respond to anticoagulation therapy.
Objective: We describe the rare case of a patient who was treated for a ruptured distal posterior inferior cerebellar artery (PICA) aneurysm via an ipsilateral persistent primitive proatlantal artery (PPPA).
Case Presentation: An 86-year-old female with a medical history of hypertension presented with headache and nausea. CT showed subarachnoid hemorrhage in the posterior cranial fossa, and CTA revealed an aneurysm at the left-side distal PICA. In the left-sided common carotid angiography, the artery with a branch of the occipital artery from the external carotid artery was described. This artery continued as the V3 segment and entered the dura via the foramen magnum. The artery perfused the territory of the left vertebral artery and PICA. We concluded that the artery, which entered the dura, was a PPPA. We decided to perform endovascular therapy that passed through the PPPA. The aneurysm was located in the cortical segments, beyond the cranial loop. We decided that parent artery occlusion (PAO) would be more effective than selective coil embolization to achieve safe and adequate hemostasis. The patient had a good outcome with PAO not assessing collateral circulation.
Conclusion: The emergency endovascular treatment with rare vascular variations requires accurate anatomical knowledge for treatment.
Objective: Stent-assisted coil embolization for cerebral aneurysms may lead to straightening of the parent vessel. However, detailed reports documenting the hemodynamic change in bifurcation type aneurysms due to straightening of the parent vessel immediately after stent deployment are scarce.
Case Presentation: A 48-year-old woman with a history of polycystic kidney disease underwent aneurysm neck clipping with left frontotemporal craniotomy for a ruptured bifurcation-type anterior communicating artery (AComA) aneurysm. Angiography 18 days after clipping showed a recurrent AComA aneurysm, for which stent-assisted coil embolization was performed. Straightening of the parent vessel immediately after deployment of a low-profile visualized intraluminal support junior (LVIS Jr.) stent from the AComA to the A1 segment of the right anterior cerebral artery was confirmed by working projection angiography. The aneurysm was easily embolized with coils with the support of the stent covering the aneurysm neck. The embolization was finished with a slight dome filling of the aneurysm. The parent vessel angle in 3D angiography changed from 90° before stent deployment to 160° immediately after stent deployment. Angiography 2 months after embolization showed the aneurysm with a complete occlusion and the parent vessel angle of 170° in a 3D image.
Conclusion: The hemodynamic change in a bifurcation-type AComA aneurysm due to straightening of the parent vessel immediately after the LVIS Jr. stent deployment led to the covering of the aneurysm neck, resulting in good coil embolization, to which the vessel mobility and the stenting method may have contributed.
Objective: We report a new contact aspiration technique using syringe aspiration called repeated-manual aspiration with maximum pressure (r-MAX).
Case Presentation: From January 2020 to May 2021, 18 patients underwent mechanical thrombectomy with r-MAX for occlusion of the internal carotid artery, the first division of the middle cerebral artery (M1), and basilar artery occlusion. In this method, the aspiration catheter is first guided to the occlusion site, and then, two VacLok syringes are connected to the aspiration catheter. Next, the three-way stopcock is released in one direction. After 15 seconds, the direction of the three-way stopcock is switched. In the meantime, negative pressure is reapplied through the syringe, and the direction of the three-way stopcock is switched again. After reapplying negative pressure through the syringe and switching the three-way stopcock two more times, the aspiration catheter is removed. First-pass thrombolysis in cerebral infarction (TICI) scale 3 recanalization was achieved in 11 out of 18 patients (61.1%). In all, 11 patients (61.1%) achieved modified Rankin Scale scores of 0–2 at 90 days. Asymptomatic hemorrhage was observed in two patients (11.1%), and no patients had symptomatic hemorrhage.
Conclusion: The r-MAX technique using syringe aspiration can be employed as one of the methods of contact aspiration.