Objectives: The HydroSoft and HydroFrame coils are a new generation of coils designed to further improve the safety and durability of aneurysm coiling using hydrogel technology. The authors report their experience using the HydroSoft and HydroFrame coils for the treatment of intracranial aneurysms. Methods: Immediate and follow-up angiographic results, procedure-related complications, and retreatments were retrospectively analyzed for 106 intracranial saccular aneurysms in 103 patients treated with the HydroSoft and HydroFrame coils during a 50-month period. Results: The incidence of thromboembolic complications was 5.7%. Procedure-related morbidity and mortality rates were each 0.9%. None of the patients with unruptured aneurysms developed hydrocephalus. Immediate post-procedure angiograms showed complete aneurysm occlusion in 34.9% of cases, neck remnant in 36.8%, and incomplete occlusion in 28.3%. Angiographic follow-up was obtained in 51.9% (55 of 106 aneurysms; average, 16 months; range, 6-45 months). In these 55 aneurysms, the rate of immediate complete occlusion was 27.3% after treatment, which increased to 50.9% on follow-up, and the overall recanalization rate was 14.5%. No recanalization was observed in the 8 aneurysms treated with stent-assisted coiling in combination with HydroSoft and HydroFrame coil placement. Conclusions: The overall safety profile of the HydroSoft and HydroFrame coils appears to be acceptable. Preliminary midterm observation suggests that these new-generation hydrogel coils will improve the durability of angiographic occlusion, when compared with immediate post-embolization results, and can reduce the rate of aneurysm recanalization.
Objectives: In recent years, endovascular treatment, especially parent artery occlusion, has become a first-line treatment for ruptured vertebral artery dissecting aneurysms (VADAs). This study reports the outcomes of endovascularly treated ruptured VADAs. Methods: The subjects comprised 50 patients who underwent endovascular parent artery occlusion of ruptured VADAs between 2004 and 2011 (29 men, 21 women; mean age, 50.7 years [range, 28-74 years]). Hunt and Hess (H/H) grades just prior to endovascular treatment were grade 1 in 4 patients (8.0%), grade 2 in 8 (16.0%), grade 3 in 14 (28.0%), grade 4 in 9 (18.0%), and grade 5 in 15 (30.0%). Clinical outcomes were assessed using the Glasgow Outcome Scale. Locations of dissecting aneurysms relative to the ipsilateral posterior inferior cerebellar artery (PICA) were proximal type in 3 patients (6.0%), distal type in 25 (50.0%), PICA-involved type in 6 (12.0%), and non-PICA type in 16 (32.0%). Results: Forty-two patients (84.0%) underwent internal trapping, and the remaining 8 patients (16.0%) underwent proximal occlusion. One patient rebled during the diagnostic angiography before the coil embolization procedure. There were no procedure-related complications. Clinical outcomes at discharge were good recovery in 26 patients (52.0%), moderate disability in 4 (8.0%), severe disability in 10 (20.0%), vegetative survival in 4 (8.0%), and death in 6 (12.0%). Notably, 41.5% of the patients with an H/H grade of 4 to 5 had a good clinical outcome. Conclusions: This study shows that endovascular parent artery occlusion for ruptured VADAs is feasible and safe.
Objective: The aim was to determine the frequency of and contributing factors related to subarachnoid hemorrhage (SAH) after mechanical thrombectomy using the MERCI retriever in acute ischemic stroke patients. Methods: Data collected from the records of acute ischemic stroke patients treated within an 8-hour time window by an intracranial endovascular revascularization technique involving the use of the MERCI retriever were analyzed retrospectively. Results: Twenty-three consecutive acute ischemic stroke patients with intracranial major-vessel occlusion were treated at our department between April 2009 and February 2012. The MERCI retriever was used in 12 patients (52.2%). There was a non-significant trend for increasing SAH in the MERCI group compared with the non-MERCI group (5 of 12 patients, 41.7% vs. 1 of 11 patients, 9.1%, p=0.155). There were no symptomatic intracranial hemorrhages. The total number of passes of the MERCI retriever through the occluded vessel was significantly greater in the SAH subgroup than in the non-SAH subgroup (average 3.6 vs. 1.6 times, p=0.038). Conclusion: SAH after mechanical thrombectomy using the MERCI retriever was associated with the total number of passes through the occluded vessel. The absence of symptomatic intracranial hemorrhages in this study implies that the use of the MERCI retriever in endovascular therapy is safe. However, to ensure the safety of MERCI retriever use in endovascular therapy, the number of passes might have to be limited to 2 or 3 times.
Objective: Microembolic signals (MES) are a predictor of future stroke in patients with carotid artery stenosis. We report a case of carotid artery stenosis in which transcranial Doppler (TCD) showed disappearance of MES after carotid artery stenting (CAS). Case presentation: A 65-year-old man presented with transient left hemiparesis and homonymous left hemianopsia. Diffusion-weighted magnetic resonance (MR) imaging showed new infarction in the territory of the left middle cerebral artery, and MR angiography showed moderate stenosis in the left cervical internal carotid artery. Although dual antiplatelet treatment was administered, diffusion-weighted MR imaging showed increased infarction, and TCD detected 5 MES in 30 minutes. We decided to perform CAS to prevent artery-to-artery embolism, which was recurrent despite optimal medical treatment. CAS was performed with a Carotid Wallstent 19 days after the onset. TCD obtained 5 days after CAS detected no MES, and no new infarcts were detected as of 1 year after CAS. Conclusion: CAS using the Carotid Wallstent can prevent medication-resistant embolic stroke due to carotid artery stenosis, and TCD is useful to evaluate the effect of the treatment.
Objective: In this report, we present a case of carotid artery stenting (CAS) by direct puncture of the common carotid artery through a small skin incision. Case presentation: An 83-year-old man suffering from recurrent transient dysarthria and right hemiparesis was referred to our hospital. Diffusion-weighted images showed multiple small cortical infarctions in the left cerebral hemisphere. 3D CT angiograms revealed severe stenosis at the origin of the left internal carotid artery. CAS was planned because it is less invasive for the patient. Direct puncture of the left common carotid artery was preferred in this case due to severe atherosclerosis of the aorta. We exposed the left common carotid artery by making a small skin incision. Arterial puncture was performed and homeostasis was achieved easily and safely through this skin incision. Conclusion: CAS using direct puncture of the carotid through a small skin incision may be safer than direct percutaneous carotid puncture.
Objective: We present a case of ruptured aneurysm of the posterior inferior cerebellar artery associated with persistent primitive hypoglossal artery. Case presentation: A 42-year-old female presented with a subarachnoid hemorrhage. Coil embolization of the saccular portion of the aneurysm through a persistent primitive hypoglossal artery brought about a good clinical outcome. Conclusion: It is reasonable to occlude only the saccular portion of the aneurysm to prevent rebleeding. Further studies are needed to confirm the phylogenetic background of the aneurysm.
Objective: We report a case of disruption and migration of the distal portion of the delivery wire from an Enterprise Vascular Reconstruction Device (VRD) during coil embolization for an unruptured cerebral aneurysm. Case presentation: A 63-year-old woman, who had undergone neck clipping for an aneurysm of the right internal carotid-posterior communicating artery 12 years previously, suffered a recurrence at the same location. Stent-assisted coil embolization using an Enterprise VRD was chosen for repair because of its wide neck. After insufficient coil embolization with the initial Enterprise VRD, a second Enterprise VRD was deployed in a stent-in-stent manner. Following deployment of the second stent, a distal section of the delivery wire became disrupted and migrated distal to the aneurysm. Craniotomy was performed for direct surgical removal of the migrated wire because endovascular retrieval with a goose neck snare proved too difficult. Conclusion: Disruption of the delivery wire from an Enterprise VRD is extremely rare but possible. Physicians should be aware of this potential problem in patients with a tortuous parent artery and proceed with caution to avoid excessive stress to the device.
Objective: There have been no reports on the dural arteriovenous fistula (dAVF) of the occipital sinus (OS). We present a case of dAVF involving the OS. Case presentation: A 51-year-old woman suffered from pulsating tinnitus for a year and gradually worsening tinnitus. Angiograms showed the presence of a dAVF fed by the bilateral occipital arteries and bilateral middle meningeal arteries. The fistula was located in the occipital sinus and drained into the bilateral transverse sinuses. Cortical venous reflux was not observed. We chose transvenous embolization (TVE). A microcatheter was introduced into the fistulous pouch of the OS via the left transverse sinus (TS). Six detachable coils were placed in the fistulous pouch, and an angiogram showed complete occlusion of the dAVF. After the procedure, there was no observable neurological deficit or tinnitus. Conclusion: dAVF draining into the OS is very rare. It is important to identify the fistulous point by 3-dimensional rotational angiography (3D-RA). Hemodynamic function of the OS, in particular, should be evaluated to perform transvenous embolization.