Objective: During balloon-assisted coil embolization of intracranial aneurysms with the HyperForm balloon microcatheter (HyperForm; eV3 Neurovascular, Irvine, CA, USA) we encountered an instance where the balloon was inflated unexpectedly when a guidewire was fixed by the thumbwheel of the Y-connector provided with the one-touch slide-type valve. We report this phenomenon with a description of procedural precautions.
Method: Between April 2011 and December 2012, balloon-assisted coil embolization with HyperForm was performed in 24 patients with intracranial aneurysms at our facility. The Y-connectors that were used to connect the HyperForm were provided with either a one-touch slide-type valve (13 patients) or a conventional throttle valve (11 patients).
Result: The balloon inflated in all 13 patients when the guidewire was fixed by turning the thumbwheel of the Y-connector provided with the one-touch slide-type valve during the setup of HyperForm. In Y-connectors with the conventional throttle valve, balloon inflation was not observed after performing the same procedure.
Conclusion: The Y-connector provided with the one-touch slide-type valve is beneficial for reducing blood loss from cases requiring the frequent insertion and removal of devices. However, if the Y-connector is used with a single-lumen balloon catheter, which is inflated after the tip opening is closed with a guidewire, turning the thumbwheel will increase the internal pressure of the catheter and consequently pose a risk of unexpected balloon inflation.

View full abstract

Objective: An aberrant internal carotid artery (ICA) is a rare congenital vascular malformation and many previous studies have emphasized this anomaly because of an increased risk of injury during otological surgical procedures. However, neither spontaneous massive bleeding nor infectious pseudoaneurysm associated with aberrant ICA has been reported to date.
Case presentation: We present the case of a 54-year-old healthy female patient who experienced sudden massive bleeding from the ear following a single sneeze. This patient had suffered from ipsilateral otorrhea due to acute otitis media for one month. Based on a radiological examination in combination with past medical history, infectious pseudoaneurysm associated with aberrant ICA was diagnosed as the cause of bleeding. Although an embolic infarction during the endovascular procedure induced slight hemiparesis, the pseudoaneurysm was successfully managed with endovascular coil trapping.
Conclusion: Although aberrant ICA has been reported as a possible cause of ear bleeding during otological procedures in the past, this is the first report of a spontaneously ruptured pseudoaneurysm associated with aberrant ICA. This case indicates that it is important to consider ruptured pseudoaneurysm in the differential diagnosis of ear bleeding, and also provides evidence that endovascular treatment is suitable for this condition.

View full abstract

Objective: A right-sided aortic arch is an anomaly of the aorta in early fetal life. We report a case of ruptured cerebral aneurysm with a right-sided aortic arch, which was treated by coil embolization.
Case presentation: A 60-year-old male patient was admitted on foot on the 6th day after onset of sudden headache. Neuroradiological imaging studies showed a subarachnoid hemorrhage and an aneurysm at the bifurcation of the left middle cerebral artery. During procedures for endovascular treatment, an aortic angiogram revealed a right-sided aortic arch with Kommerell's diverticulum from which the aberrant left subclavian artery originated. Coil embolization of the aneurysm was performed meticulously. The patient's postoperative course was uneventful, and the patient was discharged without any neurological deficits.
Conclusion: A right-sided aortic arch is a rare congenital anomaly, but it is crucial to have knowledge on this anomaly since it may be detected during some treatments.

View full abstract

Objective: We report a case of ruptured peripheral dissecting superior cerebellar artery (SCA) aneurysm as a rare and difficult to confirm source of subarachnoid hemorrhage (SAH).
Case presentation: A 55-year-old male patient was admitted to our hospital with impaired level of consciousness. Although the patient's CT showed SAH, no intra-cranial arterial saccular aneurysm was seen on DSA. However, there was a suspicion of morphological changes in the lateral pontomesencephalic segment of the left SCA. An MRI 4 days after onset showed cerebellar infarction in the left SCA territory. This raised reasonable suspicion that the SAH was caused by a ruptured dissecting SCA. On day 6 after onset, a parent artery occlusion of the left SCA was performed. After the operation a transient right conjugate gaze deviation was observed.
Conclusion: A dissecting SCA may be the possible cause of SAH. We expect that parent artery occlusion can be an effective method of management, as it is in other locations for this type of pathology.

View full abstract

Objective: We report on a case of staged carotid artery stenting (CAS) for bilateral severe asymptomatic carotid artery stenosis followed by coronary artery bypass grafting (CABG) in a patient with unstable angina pectoris.
Case presentation: A 60-year-old male patient suffering from unstable angina pectoris with triple-vessel coronary artery disease was diagnosed with bilateral severe asymptomatic carotid artery stenosis before CABG. Due to severe atherosclerosis of the aorta (shaggy aorta) and severe renal dysfunction, a right CAS was performed via the trans-brachial arterial approach under ultrasound guidance to eliminate the need for iodine contrast use, and a left CAS was performed via direct puncture to minimize iodine contrast.
Conclusion: We reported the strategy and ingenuity of CAS for a pre-CABG patient with shaggy aorta, renal dysfunction and subclavian artery dissection.

View full abstract

Objective: Mo. Ma Ultra (Mo. Ma) is used during carotid artery stenting (CAS) and, in two cases, we experienced difficulties withdrawing the stent delivery system. Here we report the mechanism and procedures that should be performed for safe withdrawal of the system.
Case presentation: Representative case 1: An 81-year-old male patient with symptomatic carotid stenosis who underwent CAS using Mo. Ma. During the operation, we encountered issues with withdrawing the stent delivery system.
Conclusion: The cause of difficulties in withdrawing the stent delivery system in CAS using Mo. Ma is the stent tip getting caught in the outlet port of Mo. Ma. The stent system can be safely withdrawn by resheathing the outer sheath of a Precise stent accurately.

View full abstract

Objective: We report a unique case of carotid cavernous fistula (CCF) with thrombosed draining vein, making usual transvenous approaches impossible.
Case presentation: This 69-year-old male patient presented with typical symptoms of CCF. Cerebral angiography revealed left CCF being fed by bilateral meningohypophyseal trunks (MHTs). Presumably due to anatomical variations of the cavernous sinus, attempts to access the shunting point by using the usual inferior petrosal sinus route failed. Thereafter peripheral draining vein thromboses might cause paradoxical worsening. Since urgent treatment appeared necessary, a transvenous coil embolization via direct puncture of the superior ophthalmic vein (SOV) was performed to obliterate the shunting point. Postoperatively that patient's visual symptoms recovered well.
Conclusion: Direct puncture of the SOV to obliterate CCF is a possible alternative choice of treatment when the usual transvenous access route was available. To reduce risk of complications we believe biplane angiographical devices, preparation of liquid embolic material, 20G elastic needles, and prevention of heparinization are necessary.

View full abstract