Interpretation of a detailed vascular anatomy is essential for safe and secure, surgical and/or interventional treatmentsof the vascular diseases of the central nervous system. To obtain such anatomical data, modern CT/MR imaging is lessinvasive and has become the primary diagnostic modality today. Catheter angiography has an inherent risk of variouscomplications, but still remains useful diagnostic modality in many situations. The author has reviewed the role ofstereoscopic viewing of the vascular images of the central nervous system, especially digital subtraction angiograms, aswell as three-dimensional angiograms reconstructed by CT/MR imaging.

View full abstract

Objective: We recently developed and launched an 8Fr Optimo balloon catheter as the guiding catheter for endovascular coil embolization. Here, we describe our experience with the use of this flow-controlling guiding system.
Methods: Between August 2013 and June 2014, patients who underwent endovascular coil embolization in our hospital were retrospectively analyzed. Records were reviewed for age, sex, aneurysm characteristics, and adjunctive technique.
Results: Endovascular coil embolization using the 8Fr Optimo was performed for 35 patients presented with 37 anterior circulating cerebral aneurysms. Six aneurysms were treated under proximal blood-flow control using the 8Fr Optimo. In three cases, we could successfully prevent the coil herniation from the aneurysms. In two cases of intraoperative aneurysmal ruptures, we could immediately reduce the blood-flow into the aneurysm and stop the bleeding. In one case of giant aneurysm, we could navigate the micro-guidewire to the distal parent artery owing to the proximal flow control.
Conclusion: Intraoperative proximal flow control can be safely and effectively performed using an 8Fr Optimo as a guiding catheter.

View full abstract

Objective: Endovascular embolization of very small aneurysms (under 3 mm in maximum diameter) is considered to be high risk for aneurysm perforation.
Methods: We compared initial angiographic results of ruptured aneurysms between under 3 mm in diameter (21 cases, small group) and over 3 mm in diameter (85 cases, non-small group), the results of short-term follow-up angiography in the small group were also demonstrated. In the small group, extremely soft coils were mainly used for aneurysmal filing.
Results: The technical success rates in the small and in the non-small groups were 95.2% and 100%, respectively. Initial angiographic results showed that complete occlusion was obtained in 65.0% of the small group and 52.9% of the non-small group. The mean packing densities in the small and non-small groups were 47.1±11.4% and 26.4±9.5%, respectively, showing the packing density in the small group was significantly higher than those in the non-small group (p<0.001). Intra-operative aneurysmal perforation occurred in 14% and 2.4% in the small and non-small groups, respectively (p=0.08), but none resulted in neurological worsening. In the small group, post-operative rerupture occurred in 5%. Follow-up angiography was performed in 12 cases (60%) at 3–12 months after the procedure, and complete occlusion was obtained in 92%.
Conclusion: Endovascular embolization of very small aneurysms is more likely to result in intra-operative aneurysmal perforation compared to larger aneurysms. The use of extremely soft coils could obtain a high packing density, and suitable for repairing these perforations.

View full abstract

Objective: We hereby report a rare case of Barrow type B cavernous sinus dural arteriovenous fistula (CSdAVF) thatwas treated by coiling the affected sinus through a trans-arterially placed microcatheter via the ipsilateral accessorymeningeal artery (AMA).
Case presentation: A 75-year-old man presented with chemosis and exophthalmos on his left eye. The patient didnot have a previous medical history of head trauma. Left external carotid artery angiogram revealed a CSdAVF withtwo feeders, the accessory meningeal artery and artery of foramen rotundum. Retrograde venous drainage was seen tothe ipsilateral superior orbital and deep middle cerebral veins. During the intervention, a microcatheter was advancedbeyond the fistula into the cavernous sinus through the large AMA. The microcatheter was easily manipulated in thesinus and packing of the sinus was achieved with coils.
Conclusion: A rare case of CSdAVF treated by trans-arterial coiling via the AMA is reported. The trans-arterialapproach to the cavernous sinus may be an unexpected option and should be considered in case with limited access tothe sinus.

View full abstract

Objective: We report a case with ruptured basilar artery (BA) fusiform aneurysm treated with coil embolization byusing a “parallel stenting” at the chronic stage.
Case presentation: A 63-year-old woman was admitted to our hospital with a sudden headache. CT demonstrated asubarachnoid hemorrhage and DSA showed a fusiform BA aneurysm (18×12 mm). Both anterior inferior cerebellararteries arose from the dorsal aspect of the fusiform aneurysm. Three weeks later, intravascular surgery was carried out.To protect the flow of the BA, two stents (Enterprise VRD 4.5×37 mm) were navigated and positioned from BA to bothVAs in a side-by-side (parallel) manner. After parallel stenting, the coil embolization of the aneurysm was successfullyperformed. Several weeks after the surgical treatments, the patient got discharged from the hospital with no neurologicaldeficit.
Conclusion: The parallel stenting technique may be useful for the treatment of fusiform aneurysm.

View full abstract

Objective: We report a rare case of transient occlusion of the parent artery during stent assisted coil embolization foranterior cerebral artery aneurysm.
Case presentation: A 75-year-old man underwent stent assisted coil embolization of an unruptured right anteriorcerebral artery (ACA) aneurysm, 10 mm in diameter. A 22 mm Enterprise stent (Codman Neuroendovascular, Johnson& Johnson, Miami, FL, USA) was deployed at the A2 portion of the right ACA after deploying the 1st flaming coil.Therefore, additional coils were introduced with jailing technique. Toward the end of embolization, the parent artery(right ACA) was suddenly occluded when a filling coil was inserted withdrawing the microcatheter. After retrieving thelast coil and decannulating the microcatheter from the parent artery, the parent artery was recanalized completely.
Conclusion: The microcatheter was thought to be trapped in the coil mass and between the wall of the parent vesseland the stent, then the parent artery was elongated. Therefore, the parent vessel is kinked and occluded. In cases of stentassisted coil embolization for the narrow parent vessel, microcatheter could be trapped between the wall of the parentvessel and stent.

View full abstract

Objective: Here we report a rare case of coiling a ruptured aneurysm on the artery of Davidoff and Schechter feedingthe falcotentorial dural arteriovenous fistula (DAVF).
Case presentation: Our patient was a 51-year-old man with a WFNS Grade 1 subarachnoid hemorrhage (SAH)resulting from a ruptured aneurysm on the posterior cerebral artery dural branch (the artery of Davidoff and Schechter)that was a major feeder of a falcotentorial DAVF. The artery harbored three aneurysms. We performed endovascularcoil embolization of the largest aneurysm and the parent vessel. The second embolization of the other feeders wasperformed, during the chronic phase, which resulted in almost total disappearance of the shunt.
Conclusion: To the best of our knowledge, this is the first report of a very rare case of coiling a ruptured aneurysm onthe artery of Davidoff and Schechter feeding a falcotentorial DAVF. This meningeal branch of the posterior cerebralartery may present as a feeding artery of the falcotentorial DAVF. The endovascular treatment for the rupturedaneurysm on the artery of Davidoff and Schechter was a useful treatment.

View full abstract

Objective: The Amplatzer vascular plug (AVP) is a new embolic device with advantages in embolization of high-flow vessels. We report a case involving implantation of an AVP into the retromandibular vein and coil-embolization of an arteriovenous fistula (AVF).
Case presentation: We present the case of a 31-year-old woman with an external carotid artery (ECA)-retromandibular vein AVF. She complained of pulsatile tinnitus after a sagittal split-ramus osteotomy. The high-flow left ECAretromandibular vein AVF was depicted in the arterial phase using selective external carotid angiography (ECAG). Endovascular embolization treatment of the fistula using an AVP and coils was planned. We initially intended to introduce the AVP into the fistula via a transvenous route through the left external jugular vein, but could not pass the 5-Fr guiding catheter round the hairpin curve between the fistula and ECA. We therefore changed treatment strategy, placing an 8 mm AVP into the retromandibular vein. Fistula closure was almost obtained after implantation, but shunt flow from a narrow channel remained. We then embolized the fistula using coils, from the AVP to the fistula inlet. The fistula was occluded using five coils.
Conclusion: We treated the patient with implantation of an AVP in the retromandibular vein and coil-embolization of the AVF. Advantages of the AVP are its stability for high-flow vessel occlusion and its cost-effectiveness when compared with coils. However, this device has disadvantages in the ease of its delivery to distal vessels. Therefore, using this device in craniofacial lesions needs technical refinement.

View full abstract