Objective: Navigation of the guiding catheter (GC) is important in performing neuroendovascular therapy, as the GC may often disturb blood flow of the parent artery. In the present study, we aimed to examine the risk factors of mechanical vasospasm (mVS) of the parent artery during neuroendovascular therapy. Methods: We assessed a total of 64 consecutive cases who underwent coil embolization for unruptured intracranial aneurysms. mVS was defined as a stenotic change of the parent artery of > 25% after navigating GC. Results: mVS was observed in 24 cases (38%), and in 5 cases the GCs were changed to smaller sizes. The vasospastic changes in all the cases improved after changing the position of GC or the GC itself. Young age, female gender, and absence of hypertensive history were significantly associated with mVS. However, body mass index, adjunctive technique of coil embolization, and presence of hyper-intense lesions on diffusion weighted images were not associated with mVS. Conclusions: We suggest that care should be taken when navigating the GCs in patients with young age, female gender, and the absence of a history of hypertension in terms of the occurrence of mVS.
Objective: In mechanical thrombectomy for acute ischemic stroke, we formed a neurointerventional team called “Mobile Endovascular Therapy Team (MET)” to offer EVT at outside hospitals. In this study, we compared the elapsed time until the beginning of EVT between patients who performed EVT at outside hospitals and who received EVT in our hospital after they were transferred. Method: From July 2012 to June 2015, acute ischemic stroke patients who performed EVT within 8 hours from onset by MET (MET group) and received EVT after they were transferred to our hospital (transfer group) were enrolled. We defined the beginning of EVT as the time of injection from guiding catheter for EVT. We compared the time from initial imaging to the beginning of EVT (“picture to treatment” time) between the two groups. Results; Fifty-five patients in MET group and 9 patients in transfer group were analyzed. Picture to groin puncture time (MET group vs. transfer group: 54 minutes vs. 128 minutes, p < 0.0001), picture to treatment time (105 minutes vs. 168 minutes, p = 0.0003), and notification to treatment time (80 minutes vs. 125 minutes, p<0.0001) were significantly shorter in MET group than in transfer group. Conclusions: MET can provide EVT at outside hospitals without time delay and can be an alternative system to patient transfer.
Objective: To assess whether restenosis after carotid artery stenting (CAS) affects the development of ipsilateral stroke after the periprocedural period and to investigate significant predictors of restenosis after CAS. Methods: Between January 2009 and September 2014, patients who underwent CAS at our institution and had been followed for more than 180 days were retrospectively analyzed. Results: Two hundred and fifty patients who underwent CAS were included. An ipsilateral stroke and restenosis were detected in 9 (3.6%) and 19 (7.6%) patients, respectively. Of these, the ipsilateral stroke was associated with restenosis in three patients. The risk of ipsilateral stroke was significantly higher in the group with restenosis [hazard ratio (HR), 5.98; 95% confidence interval (CI), 1.19–24.47; p = 0.032]. Multivariate logistic regression analysis revealed that the placement of the closed-cell stent was an independent predictor of restenosis after CAS (HR, 5.12; 95% CI, 1.30–34.34; p = 0.017). Conclusion: Restenosis after CAS was associated with ipsilateral stroke after the periprocedural period. The placement of the closed-cell stent was an independent predictor of restenosis after CAS.
Objective: We report the case of a patient with cavernous sinus dural arteriovenous fistula (CSdAVF) who was treated by open craniotomy with direct transvenous embolization via the Sylvian vein, as embolization using the usual transfemoral approach was impossible. Case presentation: A 72-year-old woman presented with chemosis. Cerebral angiography revealed right CSdAVF with retrograde venous drainage to the ipsilateral Sylvian vein. Preoperative magnetic resonance imaging showed asymptomatic ipsilateral temporal hemorrhage. Transfemoral access to the CSdAVF via the inferior petrosal sinus and contralateral cavernous sinus failed. The patient underwent direct puncture of the Sylvian vein via frontotemporal craniotomy, and transvenous coil embolization was performed under fluoroscopic guidance to obliterate the shunting point. Conclusion: Direct puncture of the Sylvian vein is a useful approach to obliterate CSdAVF with retrograde venous drainage to the Sylvian vein when the usual transvenous access is not available.
Objective: We report a case of deformation of open-cell stent that occurred during carotid artery stenting (CAS) using Mo.Ma Ultra (MOMA) device in stenotic common carotid artery (CCA). Case presentation: A 66-year-old man was admitted to our hospital with recurrent right amaurosis fugax, and was diagnosed with symptomatic severe stenosis of the right carotid artery. CAS was performed under proximal protection with MOMA. A Protégé stent was placed in the stenosis from the internal carotid artery to the CCA. After the MOMA was removed, cone-beam computed tomography revealed a folding deformation of the Protégé stent in the CCA. The patient had no ischemic complications after the procedure. Later, using simple stenosis models, we tested whether any stents could be folded in such situations. We found that the stent could be folded inward under specific circumstances such that the stent does not expand enough to be placed in the stenosis with the device that has a relatively larger diameter outside of the stent. This situation can lead the stent to be folded when post-dilatation is performed. Conclusion: Because our experiment indicated that an open-cell stent can be folded inward in some cases, this possibility should be kept in mind by surgeons.
Objective: We report a rare case of multiple unruptured cerebral aneurysms associated with persistent primitive hypoglossal artery (PPHA). Case presentation: A 70-year-old female was admitted to our hospital for further examination of left hearing impairment and bilateral tinnitus. 3D-CTA and cerebral angiography showed a large aneurysm at the cavernous segment of the right internal carotid artery (ICA) and a small aneurysm at the top of basilar artery associated with PPHA. The patient underwent balloon-assisted coil embolization of the large aneurysm of the right ICA and rescue stenting for the protruding coil into the right ICA. Postoperative course was uneventful. Conclusion: This is the first report of a large unruptured aneurysm at the cavernous segment of the ICA in multiple cerebral aneurysms associated with PPHA.
Objective: Coil or stent migration during endovascular coiling procedures for intracranial aneurysm can result in devastating thromboembolic complications. We present a case with migration of coils and movement of a Neuroform stent during coil embolization of a left carotid-posterior communicating artery aneurysm. The complication was effectively managed with the use of a gooseneck snare. Case presentation: A 79-year-old right-handed man with left unruptured carotid-posterior communicating artery aneurysm was treated with stent-assisted coil embolization. During the procedure, a coil got entangled with the stent that had already been placed in the left carotid artery. Retraction of the coil made the coil-stent complex slip to the proximal side of the aneurysm within the left carotid artery. The coil-stent complex was successfully retrieved with a gooseneck snare. Conclusion: The frequency of stent movement is not particularly high, but the risk must be recognized. Retrieval or repositioning of these migrated foreign bodies should be performed carefully to prevent secondary complication.
Objective: Dual antiplatelet therapy is recommended for carotid artery stenting (CAS) to prevent ischemic complications. We report a case of CAS where the novel antiplatelet agent, prasugrel, was used because multiple antiplatelet agents were unavailable. Case presentation: A 70-year-old man presented with minor stroke associated with cervical carotid artery stenosis. CAS was considered appropriate as a cerebral revascularization therapy. However, both clopidogrel and cilostazol were contraindicated because they were suspected as causes of agranulocytosis. We performed CAS under dual antiplatelet therapy with aspirin and prasugrel. His postoperative course was uneventful. Conclusion: We described a successful CAS performed under dual antiplatelet therapy including prasugrel, in Japan. Further investigations would be warranted to address the safety and efficacy of prasugrel in neuroendovascular therapy.
Objective: This is a case report of delayed distal coil migration after coil embolization of the ruptured cerebral aneurysm. Case presentation: A 68-year-old man became unconscious suddenly and was transferred to our hospital. Glasgow Coma Scale (GCS) score was E1V1M5. Head CT revealed subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) revealed an anterior communicating artery (Acom) aneurysm. Endovascular coiling of the Acom aneurysm was performed to prevent re-bleeding. under general anesthesia. Acute cardiac infarction developed on day 16, and the patient was treated in the cardiovascular department. Follow-up CT on day 38 revealed a high-density sign at the distal part of the anterior cerebral artery. No further treatment was performed since the patient was asymptomatic. Conclusions: Delayed distal coil migration may occur after coil embolization of cerebral aneurysm. X-ray examinations (CT and craniogram) were helpful for diagnosis of delayed distal coil migration after endovascular treatment of cerebral aneurysm.
We describe our experience with a patient who had a mobile plaque showing a jellyfish sign at the carotid bifurcation and an unstable plaque with severe stenosis at the origin of the internal carotid artery. Treatment with a statin decreased plaque mobility, allowing a stent to be safely placed. Case report: A 71-year-old man. Examination before coronary artery bypass grafting revealed severe stenosis at the origin of the right internal carotid artery and a mobile plaque showing a jellyfish sign at the right carotid bifurcation. Carotid endarterectomy was considered high risk because of occlusion of the left carotid artery. Percutaneous transluminal angioplasty was performed to treat the stenosis at the origin of the internal carotid artery, avoiding the mobile plaque. Cerebral blood flow improved, but restenosis occurred and additional treatment was performed using the same strategy. After repeated restenosis, the mobility of the plaque at the bifurcation decreased. A stent was placed from the site of stenosis of the internal carotid artery to the common carotid artery, without any embolic complications, resulting in good dilatation. Conclusion: We described a patient in whom endovascular therapy after administration of a statin was useful for the management of severe stenosis at the origin of the internal carotid artery, associated with a proximally located mobile plaque showing a jellyfish sign. Our experience suggests that statin treatment might reduce perioperative ischemic complications caused by carotid artery stenting in patients with mobile plaque showing a jellyfish sign.
Objective: We report a case of acute occlusion of the intradural vertebrobasilar artery due to atherosclerotic vertebral artery (VA) stenosis treated by emergent thrombectomy and balloon angioplasty followed by intracranial stenting at chronic phase. Case presentation: A 68-year-old male was admitted to our hospital with dysarthria, nausea, and hemianopsia. Diffusion weighted image (DWI) MRI showed acute infarction at the cerebellar hemisphere and occipital lobe, and MRA showed poor flow signal of bilateral VA and basilar artery (BA). After admission, his symptom was progressive with sudden disturbance of the consciousness, suggesting acute BA occlusion. DSA demonstrated complete occlusion of the intracranial vertebrobasilar artery between distal portion of posterior inferior cerebellar artery and proximal portion of anterior inferior cerebellar artery with right VA hypoplasia. The rapid thrombectomy with the Penumbra system was performed, which resulted in successful recanalization with left VA stenosis, and then balloon angioplasty was added. After 6 weeks, stent deployment for the treatment of persistent left VA stenosis was performed and obtained good VA dilatation. The patient improved to modified Rankin Scale 1 postoperatively, and no recurrent symptoms were observed during the 1-year follow-up period. Conclusion: Thrombosis of atherosclerotic VA and subsequent vertebrobasilar artery occlusion can cause fatal stroke. Emergent thrombectomy and balloon angioplasty followed by stenting at chronic stage were considered to be useful for such case.
Objective: Heparin is used routinely for anticoagulation during cerebral angiography and neurointerventional procedures. Heparin-induced thrombocytopenia is an immune-mediated syndrome that results from unfractionated heparin or low molecular weight heparin exposure. It often remains unrecognized and undertreated and can cause local and/or life-threatening thrombosis. Case presentation: A 73-year-old male presented with a symptomatic right carotid artery stenosis. During intensive medical therapy in the acute stage, waiting for the revascularization of suffered carotid lesion, the patient developed heparin-induced thrombocytopenia. One hundred and thirty-three days after the thrombo-embolic event, the patient received carotid artery stenting without using heparin. Argatroban was used as an alternate to heparin for anticoagulation. Argatroban was given in a loading dosage of 100 mcg/kg followed by an infusion of 6 mcg/kg/min. During the procedure, there were no procedural complications and MRI after the procedure revealed no evidence of any cerebral infarction. Conclusion: The authors report a safety alternative method of anticoagulation to prevent clot formation during the procedure of carotid artery stenting in a case with heparin-induced thrombocytopenia.
Objective: We report a case of a ruptured distal anterior choroidal artery (AChoA) aneurysm associated with Moyamoya disease that was successfully treated by coil embolization.Case presentation: A 70-year-old female with Moyamoya disease presented with intracerebral hematoma and underwent emergent evacuation of the hematoma. Postoperative angiogram revealed a right distal AChoA aneurysm, which was considered the culprit lesion. Initially, the occlusion of AChoA with n-butyl-2-cyanoacrylate was planned. Selective angiogram of AChoA, however, showed extensive collateral flow to the ipsilateral middle cerebral artery, thus we changed therapeutic strategy to the endovascular occlusion of the aneurysm. The aneurysm was successfully embolized with electrical detachable coils and the patient was discharged eventfully.Conclusion: In treating distal AChoA aneurysms associated with Moyamoya disease, selective angiography was useful to evaluate the extension of collaterals, which strongly influence therapeutic strategy.
Objective: We describe how to use different hemostasis valves to improve the operability of coil embolization for cerebral aneurysms by a single surgeon. Methods and Results: Between October 2007 and May 2015, a single surgeon performed coil embolization for 50 cerebral aneurysms using different suitable types of hemostasis valves in guiding-catheter and microcatheter.There was no excessive bleeding from the guiding-catheter during coil insertion, and the delicate operation of microcatheter and coil insertion could be performed by both hands in all cases. Conclusion: We performed coil insertion using the two-handed technique safely and delicately by using different suitable hemostasis valves.
Objective: We report a case of the tentorial dural arteriovenous fistula (dAVF) with a dilated cortical venous drainage and varices, treated by transarterial and transcortical venous embolization. Case presentation: A 76-year-old man presented with tinnitus and MRI revealed a right temporoparietal cortical vessel abnormality. DSA revealed a right lateral tentorial sinus dAVF draining directly into the right vein of Labbé with cortical venous ectasia and varices. The fistula was located on the right lateral tentorial surface. The shunt flow was reduced by transarterial embolization with coils and N-butyl cyanoacrylate, but relapsed after 1 year. The residual dAVF was successfully obliterated by transcortical venous embolization, which required a triple coaxial system to reach the right vein of Labbé through the superior sagittal sinus via the contralateral jugular vein. Conclusion: To our knowledge, this is the first case of a lateral tentorial sinus dAVF treated by transcortical venous embolization.
Objective: We report a case of brachiocephalic artery stenosis effectively treated using angioplasty with stent (stenting) by direct puncture of right common carotid artery (CCA). Case presentation: Stenting was performed under general anesthesia for brachiocephalic artery stenosis. An 8-Fr sheath was inserted into the right CCA using a direct puncture. After a wire was crossed, stenotic lesion and occluded right CCA Express stent were deployed. Conclusion: Stenting using direct puncture is a useful alternative for cases presenting with brachiocephalic artery stenosis.
Objective: We designed a direct road map method during carotid artery stenting (CAS) in March 2015, and evaluated the effectiveness of this method in the present study. Method: A Mo. Ma Ultra (MoMa) device is used as the introducing catheter. Both balloons of the MoMa device (the distal balloon in the external carotid artery and the proximal balloon in the common carotid artery) are inflated and a tolerance test is performed. If a negative result is obtained in the tolerance test, a PercuSurge GuardWire (PSGW) is advanced into the internal carotid artery (ICA) as a distal embolic protection device. Contrast medium is then slowly injected from the MoMa device, and the ICA is filled with contrast medium. The PSGW is inflated during this injection, and contrast medium is trapped in the ICA. This trapped contrast medium is continuously checked during CAS. Result: Both the MoMa device and the PSGW were introduced into the target vessel in seven lesions. Among the seven lesions, direct road mapping was clinically useful in five lesions. Discussion: Straightening of the vessel occasionally happens, especially during deployment of a stent. An image obtained during conventional road mapping sometimes tilts with the straightening of the vessel. Direct road map solves this problem. Conclusion: The direct road map method using a MoMa device and a PSGW is useful during CAS.