We evaluate the safety and efficacy of ozagrel sodium (ozagrel) in stent-assisted coil embolization (SACE) of acutely (＜72 hours) ruptured wide-necked intracranial aneurysms, including primary success rates and short-term follow-up results. Approval by an institutional review board was obtained for this retrospective study. Results in 20 consecutive patients (6 men, 14 women; mean age, 68.2 years; range, 45–89 years) who were treated with SACE for acutely ruptured wide-necked intracranial aneurysms were evaluated. All patients were treated with Enterprise VRD stents (Johnson & Johnson Codman, Miami, FL, USA). Patients were treated with systemic heparinization and treated intraoperatively with an intravenous bolus infusion of 40 mg of ozagrel followed by intravenous drip infusion of 40 mg of ozagrel for 30 minutes. Single or dual oral antiplatelet agents were administrated immediately after the procedures. The modified Rankin Scale (mRS) was recorded at discharge.
The indications for use of stent-assist were failure of the balloon remodeling technique (n＝10), coil tail protrusion (n＝1), coil instability (n＝5), and intentional (n＝4). All aneurysms were treated successfully with SACE. Complete occlusion was achieved in 13 cases (65%), nearly complete occlusion in six (30%), and partial occlusion in one (5%). One patient (5%) with a large middle cerebral artery aneurysm that resulted in partial occlusion developed embolic complications three days after the procedure, but she recovered and was discharged with an mRS score of 1. Perioperatively, ventricular drainage was performed in four patients (20%), spinal drainage in 11 (55%), and ventriculo-peritoneal shunt in two (10%). None presented with hemorrhagic complications. At the time of discharge, 15 patients (75%) had recovered in good condition (mRS 0–2), four were moderately or severely disabled (mRS 3–5), and one (5%) died (mRS 6) from primary brain damage. The remaining 19 patients developed no ischemic or hemorrhagic complications during the mean follow-up duration of 6.7 months. Our results indicate that ozagrel is a safe and effective antiplatelet agent in Enterprise VRD-assisted coiling in acutely ruptured intracranial aneurysms.
Several approaches to the treatment of intracranial dissecting aneurysms have been used. We report our experience with endovascular treatment of intracranial dissecting aneurysms since Enterprise VRD (Johnson & Johnson Codman, Miami, FL, USA) stent was introduced into Japan. Between July 2010 and December 2012, 18 patients (eight ruptured and 10 unruptured) underwent endovascular treatment of intracranial dissecting aneurysms. Patients with a ruptured dissecting aneurysm were treated as follows: Four patients were treated with internal trapping using coils, three patients with blood blister-like aneurysms (BBAs) were treated with placement of three or four stents, and one by stent-assisted coil embolization. All patients with an unruptured dissecting aneurysm except one treated with internal trapping were treated by stent-assisted coil embolization. All aneurysms were completely occluded. Procedural complications occurred in one BBA with parent artery occlusion and cerebral infarction. Of all the other patients treated with stents, all parent arteries were preserved.
Treatment using stents is an effective alternative for the treatment of intracranial dissecting aneurysms. However, in cases of ruptured dissecting aneurysm, strict indications for the use of stents may be needed.
There are technical difficulties that may be encountered during endovascular coiling for saccular vertebral artery-posterior inferior cerebellar artery (VA-PICA) aneurysms because some have unfavorable morphology such as a side branch arising from the aneurysm neck and a shallow aneurysm dome. We analyzed the clinical and radiological outcomes of endovascular coiling for saccular VA-PICA aneurysms. We also investigated morphological factors associated with coiling success and failure to evaluate the safety and feasibility of this treatment. Between March 1997 and September 2012, we treated 24 cases (19 ruptured and five unruptured aneurysm cases) of saccular VA-PICA aneurysms with endovascular coiling. All 24 aneurysms demonstrated a side-branch arising from the neck on digital subtraction angiography. Twenty cases with VA-PICA aneurysms were successfully embolized with coiling while there were four failures. One ruptured case experienced symptomatic ischemic complication that resulted from delayed distal coil migration. An aspect ratio of ＜1.2 and an aneurysm-parent artery angle of ＜90° were associated with failure of endovascular coiling. Of the 20 coil-treated aneurysms, immediate angiographic results showed near-complete aneurysm occlusion in 12/20 (60.0%) cases, neck remnant in five (25.0%), and residual aneurysm in three (15.0%). One patient (5%) had a major aneurysm recurrence that was uneventfully reembolized. Thirteen of 19 ruptured cases (68.4%) cases had good outcomes (modified Rankin Scale 0–2), two (10.5%) had moderate disability (mRS 3), and one (5.3%) had severe disability (mRS 4–5) at three months after treatment.
The results of this study suggest that endovascular coiling is safe and feasible for saccular VA-PICA aneurysms. However, surgical clipping can be expected to benefit younger patients and/or cases of unfavorable morphology such as low aspect ratio. In addition, adverse angulation between aneurysm and parent artery can be another morphological factor for which an endovascular procedure is technically demanding.
We retrospectively analyzed the outcome of patients with subarachnoid hemorrhage (SAH) who received surgical clipping in the acute stage between April 2007 and July 2012. Patients aged 80 and older were compared with those below 80. Patients were graded on admission according to the World Federation of Neurological Societies (WFNS) grade, and modified Rankin Scale (mRS) was used to evaluate outcome at discharge. During this period, 216 patients received clipping. There were 37 patients aged 80 and older among them. Their age ranged from 80 to 96 (average 84.4). Thirty-three (89%) were women. There was no significant difference related to grades between the two groups. The younger patients tended to have favorable outcomes. Better outcomes were obtained in both younger and elderly patients with WFNS Grade I–II. The patients with WFNS Grade III–V proved to have poor outcomes, especially in the elderly patients. The factors causing poor outcomes were primary brain damage in 9 (35%), disuse syndrome in 7 (27%), vasospasm in 5 (19%), and pneumonia in 2 (8%). We added cilostazol administration and increased nutritional support to the postoperative protocol from April 2010. Under the new protocol, the frequency of angiographic vasospasm (VS) decreased from 26% to 11%, symptomatic VS decreased from 26% to 6% and cerebral infarction related to VS decreased from 26% to 0%. The overall outcome tends to be better in patients after April 2010. However, significant differences have not been seen yet.
We conclude that favorable outcomes can be achieved even in elderly patients with ruptured cerebral aneurysms even if they are treated by surgical clipping, especially in the patients with WFNS Grade I–II.
Surgical clipping may be considered a treatment option even for elderly patients with ruptured cerebral aneurysms in the acute stage, especially when the endovascular surgery is unavailable.
EC-IC bypass based on the inclusion criteria of Japanese EC-IC Bypass Trial (JET study) is recommended for chronic total occlusion (CTO) of the internal carotid artery (ICA). But patients who do not meet the inclusion criteria of the JET study are also entitled to the best possible medical treatment. Recently several authors have reported the successful endovascular recanalization of CTO of the ICA.
We report 10 cases of symptomatic CTO of the ICA that did not meet the inclusion criteria of the JET study that were treated by endovascular recanalization. Cerebral angiogram showed complete occlusion of the ICA and opacification of the cavernous segment of ICA or the more proximal portion of the ICA via collateral channels. Xenon CT (Xe-CT) showed hemodynamic compromise in all cases. The endovascular procedure was performed by proximal balloon protection of the common carotid arery and the external carotid artery via transfemoral route under local anesthesia. The occlusion of the ICA was recanalized successfully in all cases. Carotid artery stenting (CAS) was performed in eight cases identified as occlusion at the cervical ICA, and percutaneous transluminal angioplasty (PTA) with stenting using coronary stents was performed in two cases identified as occlusion at the cavernous or petrous ICA. Neither new ischemic symptoms nor hyperperfusion syndrome appeared after treatment.
Endovascular recanalization of symptomatic CTO of the ICA can be considered as an alternative treatment for patients who do not meet the inclusion criteria of the JET study.
Basilar artery and internal carotid paraclinoid aneurysms are still surgically challenging. We performed 31 clipping surgeries (basilar tip aneurysm 6, basilar artery-superior cerebellar artery aneurysm 8, and internal carotid aneurysm 17) via the extradural temporopolar approach. After the frontotemporal craniotomy, the meningo-orbital band was incised and the dura propria of the temporal lobe was peeled from the lateral wall of the cavernous sinus. The anterior clinoid process was removed extradurally. The distal dural ring and falciform ligament were incised for mobilization of the internal carotid artery and optic nerve. The temporal lobe was retracted posteriorly with the dura mater. The aneurysm clipping was performed through the relatively wide operative trajectory over the opened cavernous sinus. Postoperative outcome was modified Rankin Scale (mRS) 0 in 28 patients and mRS in three patients with visual deficits. No temporal lobe contusion occurred.
The extradural temporopolar approach is a useful skull base technique for deeply situated aneurysms.
To prevent rebleeding of a subarachnoid hemorrhage (SAH) due to intracranial artery aneurysms, early treatment is indispensable. We investigated such cases at the time of initial diagnosis of walk-in patients in hospitals. The study covered 293 patients with SAH caused by ruptured intracranial artery aneurysms who were hospitalized in our department between 1996 and 2005. The individuals were treated at the Yamagata University between 1996 and 2005. All 293 cases had a sudden onset. In 89 cases (30.3%), the individuals consulted physicians at various medical facilities without the use of ambulances.
In 129 of these cases (44%), the individuals presented with headache only, including Hunt & Kosnik (H&K) Grade I: 27 (9.2%) and Grade II: 102 (34.8%). These findings revealed that headache is common in such cases. Moreover, 24 of the 27 (88.9%) cases of H&K Grade I and 65 of 102 (63.7%) cases of Grade II were walk-in patients, and the consultation rate of walk-in patients presenting only a headache was very high. The average number of days that individuals waited before consulting a physician was 2.2 (0–35 days). Of the 89 cases of walk-in patients, 24 were very difficult to diagnose (26.9%). Two cases (both H&K I) were difficult to diagnose even under CT examination, and 22 cases (H&K I: 8, II: 14) were not suspected to be SAH cases, and their CT were not examined. These difficult cases were first diagnosed as follows: common cold, 4; high blood pressure, 2; facial palsy for oculomotor nerve paralysis, 1; and ordinary headache, 17. Of these 24 cases for which a confirmed diagnosis was difficult, upon subsequent visits, 18 were diagnosed as having persistent headache; 5, rerupture of SAH (admitted by ambulance); and 1, symptomatic spasm (admitted by ambulance). The location of aneurysms of the walk-in 89 patients were ICA: 21, MCA: 22, ACA: 34, VBA: 3, and other: 9. The overall results of the walk-in 89 patients were GR: 73 (82%), MD: 9 (10%), SD: 1 (1%), D: 6 (7%).
Our investigation indicated that difficulty in making a confirmed diagnosis is not rare when only the symptoms are considered.
Technical skills for superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery are considered to be easily acquired through off-the-job training. To develop optimal practice methods, we investigated which stage of STA-MCA bypass surgery was time-consuming.
Between March 2010 and May 2013, STA-MCA (M4) bypass surgery was performed in 74 cases. Of these cases, this study included 29 cases of anastomosis performed by the author and 28 cases of anastomosis performed by beginners (11 surgeons during the same period). Video recordings of the anastomosis procedure in each case were reviewed, and the procedure was divided into eight segments to measure the time (unit: second) required for each segment. These segments were grouped into the key procedure of four segments and the preparatory stage of the other four segments to compare each segment group between the author and the beginners.
The mean MCA clamping time was 876±82 seconds (mean±standard deviation) for the author and 2127±410 seconds for the beginners. The total duration of the preparatory stage was 91±39 seconds vs. 245±228 seconds, respectively, and the difference in duration was 154 seconds. This study revealed that the beginners are spending substantial time in non-anastomosis procedures, such as handling needles, tools, etc. To smoothly perform STA-MCA bypass surgery, efforts should simultaneously be aimed at reducing the duration of procedures other than anastomosis.
The prognosis and the best treatment strategies of the elderly patients with ruptured aneurysmal subarachnoid hemorrhage are unclear. We retrospectively analyzed 21 patients over the age of 80 in comparison with 139 patients younger than 80. The patients over 80 years old had significantly worse clinical presentation representing World Federation of Neurosurgical Societies Grade IV and V, significant predilection of conservative treatment and significantly worse clinical outcomes representing modified Rankin Scale 4 or more. Clinical outcomes were significantly worse even in the case of the good grade patients such as World Federation of Neurosurgical Societies Grade I/II/III. Surgical interventions did not bring better outcomes. The choice of the surgical interventions between direct surgery and endovascular treatment did not affect the outcomes of the patients.
The patients of the ruptured aneurysmal subarachnoid hemorrhage over the age of 80 presented poorer grade and showed worse outcomes unrelated to the presenting grade than those of a younger age. There may be non-neurosurgical reasons affecting the outcomes in the elderly such as the emergency nature of the disease itself and the longer duration of the surgical intervention. The choice of treatment should depend not only on the neurosurgical conditions but also on the anatomical backgrounds relating to the surgical approaches and the general status.
We report a rare case of dissecting aneurysm of the posterior inferior cerebellar artery (PICA) with vascular variation. A 38-year-old man, who had no medical, familial or traumatic histories, presented with headache, nausea and mild consciousness disturbance. Computed tomography (CT) imaging demonstrated subarachnoid hemorrhage with intra-ventricular hemorrhage. Angiography disclosed an aneurysm of left PICA, which did not involve the vertebral artery. The PICA was well developed and widely perfused the cerebellum and lower brain stem, which was accompanied by lack of ipsi-lateral anterior inferior cerebellar artery (AICA) and contra-lateral PICA. The aneurysm was successfully treated by trapping and revascularization procedure with occipital artery (OA)-PICA anastomosis.
We suggest that congenital vascular variation related to well-developed PICA might lead to dissecting aneurysm, and that direct surgical treatment with bypass would be indicated for such patients to preserve hemodynamic integrity.
The mainstay surgical treatment for patients with moyamoya disease is vascular reconstruction to increase blood flow in the middle cerebral artery territory. We have added the superficial temporal artery as the direct and the pericranium as the indirect vascular reconstruction technique to irrigate the anterior cerebral artery territory. Although as a result cerebral blood flow improved in a wide tissue area, the incidence of wound complications due to the sacrifice of blood flow to the external carotid artery territory tended to increase. It is necessary to continue searching for a procedure that will result in good cerebral blood flow with a reduced incidence of complications.