Efficacy and Safety of Lumbar Drainage before Endovascular Treatment for Ruptured Intracranial Aneurysms

Objective

Intraoperative rebleeding during endovascular treatment for ruptured intracranial aneurysms is associated with poor prognosis. Lumbar drainage is performed preoperatively to control intracranial pressure; however, it is associated with a risk of brain herniation or rebleeding because intracranial pressure may change rapidly. Therefore, this study aimed to examine the efficacy and safety of preoperative lumbar drainage.

Methods

This retrospective study enrolled 375 patients who underwent endovascular treatment of ruptured intracranial aneurysms at our institution between April 2013 and March 2018. The incidence of rebleeding and clinical outcomes were compared between patients who did and did not undergo preoperative lumbar drainage.

Results

Among the 375 patients with ruptured intracranial aneurysms, 324 (86.0%) and 51 (14.0%) patients did and did not undergo lumbar drainage, respectively. The incidence of rebleeding was 11/324 (3.4%) and 2/51 (3.9%) in lumbar drainage and nonlumbar drainage groups, respectively, with no statistical differences (p = 0.98). Of the rebleeding cases, 9/11 (81%) and 2/2 (100%) in lumbar drainage and nonlumbar drainage groups, respectively, were due to intraoperative bleeding, and 2/11 (19%) in the lumbar drainage group, the causes of the rebleeding were undetermined. The incidence of symptomatic vasospasm did not differ significantly between the groups (13.2% vs. 11.8%, P = 0.776), while the incidence of hydrocephalus (24.6% vs. 11.8%, P = 0.043) and meningitis (15.2% vs. 5.9%, P = 0.075) were slightly higher in the lumbar drainage group. Favorable clinical outcomes (modified Rankin Scale score <2) at discharge were less frequent in the lumbar drainage group (55.3% vs. 70.0%, P = 0.051). No significant differences were observed in the propensity score-matched analysis.

Conclusion

Lumbar drainage before endovascular treatment for ruptured intracranial aneurysms is a safe procedure that does not increase the incidence of rebleeding.

Stenting of the Common Carotid Artery Ostium: Balloon Catheter Lifting-Up Technique With a Gooseneck Snare

Endovascular revascularization of a stenotic lesion requires appropriate stent positioning. In particular, stenting of the common carotid artery (CCA) ostium makes it difficult to avoid proptosis into the aorta. Furthermore, the guiding catheter may become unstable during the stenting because of its position under the aortic arch. To resolve these problems, we performed antegrade stenting for a patient with a symptomatic stenotic left CCA ostium that was treated by lifting a balloon-guiding catheter with a gooseneck snare. Our patient was a 74-year-old man who presented to the hospital with main complaints of right hemiparesis and motor aphasia. A left cerebral infarction due to severe stenotic left CCA ostium was diagnosed. A CT perfusion study showed decreased cerebral blood flow in the left hemisphere. Stenting of the stenotic left CCA ostium was performed using an antegrade approach. A balloon-guiding catheter positioned under the aortic arch was inflated and lifted from the right brachiocephalic artery using a gooseneck snare. The guiding catheter was stabilized during stenting. This method is highly effective for stenting CCA ostium.

Two Cases of Chronic Subdural Hematoma with Spontaneous Intracranial Hypotention Treated with Hematoma Drainage Followed by Epidural Blood Patch Under Intracranial Pressure Monitoring

Both chronic subdural hematoma (CSDH) and spontaneous intracranial hypotension (SIH) cause headaches. However, the etiologies are different: SIH headache is caused by decreased intracranial pressure (ICP), whereas CSDH headache results from increased ICP. Moreover, CSDH is treated by hematoma drainage, while SIH is treated by epidural blood patch (EBP). Treatment for the cases of combined SIH and CSDH is not well-established. Herein, we report two cases wherein ICP was monitored and safely controlled by EBP after hematoma drainage. Case 1: A 55-year-old man with progressive consciousness disturbance was diagnosed with bilateral CSDH. He underwent bilateral hematoma drainage; however, the headache became apparent during standing. We diagnosed SIH by diffuse pachymeningeal enhancement on brain MRI and epidural contrast medium leakage on CT myelography. Due to the re-enlargement of bilateral CSDH, we performed EBP after hematoma drainage and ICP monitor insertion. Finally, the headache and bilateral CSDH were resolved. Case 2: A 54-year-old man with persistent headache was diagnosed with bilateral CSDH. He underwent multiple hematoma drainage sessions. However, headache on standing persisted. We diagnosed SIH by diffuse pachymeningeal enhancement on brain MRI and epidural contrast medium leakage on CT myelography. Due to the re-enlargement of the left CSDH, we performed EBP after left hematoma drainage and ICP monitor insertion. Finally, the headache and bilateral CSDH were resolved. EBP after hematoma drainage and ICP monitoring was useful for SIH with bilateral CSDH. By monitoring ICP before EBP, the ICP was safely controlled and CSDH was resolved.

Anterior cerebral artery dissection for a patient with ipsilateral aplastic or twig-like middle cerebral artery: An illustrative case report

Background

An aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare anomaly, which sometimes causes ischemic infarction. Collateral flow from the ipsilateral anterior cerebral artery (ACA) is important for patients with Ap/T-MCA. If ipsilateral ACA stenosis or occlusion occurs, a large infarction with a wider field than the ACA territory could happen. First, mechanical thrombectomy was performed for the right ACA near occlusion caused by arterial dissection with ipsilateral Ap/T-MCA in this case. Second, Wingspan stenting was performed for the right ACA restenosis.

Case Description

A 77-year-old female presented to the hospital with the left hemiparesis. We diagnosed a right ACA infarction caused by right ACA occlusion. Digital subtraction angiography showed right Ap/T-MCA and ipsilateral ACA near occlusion. Thrombectomy was performed, and recanalization was achieved with mild ACA stenosis. The lesion was the dissection due to angiographical finding. Two months after treatment, transient left hemiparesis occurred and right ACA stenosis progressed. Computed tomography perfusion showed hypoperfusion of the right hemisphere. Wingspan stenting was performed from the left internal carotid artery through the anterior communicating artery with an intermediate catheter. The patient was discharged without any neurological deficit.

Conclusion

We reported the first case of a patient who underwent Wingspan stenting for the right ACA dissection with Ap/T-MCA. Short-term follow-up and aggressive intervention should be considered for collateral pathway dissection with Ap/T-MCA because the symptoms can become serious. The patients with Ap/T-MCA should be cautious about the collateral pathway arterial changes in particular ipsilateral ACA due to the increasing hemodynamic stress.

Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome

Background:

Vertebral artery stump syndrome (VASS) develops into recurrent posterior circulation ischemic stroke after ipsilateral vertebral artery (VA) occlusion at its origin.

Case Description:

The patient was a 46-year-old man with the right posterior cerebral artery occlusion. We used a recombinant tissue plasminogen activator (rt-PA) and then performed mechanical thrombectomy using a stent retriever. Angiography revealed left VA occlusion and stagnant flow to the left VA from the right deep cervical artery; therefore, we diagnosed VASS. Within 24 h of the rt-PA injection, the symptoms had dramatically improved, and so we avoided additional antithrombotic agents. Only 13 h later, the patient developed a basilar artery occlusion and died in spite of a repeated mechanical thrombectomy.

Conclusion:

Vigilance against early (and sometimes fatal) recurrent stroke induced by VASS is required.

The Relationships between Anatomical Factors and Treatment Procedures for the Endovascular Treatment of Anterior Communicating Artery Aneurysms

Objective

Endovascular treatment of anterior communicating artery aneurysms is difficult due to their complex anatomical structure. We retrospectively analyzed the relationships among the anatomical features, initial microcatheter positions, and initial occlusion outcomes.

Methods

In all, 66 cases were treated at our hospital. We investigated the relationships among the anatomical features of the aneurysm and A1 segment of the anterior cerebral artery (ACA), treatment procedures, and initial occlusion outcomes. We divided the initial microcatheter positions into greater and lesser curvatures based on the curvature from A1 to the aneurysm, and evaluated the outcomes.

Results

In total, 54 out of 66 patients (82%) achieved complete obliteration (CO) or had residual neck (RN) aneurysms, and 12 had residual aneurysms (RAs: 18%). Neck diameters and superior position aneurysms were correlated with initial occlusion outcomes in the multivariate analysis. The relationship between initial occlusion outcomes and initial microcatheter positions in superior position aneurysms (37 patients) was then examined. Eleven out of 26 patients (42.3%) had residual aneurysms at the greater curvature microcatheter position, whereas no residual aneurysms were detected at the lesser curvature microcatheter position. The A1 angle was not correlated with the outcomes.

Conclusion

Wide-necked aneurysms and superior position aneurysms were identified as factors leading to incomplete occlusion in the endovascular treatment of anterior communicating artery aneurysms. The microcatheter position at the greater curvature in superior position aneurysms was a factor for incomplete occlusion. This suggests that guiding the microcatheter to the lesser curvature position of A1 is important in the treatment of superior position aneurysms.

Stent-Jack Technique for Ruptured Vertebral Artery Dissecting Aneurysm Involving the Origin of Posterior Inferior Cerebellar Artery

We herein report a case of a ruptured vertebral artery dissecting aneurysm involving the origin of the posterior inferior cerebellar artery that was treated using the stent-jack technique. After parent artery occlusion of the distal vertebral artery, stenting of the posterior inferior cerebellar artery was performed. Further coiling was needed because distal vertebral artery recanalization occurred due to transformation of the coil mass. The stent-jack technique for a ruptured vertebral artery dissecting aneurysm involving the origin of the posterior inferior cerebellar artery is effective; however, careful attention to recanalization after stenting is needed due to transformation of the coil mass.

Effectiveness of Low-Dose Intravenous Fentanyl for Postoperative Headache Management After Neck Clipping of Ruptured Intracranial Aneurysms

BACKGROUND

After subarachnoid hemorrhage (SAH), headache management is often difficult owing to the need to use multiple analgesic drugs. Fentanyl is an opioid we can use after surgery, and it can decrease pain post SAH. The aim of this study was to investigate the effectiveness and safety of fentanyl for management of headache after SAH.

METHODS

Twenty-two patients who underwent surgical clipping for ruptured intracranial aneurysms and complained of severe headache after the surgery were enrolled. Among them, 9 patients were given fentanyl combined with other analgesic drugs. The numeric rating scale score and dietary intake were measured in the acute phase after the SAH.

RESULTS

The numeric rating scale scores were significantly lower in the fentanyl (+) group. The maximum numeric rating scale decreased to <5 points within 16.5 ± 2.9 days in the fentanyl (-) group and within 12.0 ± 2.6 days in the fentanyl (+) group. The median numeric rating scale decreased to <5 points over 14.0 ± 4.2 days in the fentanyl (-) group and >7.7 ± 3.8 days in the fentanyl (+) group. At day 14, the fentanyl (+) group showed significantly better dietary intake than that of the fentanyl (-) group.

CONCLUSIONS

Using fentanyl after surgical clipping for ruptured intracranial aneurysms might decrease headache and produce few adverse effects. Adequate headache control showed improved dietary intake after SAH.

Intradiploic Arachnoid Cyst with Meningothelial Hyperplasia: A Case Report

We report the case of a 40-year-old man presenting with focal headache and a bulge at the right parietal bone, diagnosed as an intradiploic arachnoid cyst. The cyst wall included “meningothelial hyperplasia,” which is a rare finding. While over 40 cases of intradiploic arachnoid cysts have been reported to date, meningothelial hyperplasia in an intradiploic arachnoid cyst does not appear to have been reported. We also discuss the pathological findings of arachnoid cysts with meningothelial hyperplasia and mechanisms of enlargement of the arachnoid cyst.

[Malignant melanoma in Japan: unique distribution and effect of DAV chemoimmunotherapy (part II)]

This study, based on a cooperative group project involving 4 major medical institutes in Japan, presents the second survey of malignant melanoma patients (198 cases) where an attempt is made to systemically evaluate the survival rates of these patients with respect to the tumor thickness and location of primary lesions, and the response to chemoimmunotherapy. More than 50% of total collected cases showed the primary lesions on the limbs. The most common type and site of involvement is the acral lentiginous melanomas involving the plantar areas (more than 30). The survival rates affecting the limbs were better than those affecting the non-limb areas. However, the comparison of the survival rates did not reveal any difference between those cases affecting the plantar and non-plantar areas. The difference in the prognosis of melanoma patients appeared to be related to the tumor thickness. By historical comparison, the DAV (DTIC, ACNU, VCR) treated group exhibited a better survival rate than the non-DAV treated group. Furthermore, the DAV group with immunoadjuvant therapy (mainly OK-432) showed a better prognosis than the DAV group without any immunoadjuvant therapy.

[Phase I study of forphenicinol, a new biological response modifier]

Forphenicinol, [L-(4-hydroxymethyl-3-hydroxyphenyl) glycine], a new biological response modifier, is a derivative of forphenicine, an inhibitor of chick intestine alkaline phosphatase, discovered by H. Umezawa from the microbial culture filtrate. In order to find an optimal dose schedule of forphenicinol, the drug was given p.o. at doses ranged from 10, 50, 100, 400 to 800 mg once a day for 7 days to 103 patients (39 malignant and 64 benign). No side effect was observed. Statistical analysis was performed on immunological parameters, including WBC; lymphocyte, T-cell, B-cell, T gamma-cell (each % and count); S.I. of PHA and Con A, NK cell activity and K cell activity before and after administration. The patients were divided into the "low-dose" group given less than 100 mg/day of the drug and the "high-dose" group given more than 400 mg/day. Further, on the basis of values of each parameter before administration, the patients were divided into the "low-before" or the "high-before" group, when the pretreated value of parameters was lower or higher than the median of all cases. In the malignant patients, lymphocyte (% and count), T-cell (% and count) and B-cell (% and count) significantly increased in the "low-dose"-"low-before" group (p less than 0.05), but B-cell (%) and S.I. of PHP and Con A decreased in the "low-dose"-"high-before" group. On the contrary, there was no significant change in both the "low-before" and the "high-before" group, when "high-dose" of the drug was given. In the benign patients T gamma-cell (% and count) and NK cell activity were found to be significantly increased in the "high-dose"-"low-before" group, indicating some difference in response of parameter from cancer patients. An optimal dose of forphenicinol for cancer patients was considered to be in a range of 10-100 mg/day.

[New combination chemotherapy for malignant melanoma--PAV(peplomycin, ACNU, VCR) therapy]

A combination chemotherapy (PAV) consisting of peplomycin, ACNU and vincristine (VCR) was given to 30 patients with malignant melanoma and its therapeutic evaluation was performed. The objective response rate was 42.9% for the patients with stage IV metastatic lesions; three of 7 patients showed improvement. This regimen was particularly effective for both cutaneous and subcutaneous metastatic lesions. When PAV was applied as an adjuvant therapy to the operable cases with stage Ib and II, a five-year survival rate was 50% and the result was far better than that of operation alone. Our results in PAV regimen almost identical with those of DAV(DTIC, ACNU, and VCR) regimen as an adjuvant therapy. The result indicates that PAV regimen is useful for the treatment of malignant melanoma since toxic reactions were mild. Further studies are necessary to assess the efficacy of PAV regimen.

[Malignant melanoma in Japan: unique distribution and effect of DAV chemoimmunotherapy]

This study, based on a co-operative group project involving 4 major medical institutes in Japan presents the first survey of malignant melanoma (MM) patients (157 cases) where an attempt was made to systemically evaluate the distribution of primary MM, and the response to DAV-chemoimmunotherapy. The distribution of primary MM in Japan is unique in a sense that the MM involving the lower extremities occupied more than 50% of the total male and female cases. The commonest type and site of involvement is the acrolentiginous MM involving the plantar area (30%). The regimen of our group included the combination of DTIC, VCR and ACNU, a new nitrosourea with or without immunoadjuvants OK-432, PSK, or NK-421). By a historical comparison, the DAV-treated group showed a better prognosis in the survival rates of overall (Stages I-IV) and disseminated (Stages III-IV) patients than those of the non-DAV group. However, the effect of combined immunoadjuvants was not statistically significant, though OK-432 showed a significant inhibition of lymphopenia which always occurred during DAV therapy.