Endovascular Treatments for Aneurysms Involving a Major Branch

Remarkable advances have been made in the endovascular treatment of intracranial cerebral aneurysms. These advances include various adjunctive techniques, increased indications for endovascular treatment, and improved treatment results. Furthermore, the number of cerebral aneurysm treatments using flow diverters (FDs) is expected to increase. However, the reported long-term rate of branch artery occlusion after FD treatment has been reported is 15.8%. Moreover, the complete aneurysm obliteration rate is low if normal branches arise from an aneurysm neck or dome. Flow diverter placement for ophthalmic artery, posterior communicating artery, and anterior choroidal artery aneurysms is often difficult because these normal branches often arise from the aneurysm neck or dome. Therefore, in many cases, coil embolization, which can occlude the aneurysm while preserving branch vessels, should be selected. Although not yet established, various adjunctive techniques and other endovascular treatments that can be performed safely have been reported. Treatment must be planned after understanding the advantages and disadvantages of each treatment method.

Visual Outcomes and Surgical Approach Selection Focusing on Active Optic Canal Decompression and Maximum Safe Resection for Suprasellar Meningiomas

The goal of treating patients with suprasellar meningioma is improving or preserving visual function while achieving long-term tumor control. We retrospectively examined patient and tumor characteristics and surgical and visual outcomes in 30 patients with a suprasellar meningioma who underwent resection via an endoscopic endonasal (15 patients), sub-frontal (8 patients), or anterior interhemispheric (7 patients) approach. Approach selection was based on the presence of optic canal invasion, vascular encasement, and tumor extension. Optic canal decompression and exploration were performed as key surgical procedures. Simpson grade 1 to 3 resection was achieved in 80% of cases. Among the 26 patients with pre-existing visual dysfunction, vision at discharge improved in 18 patients (69.2%), remained unchanged in six (23.1%), and deteriorated in two (7.7%). Further gradual visual recovery and/or maintenance of useful vision were also observed during follow-up. We propose an algorithm for selecting the appropriate surgical approach to a suprasellar meningioma based on preoperative radiologic tumor characteristics. The algorithm focuses on effective optic canal decompression and maximum safe resection, possibly contributing to favorable visual outcomes.

Early recanalization and vasospasm after endovascular treatment in a case of ruptured vertebral artery dissecting aneurysm associated with COVID-19

Background

The coronavirus disease 2019 (COVID-19) pandemic has caused significant structural changes in acute care hospitals. COVID-19-associated stroke has gained attention, with abnormal coagulation and vascular endothelial damage being recognized. While ischemic cases are commonly reported, hemorrhagic cases have also been reported. This report presents a case of ruptured vertebral artery dissection aneurysm associated with COVID-19, resulting in subarachnoid hemorrhage (SAH). The treatment course, challenges in managing cerebral vasospasm, and early recanalization achieved through endovascular therapy are described.

Case Description

A 67-year-old male patient was brought to our hospital for emergency treatment of impaired consciousness that occurred while recovering from COVID-19. He underwent endovascular internal trapping using coils, and although the rupture did not recur, he required long-term tracheal management, which resulted in a cerebral infarction caused by cerebral vasospasm. In addition, early recanalization was seen, which required retreatment.

Conclusion

This case highlights the challenges in managing COVID-19-associated SAH and emphasizes the need for infection control measures and proper postoperative care. Establishing protocols for detecting and managing cerebral vasospasm is essential.

Effects of Microvascular Decompression on Pain Relief and Quality of Life in Late Elderly Patients with Trigeminal Neuralgia

Pharmacotherapy is frequently selected over surgical interventions for late elderly patients with trigeminal neuralgia (TN). However, medication may affect these patients' activities of daily living (ADL). Hence, we investigated the effect of the surgical treatment of TN on ADL in older patients. This study included 11 late elderly patients >75 years old and 26 nonlate elderly patients who underwent microvascular decompression (MVD) for TN at our hospital from June 2017 to August 2021. We evaluated pre- and postsurgical ADL using the Barthel Index (BI) score, side effects of antineuralgic drugs, the BNI pain intensity score, and perioperative medication. The BI score of late elderly patients significantly improved postoperatively, particularly in transfer (pre: 10.5; post: 13.2), mobility (pre: 10; post: 12.7), and feeding (pre: 5.9 points; post: 10 points). Additionally, antineuralgic drugs caused preoperative disturbances of transfer and mobility. Trends of a longer disease duration and frequent occurrence of side effects were observed in all patients in the elderly group, compared to only 9 out of 26 patients in the younger group (100% vs. 35%, p = 0.0002). In addition, drowsiness was observed more frequently in the late elderly group (73% vs. 23%, p = 0.0084). However, the change in scores indicating improvement after surgery was significantly greater in the late elderly group, although both pre- and postoperative scores were higher in the nonlate elderly group (11.4 ± 1.9 vs. 6.9 ± 0.7, p = 0.027). Surgical treatment can improve older patients' ADL because it relieves pain and facilitates discontinuation of antineuralgic drugs. Consequently, MVD can be positively recommended for older patients with TN if general anesthesia is acceptable.

Bold-S Signs on Computed Tomography Angiography Are Sensitive Markers for Diagnosing Subcortical Hemorrhage Due to Dural Arteriovenous Fistulae on Emergent Admission

An optimal treatment strategy for subcortical hematomas caused by dural arteriovenous fistulae (dAVF) is important because of the high rebleeding rate. However, it is very difficult to diagnose that on admission. Therefore, an early sensitive predictive marker for subcortical hemorrhage caused by dAVF is necessary, especially during the first contact on admission. S-shaped dilated vessels around the hematoma (bold-S sign) on computed tomography angiography (CTA) performed during admission could be one such marker. Herein, we evaluated the characteristics of these vessels. Among 273 patients with intracerebral hemorrhage between April 2012 and March 2020, 67 patients with subcortical hematomas who underwent CTA on admission without arteriovenous malformations were included. The patients in the dAVF group (n = 7) showed fewer disturbances in consciousness, milder neurological deficits, and more frequent seizures than patients without dAVF (without dAVF group, n = 60). All patients in the dAVF group had dilated S-shaped vessels (2.59 ± 0.27 mm) around the hematomas, and only 20% of the patients in the without dAVF group had these vessels (1.69 ± 0.22 mm). The ratio of the ipsilateral S-shaped/contralateral largest vessels was 1.80 ± 0.29 in the dAVF group and 1.07 ± 0.16 in the group without dAVF. We called the dilated S-shaped vessels the "bold-S sign," with a cutoff ratio of 1.5. Bold-S sign findings are novel and help in diagnosing subcortical hematomas caused by dAVF on admission.

Relationship between Transient Cortical Blindness and Contrast Medium Leakage That Occurs after Endovascular Treatment of Posterior Circulation Aneurysms

Objective

The mechanism of transient cortical blindness after endovascular treatment-a rare phenomenon-has not been elucidated; however, it is assumed to be related to contrast medium leakage (CML). We investigated the relationship between postoperative CML and cortical blindness in patients who underwent endovascular treatment for vascular lesions of posterior circulation.

Methods

This retrospective cohort study included 28 patients who underwent endovascular treatment for posterior circulation aneurysms at our hospital between January 2014 and December 2018. Cerebral CT was performed immediately after endovascular treatment and 24 h later. CT images were retrospectively evaluated with special interest in the presence and distribution of leakage of the contrast medium (CM). Patients were classified into the following three groups based on CT findings: Group A, no CML (11 patients); Group B, unilateral CML (5 patients); and Group C, bilateral CML (9 patients).

Results

The posterior circulation aneurysms were located in the basilar artery in 13 (52.0%) cases, in the posterior cerebral artery in 1 (4.0%) case, and in the vertebral artery in 11 (44.0%) cases. There was no difference regarding the adjunctive technique used for endovascular treatment between the groups. Patients in Group C used a significantly larger amount of CM than those in the other two groups. A longer operation time was associated with a larger amount of CM used during treatment. VerifyNow assay revealed that the P2Y12 reaction unit was significantly lower in Groups B and C. Cortical blindness was transiently observed in 2 of 9 patients (22.2%) in Group C, both of which showed CML surrounding the bilateral parieto-occipital sulcus.

Conclusion

Both patients with cortical blindness showed bilateral CML, both of which showed CML surrounding the bilateral parieto-occipital sulcus. The CM-induced blood-brain barrier disruption may be the cause of cortical blindness.

Factors Associated with Rapidly Deteriorating Myelopathy in Patients with Spinal Arteriovenous Shunts

Spinal arteriovenous (AV) shunts are rare conditions that sometimes present with myelopathy symptoms. The progression of the symptoms is usually gradual; however, some cases show rapid deterioration. We retrospectively investigated the factors that induced the rapid deterioration of myelopathy symptoms in patients with spinal AV shunts. We treated 33 patients with myelopathy with spinal AV shunts at our institutions, eight of whom experienced rapid deterioration (within 24 hours: 24.2%). Of these, three were related to the body movement or particular postures associated with playing golf, 30 minutes of Japanese straight sitting, and massage care. One patient showed deterioration after embolization for a tracheal aneurysm. The remaining four patients received steroid pulse therapy (high-dose steroid infusion) shortly before the rapid deterioration. These symptoms stopped progressing after cessation of steroid use. While positional or physical factors contributing to myelopathy deterioration might exist, we could not identify specific factors in this study. Nevertheless, rapid deterioration was frequently observed after high-dose steroid use. We must take care not to administer high-dose steroids for myelopathy caused by spinal AV shunt disease.

Efficacy of a Novel Prophylactic Barbiturate Therapy for Severe Traumatic Brain Injuries: Step-down Infusion of a Barbiturate with Normothermia

This study aimed to examine the beneficial effects of a novel prophylactic barbiturate therapy, step-down infusion of barbiturates, using thiamylal with normothermia (NOR+sdB), on the poor outcome in the patients with severe traumatic brain injuries (sTBI), in comparison with mild hypothermia (MD-HYPO). From January 2000 to March 2019, 4133 patients with TBI were admitted to our hospital. The inclusion criteria were: a Glasgow coma scale (GCS) score of ≤8 on admission, age between 20 and 80 years, intracranial hematoma requiring surgical evacuation of the hematoma with craniotomy and/or external decompression, and patients who underwent management of body temperature and assessed their outcome at 6-12 months. Finally, 43 patients were included in the MD-HYPO (n = 29) and NOR+sdB (n = 14) groups. sdB was initiated intraoperatively or immediately after the surgical treatment. There were no significant differences in patient characteristics, including age, sex, past medical history, GCS on admission, type of intracranial hematoma, and length of hospitalization between the two groups. Although NOR+sdB could not improve the patient's poor outcome either at discharge from the intensive care unit (ICU) or at 6-12 months after admission, the treatment inhibited composite death at discharge from the ICU. The mean value of the maximum intracranial pressure (ICP) in the NOR+sdB group was <20 mmHg throughout the first 120 h. NOR+sdB prevented composite death in the ICU in patients with sTBI, and we may obtain novel insights into the beneficial role of prophylactic barbiturate therapy from suppression of the elevated ICP during the first 120 h.

Delineability and anatomical variations of perforating arteries from normal vertebral artery on 3D DSA: implications for endovascular treatment of dissecting aneurysms

BACKGROUND AND PURPOSE

Endovascular trapping of the vertebral artery dissecting aneurysms (VADAs) carries a risk of medullary infarction due to the occlusion of the perforating arteries. We evaluated the detectability and anatomical variations of perforating arteries arising from the vertebral artery (VA) using three-dimensional DSA.

METHODS

In 120 patients without VA lesions who underwent rotational vertebral arteriography, the anatomical configurations of perforating arteries from the VA were retrospectively evaluated on the bi-plane DSA and reconstructed images to reach the consensus between two experienced reviewers. The images were interpreted by focusing on the numbers and types of perforating arteries, the relationships between the number of perforators and the anatomy of the VA and its branches.

RESULTS

Zero, 1, 2, 3, 4, and 6 perforators were detected in 2, 51, 56, 9, 1, and 1 patient, respectively (median of 2 perforators per VA). The 200 perforators were classified into 146 terminal and 54 longitudinal course types and into 32 ventral, 151 lateral, and 17 dorsolateral distribution types. All ventral type perforators were also terminal type. In contrast, the longitudinal type was seen in 28.5% of lateral types and in 65% of dorsolateral types. Regarding the difference in the origin of the posterior inferior cerebellar artery (PICA), non-PICA type VAs gave off larger number of perforators than the other types of VAs.

CONCLUSIONS

Non-PICA type VAs give off a significantly larger number of perforators than other types, indicating that the trapping of non-PICA type VAs is associated with a risk of ischemic complications.

Venous Anatomy of the Cavernous Sinus and Relevant Veins

The cavernous sinus (CS) is a dural sinus located on each side of the pituitary fossa. Neoplastic and vascular lesions, such as arteriovenous fistulas, frequently involve the CS. This sinus plays a role as a crossroad receiving venous blood flow from the facial, orbital, meningeal, and neural venous tributaries. The relationship between these surrounding relevant veins and the CS, as well as the CS itself, varies anatomically. For safe and effective surgical and endovascular treatment of lesions involving the CS, knowledge of the anatomy and variations of the CS and the relevant surrounding veins is highly important. In this section, the anatomy and variations of the CS and the relevant surrounding veins are outlined.

Follow-up non-contrast MRA after treatment of intracranial aneurysms using microcoils with prominent metallic artifact: a comparative study of TOF-MRA and Silent MRA

PURPOSE

Some of the detachable microcoils are associated with the prominent metallic artifact. We have applied Silent MRA to reduce the artifact. In this study, we present a retrospective study in which Silent MRA is used for cases showing prominent metallic artifact on conventional TOF-MRA due to a detachable bare platinum microcoil (Barricade coil).

MATERIALS AND METHODS

Fifteen patients, who had undergone endosaccular embolization using Barricade coil and other detachable microcoils up to 3 days previously, were scanned with TOF-MRA and silent MRA at the same time. The treatment DSA and follow-up MRA images were graded by two experienced neuroradiologists, focusing on the visibility of residual aneurysm and parent arterial lumen.

RESULTS

DSA images showed residual aneurysm (RA) in four, residual neck (RN) in six, and complete occlusion (CO) in five patients. TOF-MRA images showed RN in five, CO in four, mild defect (MD) in one, severe defect (SD) in three, and complete defect in two. In contrast, on Silent MRA, the grades were RA in two, RN in five, CO in five, and MD in three.

CONCLUSION

Barricade coils are associated with prominent metallic artifact on TOF-MRA. Silent MRA is useful for follow-up MRA after embolization using Barricade coils. The metallic artifacts were compared between TOF-MRA and Silent MRA in patients treated by using Barricade coils. Barricade coils are associated with more metallic artifact on TOF-MRA than Silent MRA. Silent MRA is useful for follow-up MRA after embolization using Barricade coils.

Additional Embolization for Intra-aneurysmal Blood Flow Resumption after Stent-assisted Embolization of Cerebral Aneurysms

Objective

Stent-assisted aneurysmal embolization (SAAE) is an effective treatment for aneurysms with a low risk of recurrence. In rare cases, retreatment is necessary due to recanalization of blood flow into the aneurysm. However, only a few studies have reported on retreatment. We examined the efficacy and complications of stent-assisted aneurysm embolization for large or wide-neck aneurysms at our hospital.

Methods

Between July 2010 and June 2018, 293 patients underwent stent-assisted aneurysm embolization at our hospital. Among them, 12 (2 women, 10 men, mean age: 62 years) needed retreatment. We evaluated the initial treatment of these 12 patients, and the methods and results of their retreatment.

Results

Six of the 12 retreated patients were treated using the simple technique. It was possible to treat nine patients (75%) without placing new stents, but three needed additional stents. We were able to guide the microcatheter into the aneurysm using the trans-cell technique even with two overlapping stents. We achieved complete embolism in seven patients (58%), and remnants were observed in the neck in five (42%) patients. No complications were associated with our surgery. We were able to perform follow-up for 10 patients and there was no recurrence.

Conclusion

Embolization should be considered in recurrent cases after the initial stent-assisted coil embolization. We achieved good results and reduced the recurrence rate by selecting the appropriate treatment in each case.

Sagittal diffusion-weighted imaging in preventing the false-negative diagnosis of acute brainstem infarction: Confirmation of the benefit by anatomical characterization of false-negative lesions

Background:

In some cases of acute brainstem infarction (BI), standard axial diffusion-weighted imaging (DWI) does not show a lesion, leading to false-negative (FN) diagnoses. It is important to recognize acute BI accurately and promptly to initiate therapy as soon as possible.

Methods:

Of the 171 patients with acute cerebral infarctions in our institution who were examined, 16 were diagnosed with true-positive BI (TP-BI) and six with FN-BI. We evaluated the effectiveness of sagittal DWI in accurately diagnosing acute BI and sought to find the cause of its effectiveness by the anatomical characterization of FN-BIs.

Results:

Considering the direction of the brainstem perforating arteries, we supposed that sagittal DWI might more effectively detect BIs than axial DWI. We found that sagittal DWI detected all FN-BIs more clearly than axial DWI. The mean time between the onset of symptoms and initial DWI was significantly longer in the TP group (17.6 ± 5.5 h) than in the FN group (5.0 ± 1.2 h; P < 0.0001). The lesion volumes were much smaller in FN-BIs (259 ± 82 mm³) than in TP-BIs (2779 ± 767 mm³; P = 0.0007). FN-BIs had a significant inverse correlation with the ventrodorsal length of infarcts (FN 3.5 ± 1.1 mm, TP 11.4 ± 3.6 mm; P < 0.0004) and no correlation with other size parameters such as rostrocaudal thickness and lateral width.

Conclusion:

Anatomical characterization clearly confirmed that the addition of sagittal DWI to the initial axial DWI in suspected cases of BI ensures its accurate diagnosis and improves the patient’s prognosis.

Gamma knife surgery-induced aneurysm rupture associated with tissue plasminogen activator injection: A case report and literature review

Background

Cases involving delayed development of intracranial aneurysms related to gamma knife surgery (GKS) have been recently reported. Here, we present a rare case of GKS-induced aneurysm rupture after intravenous injection of tissue plasminogen activator (t-PA) for occlusion of the middle cerebral artery (MCA). To the best of our knowledge, this is the first case in which t-PA-induced rupture of a GKS-related unruptured aneurysm.

Case Description

A 56-year-old woman underwent GKS for left trigeminal neuralgia. Eighteen years later, she suddenly experienced MCA occlusion with consciousness disturbance and right hemiparesis. She received an intravenous injection of t-PA and then was transferred to our hospital. We confirmed residual thrombus, and she underwent mechanical thrombectomy successfully. A postthrombectomy brain computed tomography scan revealed subarachnoid hemorrhage with a hematoma in the left cerebellar hemisphere. Cerebral angiography revealed a small irregular-shaped aneurysm at the branching site of the left circumflex branch at the distal position of the anterior inferior cerebellar artery, which was not detected on initial imaging. Coil embolization was performed. One month after the ischemic attack, she was transferred to a rehabilitation hospital, with a modified Rankin Scale score of 5.

Conclusions

The tendency to rupture is greater for GKS-induced aneurysms than for intrinsic unruptured aneurysms, according to previous reports. When performing acute treatment for cerebral infarction in patients with a history of GKS, the presence of aneurysms should be evaluated and we should keep in mind that GKS aneurysms are very small and tend to rupture.

Distribution and current problems of acute endovascular therapy for large artery occlusion from a two-year national survey in Japan

BACKGROUND

Endovascular treatment is recommended in clinical practice in Japan. However, its utilization and comprehensiveness are less well described.

AIMS

To report endovascular treatment utilization and overall geographical coverage in Japan and to analyze regional differences in the number of endovascular treatments, specialists, and endovascular treatment-capable hospitals.

METHODS

A national survey of members of the Japanese Society for NeuroEndovascular Therapy (JSNET) was conducted in 2017 and 2018. The total number of endovascular treatment cases per year was estimated, and the number of endovascular treatment cases per 100,000 people was calculated using the 2015 census. The distribution of treatment hospitals and JSNET specialists was mapped and the population coverage rate was determined.

RESULTS

The total number of endovascular treatment cases in Japan increased by 34.5% from 2016 (7702) to 2017 (10,360). The number of endovascular treatment-capable hospitals in Japan increased from 597 in 2016 to 693 in 2017, with an average annual caseload of 14.9 in 2017. The number of JSNET specialists per hospital decreased from 1.81 in 2016 to 1.76 in 2017 because of the increase in endovascular treatment-capable hospitals. Only 50 (7.2%) hospitals had > 40 endovascular treatment cases annually. The majority (97.7%) of the Japanese population lives within a 60-min drive of any endovascular treatment-capable hospital. However, only 70.4% live within a 60-min drive of a high-volume center (>40 cases annually).

CONCLUSIONS

Utilization of endovascular treatment in Japan is increasing; however, the number of cases per hospital remains low, as is the number of specialists per endovascular treatment-capable hospital. Increased number of specialists and centralization of endovascular treatment services may improve patient outcomes.

Predictive Value of Leakage Signs for Pure Brain Contusional Hematoma Expansion

Hematoma expansion is an important consideration in patients with traumatic brain injury (TBI). No precise methods are available, however, for predicting the expansion of TBI-related hematoma. We aimed to establish a more sensitive predictor for contusional hematoma expansion based on the presence of leakage signs on computed tomography angiography (CTA). Thirty-three patients with pure contusion were included in the analysis (age: 64.1 ± 20.6 years; 24 men and 7 women). We compared Hounsfield unit (HU) values within set regions of interest (diameter, 10 mm) between serial CTA phase and delayed-phase CT images (5 min after CTA phase). Positive leakage signs were defined as >10% increases in HU value. Hematoma expansion was determined using plain CT at 24 h in patients who did not undergo emergent surgery. Glasgow Coma Scale (GCS) scores measured at admission and 24 h after admission were also compared. Leakage signs predicted hematoma expansion with high specificity (100%) and sensitivity (92.8%). Patients with positive leakage signs had significant decreases in GCS scores 24 h after the scan (GCS change: positive group, -0.92 ± 0.59; negative group, 1.14 ± 0.82). Positive leakage signs were clearly associated with surgical hematoma removal. Five patients without hematoma who had positive leakage signs at admission exhibited significant expansion of hematomas 24 h later. Our results indicate that leakage signs had high sensitivity in the prediction of contusional hematoma expansion and were significantly associated with delayed neurological deterioration and the necessity of surgical removal.

Bilateral Internal Carotid Artery Aneurysms at the Subpetrosal Portion with Unilateral Lower Cranial Nerve Palsies: Review and Consideration of Surgical Strategy

BACKGROUND

Symptomatic bilateral extracranial internal carotid artery (ICA) aneurysms at the subpetrosal portion are extremely rare, and their treatment strategy remains unknown.

CLINICAL PRESENTATION

A 42-year-old man presented to our hospital with a 2-month history of sudden onset of hoarseness, dysarthria, and dysphagia. Magnetic resonance imaging, magnetic resonance angiography, and computed tomography angiography revealed extracranial bilateral ICA aneurysms at the subpetrosal portion. The left-sided aneurysm compressed the left-sided lower cranial nerves (IX, X, XI, and XII), whereas the right-sided aneurysm was asymptomatic. We prioritized the treatment of the right-sided aneurysm to prevent bilateral lower cranial nerve deficits. This strategy was used because aneurysm treatment is not guaranteed to cure the left-sided cranial nerve palsies that lasted for 2 months. The right-sided ICA aneurysm was treated with ICA ligation and high-flow extracranial-intracranial bypass using the radial artery as bypass graft. Stent-assisted coil embolization was performed to the left-sided ICA aneurysm after 17 days. The patient showed no right-sided symptoms, and his left-sided symptoms remarkably improved 1 year after surgery.

CONCLUSION

Our unique surgical strategy of prioritizing the aneurysm on the "asymptomatic" side may be one of the best treatment approaches in an extremely rare bilateral aneurysm case.

Comparative outcome analysis of anterior choroidal artery aneurysms treated with endovascular coiling or surgical clipping

Background:

Treatment of anterior choroidal artery (AChA) aneurysms with endovascular coiling or surgical clipping may increase the risk of ischemic complications owing to the critical territory supplied by the AChA. We analyzed the surgical results of endovascular coiling and surgical clipping for AChA aneurysms performed in a single institution, as well as the role of indocyanine green-videoangiography (ICG-VAG) and motor-evoked potential (MEP).

Methods:

We analyzed 50 patients (51 aneurysms; 21 men, 29 women; mean age: 58 years) including 25 with subarachnoid hemorrhage treated with endovascular coiling or surgical clipping between April 1990 and October 2013. The complication rates and clinical outcomes of the coil group (mean follow-up: 61 months) and the clip group (mean follow-up: 121 months) were analyzed with a modified Rankin scale.

Results:

The overall clinical outcome of the coil group (95%) was better than that of the clip group (85%). Especially, the outcomes in the coil group were better in the first investigated period (1990–2007) (P < 0.05). However, after the introduction of ICG-VAG and MEP, the outcomes in the clip group improved significantly (P = 0.005), and treatment-related complications decreased from 20 to 4.7%. Eleven aneurysms (coil group: 8, clip group: 3) showed small neck remnants but no remarkable regrowth, except for 1 case during the mean follow-up period of 91 months.

Conclusions:

Surgical clipping of AChA aneurysms has become safer because of ICG-VAG and MEP monitoring. Coiling and clipping of AChA aneurysms showed good and comparable outcomes with these monitoring methods.

Leakage Sign for Primary Intracerebral Hemorrhage: A Novel Predictor of Hematoma Growth

Supplemental Digital Content is available in the text.

Background and Purpose—

Recent studies of intracerebral hemorrhage treatments have highlighted the need to identify reliable predictors of hematoma expansion. Several studies have suggested that the spot sign on computed tomographic angiography (CTA) is a sensitive radiological predictor of hematoma expansion in the acute phase. However, the spot sign has low sensitivity for hematoma expansion. In this study, we evaluated the usefulness of a novel predictive method, called the leakage sign.

Methods—

We performed CTA for 80 consecutive patients presenting with spontaneous intracerebral hemorrhage. Two scans were completed: CTA phase and delayed phase (5 minutes after the CTA phase). By comparing the CTA phase images, we set a region of interest with a 10-mm diameter and calculated the Hounsfield units. We defined a positive leakage sign as a >10% increase in Hounsfield units in the region of interest. Additionally, hematoma expansion was determined on plain computed tomography at 24 hours in patients who did not undergo emergent surgery.

Results—

Positive spot signs and leakage signs were present in 18 (22%) patients and 35 (43%) patients, respectively. The leakage sign had higher sensitivity (93.3%) and specificity (88.9%) for hematoma expansion than the spot sign. The leakage sign, but not the spot sign, was significantly related with poor outcomes (severely disabled, vegetative state, and death) in all of the patients (P=0.03) and in patients with a hemorrhage in the putamen (P=0.0016).

Conclusions—

The results indicate that the leakage sign is a useful and sensitive method to predict hematoma expansion.

Nontraumatic aneurysm rupture following an endoscopic third ventriculostomy and ventricular drainage: Case report of a rare complication

BACKGROUND

Although endoscopic third ventriculostomy is a safe procedure, the authors report a case of aneurysmal subarachnoid hemorrhage as an unusual and serious complication of an endoscopic third ventriculostomy and ventricular drainage.

CASE DESCRIPTION

A 60-year-old male presented with obstructive hydrocephalus caused by midbrain tumors was admitted to our hospital. Endoscopic third ventriculostomy and external ventricular drainage were successfully performed. Two days after the operation, he became comatose, and a computed tomography (CT) scan revealed a diffuse subarachnoid hemorrhage. Emergency cerebral angiogram showed an aneurysm of the left internal carotid artery. Endovascular coil embolization of the ruptured aneurysm was then performed.

CONCLUSION

The rupture of the aneurysm may have been induced by excessive cerebrospinal fluid drainage after the endoscopic third ventriculostomy. Planning for intracranial endoscopic procedures should consider that rupture of an unknown previously unruptured aneurysm is a possible complication.

Sequential pathological changes during malignant transformation of a craniopharyngioma: A case report and review of the literature

Background:

Malignant transformation of craniopharyngiomas is quite rare, and the etiology of transformation remains unclear. The prognosis of malignantly transformed craniopharyngiomas is very poor.

Case Description:

A 36-year-old male had five craniotomies, five transsphenoidal surgeries, and two radiation treatments until 31 years of age after diagnosis of craniopharyngioma at 12 years of age. All serial pathological findings indicated adamantinomatous craniopharyngioma including those of a surgery performed for tumor regrowth at 31 years of age. However, when the tumor recurred approximately 5 years later, the pathological findings showed squamous metaplasia. The patient received CyberKnife surgery, but the tumor rapidly regrew within 4 months. The tumor was resected with the cavernous sinus via a dual approach: Transcranial and transsphenoidal surgery with an extracranial-intracranial bypass using the radial artery. Pathologic examination of a surgical specimen showed that it consisted primarily of squamous cells; the lamina propria was collapsed, and the tumor cells had enlarged nuclei and clarification of the nucleolus. The tumor was ultimately diagnosed as malignant transformation of craniopharyngioma. After surgery, he received combination chemotherapy (docetaxel, cisplatin, and fluorouracil). The tumor has been well controlled for more than 12 months.

Conclusion:

Serial pathological changes of the craniopharyngioma and a review of the 20 cases reported in the literature suggest that radiation of the squamous epithelial cell component of the craniopharyngioma led to malignant transformation via squamous metaplasia. We recommend aggressive surgical removal of craniopharyngiomas and avoidance of radiotherapy if possible.

Unusual hemodynamic stroke related to an accessory middle cerebral artery: The usefulness of fusion images from three-dimensional angiography

BACKGROUND

Ischemic stroke associated with an anomaly of the middle cerebral artery (MCA) is a rare occurrence. The diagnosis is very difficult when there are steno-occlusive lesions associated with an accessory middle cerebral artery (AMCA).

CASE DESCRIPTION

A 77-year-old female with hypertension and hyperlipidemia experienced repeated transient ischemic attacks (TIAs) of motor aphasia and dysarthria. Although angiography showed only left intracranial occlusion, the fusion images of three-dimensional digital subtraction angiography (3-D DSA) showed complex steno-occlusive lesions and an AMCA related with the TIA. The cerebral blood flow (CBF) to the left frontal lobe was supplied by the AMCA, via the anterior communicating artery from the right internal carotid artery. The left temporal and parietal lobes were supplied by the stenotic MCA, via the left posterior communicating artery from the left posterior cerebral artery. Single-photon emission computed tomography showed a marked decrease in CBF to both the left frontal and temporal lobes. A left superficial temporal artery (STA)-to-left MCA double anastomosis was performed, in which each branch of the STA supplied branches of the AMCA and MCA.

CONCLUSION

This is the first reported case of ischemic stroke in a patient with an AMCA. The exact diagnosis could be made only by using fusion images of 3-D DSA, which were useful for understanding the complicated CBF pattern and for the choice of recipient artery in bypass surgery.

Secondary prevention of stroke: Pleiotropic effects of optimal oral pharmacotherapy

Stroke is a major cause of mortality and disability worldwide. During the past three decades, major advances have occurred in secondary prevention, which have demonstrated the broader potential for the prevention of stroke. Risk factors for stroke include previous stroke or transient ischemic attack, hypertension, high blood cholesterol and diabetes. Proven secondary prevention strategies are anti-platelet agents, antihypertensive drugs, statins and glycemic control. In the present review, we evaluated the secondary prevention of stroke in light of clinical studies and discuss new pleiotropic effects beyond the original effects and emerging clinical evidence, with a focus on the effect of optimal oral pharmacotherapy.

A role for histamine in human-malignant glioma-cells

Histaminergic neuron cells send fiber terminals to almost all parts of the brain, and the histamine receptors on astrocytes are the main targets of central histaminergic neurons. But no proof of the significance of histamine and its specific receptors on human malignant astrocytoma cells has been presented to date. Our results show that six malignant glioma cell lines used in this experiment secreted histamine into the culture medium and that the histamine stimulated their DNA synthesis in a dose-dependent manner. Moreover, histamine induced accumulation of inositol triphosphate (IP3) in all cell lines in either a time- or a dose-dependent manner, whereas cAMP accumulation was not induced by it in any of these cell lines, indicating that these cell lines express the H-1-receptors but not the H-2-receptors. In vivo, thus, malignant glioma may possibly produce histamine, which then would stimulate their neoplastic behavior mediated by the H-1-receptor.

A role of matrix metalloproteinases produced by glioma-cells

The secretion of matrix metalloproteinases (MMPs), which enzymes have been suggested as degradative agents for components of the extracellular matrix, was studied in eight glioma cell lines. We investigated the relationship between the secretion of MMPs and the tumorigenicity of the glioma cells by immunoblot analysis using antisera against human MMPs. Four types of matrix metalloproteinase including MMP-1, MMP-2, MMP-3 and MMP-9 were detected in the glioma cells. MMP-2 was detected in all high-grade gliomas, while an additional MMP or two were detected in only two cell lines, U87MG and KINGS-1. Furthermore, the tumorigenetic potential was shown to correlate with the secretion of MMPs in vitro. These enzymes are capable of degrading several extracellular matrix components of the central nervous system, and thus must play an important role in the mechanism of occurence and/or growth of glioma.

Ruptured de novo aneurysm arising at a site remote from the anastomosis 14 years after superficial temporal artery-middle cerebral artery bypass: a case report

BACKGROUND AND IMPORTANCE

The long-term outcome of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is unclear. We report a very rare case of a de novo aneurysm after bypass surgery.

CLINICAL PRESENTATION

A 57-year-old woman who underwent STA-MCA bypass and internal carotid artery aneurysm treatment 14 years earlier developed a subarachnoid hemorrhage and a temporal lobe hematoma on the same side as the anastomosis. Angiography showed excellent patency of the STA bypass and a ruptured de novo saccular aneurysm at a site remote from the anastomosis. Neck clipping and hematoma evacuation were performed on the second day, and postoperative angiography showed complete aneurysmal clipping. The aneurysm was considered to be caused by hemodynamic stress because it was remote from the anastomosis and had developed after a prolonged interval of 14 years; furthermore, the aneurysm projected because of the hemodynamic force of the STA perfusion.

CONCLUSION

This is the first reported case of a de novo MCA aneurysm that developed at a site remote from STA-MCA anastomosis because of hemodynamic force. Therefore, long-term control of blood pressure and repeated imaging examination should be performed to confirm patency and to identify aneurysm formation after STA-MCA bypass.

Abstract 2383: The Antiplatelet Effect Of Clopidogrel Is Associated With CYP2C19 *2 And *3 Polymorphism But Not With Pon-1 Q192R Polymorphism In Japanese Patients Undergoing neurointervention

Background Patients with cervical carotid or intracranial stenting are routinely premedicated with antithrombotic agents, clopidogrel and aspirin (ASA). A recent study has showed paraoxonase-1 (PON-1) Q192R genotypes impacts on antiplatlet effect of clopidogrel rather than CYP2C19 mutation. We investigate the influence of CYP2C19 *2, *3, and PON-1 Q192R genotypes on antiplatelet effect of clopidogrel in Japanese patients scheduled for neurointervention such as extracranial carotid artery stenting, intracranial artery stenting, or coil embolization of the cerebral aneurysm.

Method A total of 102 consecutive patients scheduled for neurointervention and treated with ASA and clopidogrel were enrolled. Genotyping of three single-nucleotide polymorphisms (SNPs) defining the two major CYP2C19 alleles *2, *3 and PON-1 Q192R was performed with the use of TaqMan® SNP Genotyping Assays (Applied Biosystems, CA) from stored DNA. Antiplatlet effect of clopidogrel was assessed by VerifyNow P2Y12 assay.

Result The frequencies of CYP2C19 *1/*1, *1/*2, *1/*3, *2/*2, *2/*3, and *3/*3 were 28 (27.5%), 39 (38.2%), 13 (12.7%), 9 (8.8%), 11 (10.8%), and 2 (2.0%), respectively. On the basis of CYP2C19 genotype, 28 patients (27.5%) were classified as an extensive metabolizer (EM), 52 (51.0%) as an intermediate metabolizer (IM) and 22 (21.6%) as a poor metabolizer (PM). The proportion of patients harboring CYP2C19 loss of function SNPs is 72.5%. The frequencies of PON-1 QQ192, QR192, and RR192 were 8 (7.8%), 52 (51.0%), and 42 (41.2%), respectively. P2Y12 reaction unit (PRU) in the VerifyNow P2Y12 assay was significantly higher in patients with CYP2C19 loss of function SNPs than those without (253.6±100.2 vs. 161.3±85.5, P<0.001). However, the PRU in patients with QR192 or RR192 were not significantly different from those with QQ192 ( 227.0±128.1 vs. 228.8±103.0, P=0.973).

Conclusion: In Japanese patients undergoing neurointervention, antiplatlet effect of clopidogrel was associated with CYP2C19 genotype *2and *3 but not with PON-1 Q192R genotype.

Retrospective survey of endovascular treatment for ruptured intracranial aneurysm in Japan: Retrospective Endovascular Subarachnoid Aneurysm Treatment (RESAT) study

Annual retrospective surveys of 20 to 31 medical centers performing endovascular treatment of cerebral aneurysms in Japan from 1997 to 2008 were performed to analyze technical and clinical outcomes of endovascular treatment for ruptured cerebral aneurysm. Patients treated with dome embolization using bare platinum coils within 14 days after onset were retrospectively selected, and clinical features, and technical and clinical outcomes at discharge were studied. Retrospective Endovascular Subarachnoid Aneurysm Treatment (RESAT) 1 covers patients treated from 1997, when the Guglielmi detachable coil was introduced, to 2002, just after International Subarachnoid Aneurysm Trial was reported. RESAT 2 to RESAT 7 were conducted annually between 2003 and 2008. Among 5,624 patients with ruptured aneurysms treated within 14 days after onset, 4,782 patients were treated by dome embolization using platinum detachable coils. The patients in this large retrospective survey included 35.8% aged over 70 years, 36.6% with posterior circulation aneurysms, and 29.3% with poor grades (Hunt and Kosnik grades IV and V). The proportion of patients aged over 70 years tended to increase each year from 33.4% in RESAT 1 to 39.8% in RESAT 7, and the proportion of those with posterior circulation aneurysms decreased from 44.2% in RESAT 1 to 23.8% in RESAT 7 (p<0.001). Overall technical success was obtained in 4,666 patients (97.6%), and favorable clinical outcome (good recovery and moderate disability) at discharge was obtained in 88.0% of grade I-III cases and 73.6% of grade I-V cases. Procedure-related morbidity was 2.9% and mortality was 0.8%. Despite this survey involving high proportions of aged, posterior circulation, and poor-grade patients, the technical success rate and immediate clinical results were relatively favorable. The patient prognosis and aneurysm changes must be investigated over a longer period, together with the effects of the introduction of new endovascular devices for cerebral aneurysms.

Clinical features of non-hypertensive lobar intracerebral hemorrhage related to cerebral amyloid angiopathy

BACKGROUND AND PURPOSE

The present study aims to clarify the clinical features of non-hypertensive cerebral amyloid angiopathy-related lobar intracerebral hemorrhage (CAA-L-ICH).

METHODS

We investigated clinical, laboratory, and neuroimaging findings in 41 patients (30, women; 11, men) with pathologically supported CAA-L-ICH from 303 non-hypertensive Japanese patients aged >OR=55, identified via a nationwide survey as symptomatic CAA-L-ICH.

RESULTS

The mean age of patients at onset of CAA-L-ICH was 73.2 +/- 7.4 years; the number of patients increased with age. The corrected female-to-male ratio for the population was 2.2, with significant female predominance. At onset, 7.3% of patients received anti-platelet therapy. In brain imaging studies, the actual frequency of CAA-L-ICHs was higher in the frontal and parietal lobes; however, after correcting for the estimated cortical volume, the parietal lobe was found to be the most frequently affected. CAA-L-ICH recurred in 31.7% of patients during the average 35.3-month follow-up period. The mean interval between intracerebral hemorrhages (ICHs) was 11.3 months. The case fatality rate was 12.2% at 1 month and 19.5% at 12 months after initial ICH. In 97.1% of patients, neurosurgical procedures were performed without uncontrollable intraoperative or post-operative hemorrhage.

CONCLUSIONS

Our study revealed the clinical features of non-hypertensive CAA-L-ICH, including its parietal predilection, which will require further study with a larger number of patients with different ethnic backgrounds.

Anterior inferior cerebellar artery dissecting aneurysm in a juvenile: case report

A 15-year-old girl presented with a distal anterior inferior cerebellar artery (AICA) dissecting aneurysm manifesting as sudden onset of general tonic-clonic convulsion while singing a song. Physical and neurological examinations found headache, vomiting, right perceptive deafness, and right cerebellar ataxia. Cranial magnetic resonance imaging demonstrated a hemorrhagic mass in the brainstem region, and digital subtraction angiography revealed a fusiform dilatation of the anterior pontine segment of the right AICA. The diagnosis was dissecting aneurysm. Endovascular embolization was performed for aneurysm and parent artery occlusion using a Guglielmi detachable coil and 9 TruFill detachable coil systems, respectively, 2 weeks after occipital artery-AICA anastomosis. No ischemic complications were seen, and her neurological deficits completely recovered after the interventional therapy.

Simultaneous occurrence of subarachnoid hemorrhage due to ruptured aneurysm and remote brainstem hematoma--case report

A 48-year-old woman presented with simultaneous aneurysmal subarachnoid hemorrhage (SAH) and remote intracerebral hemorrhage manifesting as sudden onset of severe headache, left hemiparesis, and diplopia. Emergent computed tomography revealed localized SAH in the interpeduncular cistern, and a remote brainstem hematoma in the right dorsolateral tegment. Neuroimaging found no signs of vascular anomaly in the brainstem. The aneurysm at the basilar artery and superior cerebellar artery bifurcation was successfully embolized using coils. Her postoperative neurological status was improved except for slight diplopia. The causes of this extremely rare case of simultaneous occurrence of aneurysmal SAH and remote brainstem hematoma in the dorsolateral tegment remain obscure.

[A rare case of intracranial meningioma with intratumoral metastatic breast cancers]

We report an uncommon case of breast cancer metastasis to an intracranial meningioma. A 47-year-old female was admitted to our hospital due to general convulsion. She had undergone a radical operation for left breast cancer 4 years refore, and received postoperative adjuvant therapies. MRI revealed a solid well-circumscribed tumor in the right frontal convexity. The patient underwent tumor resection successfully. The pathological examination revealed ductal carcinoma in the tissue of a transitional meningioma. Tumor-to tumor metastasis is a rare event. Literature review and discussion of such an uncommon occurrence was presented.

Factors contributing to blood-brain barrier disruption following intracarotid injection of nonionic iodinated contrast medium for cerebral angiography: experimental study in rabbits

PURPOSE

This study was performed to investigate the role of injection methods and conditions under a fixed dose of radiographic contrast medium (CM) in respect to promoting blood-brain barrier (BBB) disruption.

MATERIALS AND METHODS

A total of 44 white rabbits (average body weight 2.7 +/- 0.4 kg) were used, and their carotid injection was performed with nonionic CM. The variables assessed for the carotid injections included the following: iodine content (300 or 150 mg I/ml), liquid temperature (37 degrees or 24 degrees C), and the injection time duration (1 or 30 s). The rabbits were divided into five groups. To evaluate BBB disruption, pre- and post-contrast-enhanced magnetic resonance (MR) studies were performed.

RESULTS

Abnormal enhancement of the brain parenchyma in MRI was noted in only one group, which consisted of high-iodine concentration CM injected at a low temperature over a short injection interval. Statistically significant increased values for the percentage of relative enhancement (RE%) were demonstrated (P < 0.05) in comparison with the saline-injected control group.

CONCLUSION

This result suggests variables that may need to be carefully considered to prevent BBB injury induced by nonionic CM for cerebral angiography, especially in the setting of a neurointerventional procedure.

Preoperative embolization of brain tumor with pial artery or dural branch of internal carotid artery as feeding artery

SUMMARY

This study evaluated the clinical usefulness of preoperative embolization of the pial artery or dural branch of the internal carotid artery (ICA) for brain tumor. Subjects comprised 17 patients with large hypervascular brain tumors who underwent preoperative selective embolization. Micro-catheters (2- or 1.7-F) and shapeable hydrophilic micro-guide wires were used for pial artery (branching from the posterior or anterior cerebral artery) or ICA dural branch embolization. Embolization was performed under digital subtraction fluoroscopy with Polyvinyl alcohol (PVA) particles (150-250 mm) and/or liquid coil.Tumor resection was performed immediately or the day after embolization. Digital subtraction angiography (DSA) before and after endovascular devascularization, blood loss during tumor resection, and clinical outcome were evaluated. All endovascular procedures were technically successful. Post-embolization DSA revealed either a disappearance or a marked decrease of the tumor stain in all cases. Control of intraoperative bleeding was easily accomplished, and intraoperative blood loss was low. Preoperative particle embolization of the feeding artery from the cortical artery or ICA dural branch is safe and effective as adjuvant therapy before tumor resection.

[Clinical study of multiple traumas with severe facial injury undergoing emergency endovascular treatment: significance of emergency embolization of the external carotid artery]

The outcome of multiple injures freqently depends on the priority of treatments, and the decision as to the procedures and timing of primary care is extremely important. We studied the patients with multiple trauma whounderwent emergency endovascular treatment for facial hemorrhage related to external carotid arterial injury. The subjects are 5 patients who underwent embolization of the external carotid artery by an endovascular approach among patients with multiple traumas who were brought to our hospital by ambulance. In these patients, the vital signs on arrival, interval between injury and intravascular surgery, type of brain injury, type and grade of concurrent injury and outcome were studied. Three patients showed hemorrhagic shock on arrival, and 1 patient showed hemorrhagic shock immediately after arrival. The mean interval between injury and endovascular surgery was 3.9 hours. All patients had skull base fracture, and abnormal intracranial lesions on initial CT including 4 focal injuries and 1 diffuse injury. Moderate to severe thoracic/abdominal injuries were noted in 3 patients. In the remaining 2 patients, there was no trauma in the thoracic or abdominal regions. Intraperitoneal hemorrhage with splenic injury was observed in 3 patients. In 3 of 4 patients died by hemorrhagic shock because of the delay of endvascular treatments. In trauma patients with persistent hemorrhage, emergency endovascular treatment should be considered as a primary survey for initial treatment without delay under intensive conservative treatment.

[Case of meningioma with extracranial extension through the internal jugular vein]

We report a case of posterior fossa meningioma extending into the cervical jugular vein, which was successfully resected. A 57-year old male with ataxia and mild hypogeusia was admitted to our hospital. MRI demonstrated a well-circumscribed large posterior fossa mass with extracranial extension through the internal jugular vein. Two-staged surgical treatment was then performed. The mass in the posterior fossa was removed at the first operation. The tumor was invading into the sigmoid sinus which was filled with tumor. The second operation for extracranial mass was performed 1 month later. Transcervically, the internal jugular vein obstructed by tumor was successfully removed. The post-operative course was uneventful and histopathological examination revealed the fibrous meningioma in the posterior fossa, but the intravenous portion of the tumor showed more atypical findings. Such a case is quite uncommon and the mechanism of tumor extension with different histological features is discussed.

[Ischemia of the sternocleidomastoid muscle following occipital artery embolization for dural arteriovenous fistula]

We report a case of localized ischemia of the sternocleidomastoid muscle (SCM) occurring after occipital artery embolization of a dural arteriovenous fistula (dAVF). A 45-year-old man presented intracerebral hemorrhage from a dAVF at the left transverse-sigmoid sinus. The dAVF had a high flow fistula from the left occipital artery (OA). Endovascular therapy was carried out one month later. Transarterial embolization of the OA was carried out prior to the transvenous approach to decrease the shunt flow. During obliteration of the proximal portion of the OA with fiber platinum coils and polyvinyl alcohol particles, the patient reported severe neck pain. The fistula was successfully embolized after transvenous packing of the left sigmoid sinus with detachable coils. The neck pain persisted for one week and disappeared after conservative treatment. T2-MR imaging 3 days after the embolization showed a hyperintensity in the left SCM. This ischemic lesion was probably induced by occlusion of the muscular branch of the OA. We discuss this common but rarely reported complication of OA embolization.

Clinical Outcomes of Coil Embolization for Acutely Ruptured Aneurysm. Comparison with Results of Neck Clipping when Coil Embolization is Considered the First Option

SUMMARY

The purpose of this prospective study was to evaluate clinical results in patients with acutely ruptured cerebral aneurysm treated by neck clipping (NC) or coil embolization (CE) when CE was considered the first option. Between 1998 and 2003, 280 patients with acutely ruptured cerebral aneurysms excluding intracerebral hematoma were evaluated. Patients were managed prospectively according to the following protocol: primary treatment modality was CE (n=179). NC (n=101) was selected for the patients with aneurysms that were small (less than 2 mm) or an unsuitable shape for CE. Surgical complication rates were 4.5% for CE and 16.8% for NC. Symptomatic vasospasm occurred in 8.4% of CE patients and 29% of NC patients. Good recovery on the Glasgow Outcome Scale was achieved by 71% of CE patients and 50% of NC patients at discharge. Surgical complications and symptomatic vasospasm were significantly reduced in CE compared to NC. Clinical outcome at discharge was also better with CE. Although 18.3% of CE patients showed various degrees of aneurysmal recanalization and 7% of CE patients required additional treatment (re-CE or NC), aneurysmal rebleeding occurred in only one patient during followup (mean, 3.95 years).

Blood brain-barrier disruption of nonionic iodinated contrast medium following coil embolization of a ruptured intracerebral aneurysm

Few reports of temporary disruption of the blood-brain barrier (BBB) following neurointerventional procedures, presumably caused by nonionic radiographic contrast medium (CM), exist in the literature. We described such a case in a 72-year-old man presenting with acute subarachnoid hemorrhage, who underwent coil embolization of a ruptured anterior communicating artery complex aneurysm. At the time of his follow-up CT examination, a large amount of iodine was found in the cerebrospinal fluid (CSF). Because of this experience, the iodine concentration in the CSF of five other patients who also underwent an intracranial endovascular procedure was measured. It was concluded that this increased iodine might have been caused by temporary leakage or breakdown of the BBB. Even if the total amount of CM may not be excessive, the disproportionately high concentration injected into a single vascular territory may pose a unique set of variables increasing the risk of BBB disruption.

Distal-tip shape-consistency testing of steam-shaped microcatheters suitable for cerebral aneurysm coil placement

BACKGROUND AND PURPOSE

Although the selection of microcatheter for endovascular aneurysmal treatment is one important factor in patient outcome, the use of steam shaping for achieving safe entry and stability during coil placement has not, to our knowledge, been systematically evaluated. The goal of this study was to compare the durability of distal microcatheter steam shaping in five different catheters with typical intraprocedural stresses that are similar to those encountered during aneurysm coil placement.

METHODS

Distal tips of microcatheters were shaped into a 90 degrees turn with distal straight-segment lengths of 3, 5, or 7 mm by using steam, performed according to the instructions for use included with each catheter. In a water bath kept at body temperature, the changes in catheter tip angle were recorded and measured following microcatheter insertion into a guiding catheter, microguidewire insertion through the microcatheter, and Guglielmi detachable coil (GDC) placement through the microcatheter.

RESULTS

The degree of distal microcatheter straightening with typical intraprocedural manipulations was more pronounced on braided microcatheters and on microcatheters with 3- or 5-mm distal-shaped segments. The degree of spontaneous recovery of the initially steamed shape was more pronounced with nonbraided catheters. The most significant single variable contributing to straightening of a steam-shaped catheter tip was the effect of microguidewire insertion. The catheter-tip straightening effect encountered with inserting GDCs was less than that encountered with microguidewire insertion. We demonstrated that the decreased catheter-tip angle encountered with a large-magnitude straightening stress spontaneously recovered once the stress was removed or when it was reduced to a smaller magnitude stress.

CONCLUSION

Our study shows that, although braided microcatheters are suitable for maintaining durable configurations when long distal-tip lengths are permissible, nonbraided microcatheters demonstrate the most durable distal-tip configurations when short distal-tip lengths are called for. This may be one of significant factors in catheter choice for endovascular treatment of aneurysm.

[Angiography]

The clinical usefulness of three dimensional images was widely recognized. The three dimensional digital subtraction angiography (3D-DSA) well demonstrated anatomical structures of cerebral arteries with high special resolution. This 3D observation allowed high quality planning for aneurysmal coil packing and neck clipping. Because of the bony structure and curvy arterial anatomy in the skull base region, 3D-CTA and MRA was sometimes distureved the demonstration of the anatomical relationship adjacent to the aneurysm. However, 3D-DSA not only demonstrated arterial anatomy, but also analyzed of vascular structure, quantifiably. And it was useful in radiation dose reduction by reduction of DSA exposure number. We believe that 3D-DSA should provided useful information for planning of surgical and endovascular treatment in the field of cerebro-vascular disease.

[A successfully treated case of a ruptured anterior wall aneurysm of the internal carotid artery (C2) which changed in form from blister-like to saccular type]

We successfully treated a case of ruptured anterior wall aneurysm of the ICA (C2) which changed in form from blister-like to saccular type. A 46-year-old woman developed subarachnoid hemorrhage on July 12, 2002. Cerebral angiogram demonstrated a blister-like aneurysm located in the left C2 portion of the internal carotid artery, but which didn't affect the arterial branches. Because of the risk of premature rupture during early surgery, delayed surgery was scheduled and the patient underwent serial study of the aneurysm. During 2 weeks of follow-up, the shape and size of the aneurysm changed in form blister-like to an enlarged saccular type aneurysm. On the day 18th, a left episubcombined approach, after insertion of a balloon catheter into the cervical ICA, was attempted and the aneurysm projecting antero-medially under the left carotid artery was exposed. The aneurysm had a distinct neck and its wall was not fragile. There was no macroscopic evidence of dissection of the ICA and the aneurysm was successfully clipped by conventional manipulation. Because of the difficulty in determining by angiographic evidence alone, whether an anterior wall aneurysm is a blister type or saccular type, careful follow-up is needed and if the shape or size changes, immediate appropriate treatment becomes mandatory. Intraoperative observation will determine the final diagnosis, as in this uncommon case.

Stability of microcatheter for cerebral aneurysm embolization after steam shaping

SUMMARY

To compare the performance of stability after steam shaping on 4 types of microcatheters, which are commonly used for cerebral aneurysm embolization, an experimental simulation was performed. Distal portion of the microcatheters were shaped into the 90 degree with length of 5 mm with the steam under the instruction of each catheter. In the temperature kept water bath, the change of the angle of the catheter tips were recorded and measured. Several stresses were added to the tips with coaxially passing through the guiding catheter, using guidewire and Guglielmi detachable coil (GDC). The degree of straightening was prominent on braided microcatheters and on the short length of shaping. The degree of recover of the primary shaping was prominent on non-braided catheter. The most influence factor of straightening of shaped catheter tip was the stress from the manipulation of guidewire. The influence from the inserting GDC was less than the guidewire manipulation. It was shown that the decreased angle after large stress was recovered under the situation of without or with small stress. Our study shows that the nonbraided microcatheter was suitable when stability of microcatheter tip after steam shaping was requested for aneurysm coiling.

Preoperative selective internal carotid artery dural branch embolisation for petroclival meningiomas

We assessed the clinical value of preoperative embolisation of the dural branches of the internal carotid artery (ICA) in cases of petroclival meningioma was evaluated. We carried out preoperative selective embolisation on seven consecutive patients with large petroclival meningiomas, using nonbraided 2 F steam-shaped microcatheters and shapeable hydrophilic microguide-wires to enter the dural branches of the ICA. The embolisations were performed using digital subtraction fluoroscopy with 150-250 microm polyvinyl alcohol particles. The tumours were resected a few days after embolisation. We reviewed angiographic findings before and after endovascular devascularisation, blood loss during tumour resection and clinical outcome. All endovascular procedures were technically successful, and postembolisation angiography showed disappearance of or marked decrease in tumour stain in all cases. Intraoperative bleeding was easily controlled, and intraoperative blood loss was low.