Trans-sphenoidal Approach to the Supraclinoid Internal Carotid Artery for Endovascular Access in a Cadaver / 신경중재치료의학

PURPOSE: Sometimes, intracranial pathology in the distal vasculature cannot be accessed by standard endovascular techniques because of occlusion or insurmountable tortuosity of theinternal carotid artery (ICA). A trans-sphenoidal surgical approach can follow a similar trajectory to the course of the supraclinoid ICA. This study evaluates the feasibility of a trans-sphenoidal approach to the supraclinoid ICA for endovascular access. MATERIALS AND METHODS: In a fresh cadaver head, the sphenoid sinus was dissected through a trans-sphenoidal route. Bone over the carotid prominence was removed to expose the ICA. The artery was catheterized using the Seldinger technique, and three-dimensional digital subtraction angiography was performed to evaluate the procedure. RESULTS: The catheter was successfully inserted into the supraclinoid ICA via the trans-sphenoidal route. Three-dimensional radiographic reconstruction confirmed placement of the catheter and the trajectory of the sheath into the supraclinoid ICA. CONCLUSION: While the trans-sphenoidal route has innumerable disadvantages over the standard endovascular access techniques, this route could be considered when other treatment options are too risky or impractical.

Initial Experience with Neuroform EZ in the Treatment of Wide-neck Cerebral Aneurysms / 신경중재치료의학

PURPOSE: Stent-assisted coiling allows embolization and parent vessel reconstruction of wide-necked intracranial aneurysms. The Neuroform EZ (Boston Scientific, Fremont, CA, U.S.A.) stent delivery system offers deployment of a Neuroform stent with fewer steps and improved operator control. Initial experience, technical considerations, and treatment outcomes using the Neuroform EZ stent delivery system in combination with coil embolization are reported. MATERIALS AND METHODS: Seventeen consecutive patients harboring 21 wide-necked saccular cerebral aneurysms were treated with stent reconstruction. Twenty aneurysms were unruptured; one was treated within 24 hours of diagnosis of rupture. Twenty aneurysms were located in the anterior circulation; one was in the posterior circulation. Immediate and six-month post-treatment angiography and clinical assessment were performed. RESULTS: In all cases, the stents were delivered and positioned without difficulty in deployment. Technical complications occurred in 4 patients, but none were directly related to the stent delivery system. On immediate post-treatment angiography, 5 of 21 aneurysms showed complete occlusion, 5 of 21 showed residual neck, and 11 of 21 showed residual contrast filling of the aneurysm sac. At six month follow-up, all 17 patients were clinically stable. Angiography of 18 of the aneurysms showed total occlusion in 12, residual neck in 3, and residual aneurysm filling in 3. Retreatment was performed in the three with residual aneurysm. CONCLUSION: The Neuroform EZ stent system offers improved anchoring and support in stent delivery, which is particularly useful when multiple stents are overlapped to further protect the parent vessel and increase flow diversion away from the aneurysm sac. The only significant problem encountered was coil prolapse, which could be treated with a second stent when necessary. The ease of deployment improves upon the already clinically successful Neuroform design.