Embolization of an Exophytic Posterior Neck Mass Secondary to a Cutaneous Renal Cell Carcinoma Metastasis / 신경중재치료의학

Renal cell carcinoma (RCC) commonly metastasizes to the lung, liver, bones, and brain; however, cutaneous metastases remain rare with few reported cases. Since RCCs have the propensity to metastasize to highly vascular areas, the scalp and skin of the head and neck region are likely locations for cutaneous metastases. We report a rare case of a large, exophytic, cauliflower-like, hemorrhagic, metastatic mass of the posterior neck. This is the first reported case of a head and neck cutaneous RCC metastasis treated with endovascular embolization prior to surgical resection. Due to the increased vascularity of RCCs and risk of excessive hemorrhage during resection, adjunctive embolization of cutaneous head and neck metastasis may have a role. Essential characteristics to our treatment strategy are discussed with a review of pertinent literature.

Mobile Real-time Tracking of Acute Stroke Patients and Instant, Secure Inter-team Communication - the Join App / 신경중재치료의학

PURPOSE: The primary correlate to survival and preservation of neurologic function in patients suffering from an acute ischemic stroke is time from symptom onset to initiation of therapy and reperfusion. Communication and coordination among members of the stroke team are essential to maximizing efficiency and subsequently early reperfusion. In this work, we aim to describe our preliminary experience using the Join mobile application as a means to improve interdisciplinary team communication and efficiency. MATERIALS AND METHODS: We describe our pilot experience with the initiation of the Join mobile application between July 2015 and July 2016. With this application, a mobile beacon is transported with the patient on the ambulance. Transportation milestone timestamps and geographic coordinates are transmitted to the treating facility and instantly communicated to all treatment team members. The transport team / patient can be tracked en route to the treating facility. RESULTS: During our pilot study, 62 patients were triaged and managed using the Join application. Automated time-stamping of critical events, geographic tracking of patient transport and summary documents were obtained for all patients. Treatment team members had an overall favorable impression of the Join application and recommended its continued use. CONCLUSION: The Join application is one of several components of a multi-institutional, interdisciplinary effort to improve the treatment of patients with acute ischemic stroke. The ability of the treatment team to track patient transport and communicate with the transporting team may improve reperfusion time and, therefore, improve neurologic outcomes.

Progressive Deconstruction of a Distal Posterior Cerebral Artery Aneurysm Using Competitive Flow Diversion / 신경중재치료의학

Progressive deconstruction is an endovascular technique for aneurysm treatment that utilizes flow diverting stents to promote progressive thrombosis by diverting blood flow away from the aneurysm's parent vessel. While the aneurysm thromboses, collateral blood vessels develop over time to avoid infarction that can often accompany acute parent vessel occlusion. We report a 37-year-old woman with a left distal posterior cerebral artery aneurysm that was successfully treated with this strategy. The concept and rationale of progressive deconstruction are discussed in detail.

Ventriculoperitoneal Shunt in a Patient with Ruptured Blister Aneurysm Treated with Pipeline Embolization Device

Cerebral spinal fluid (CSF) diversion is frequently required in patients with aneurysmal subarachnoid hemorrhage who develop subsequent hydrocephalus. Procedures such as external ventricular drain (EVD) and ventriculoperitoneal shunt (VPS) usually carry a very low rate of complications. However, as flow diverting stents such as Pipeline Embolization Device (PED) become more widely available, flow diverters are being used in treatment of some ruptured complex aneurysms. EVD and VPS placement in the setting of dual antiplatelet therapy (DAT) in these patients are associated with a significant risk of intracranial hemorrhage. We describe a management strategy and surgical technique that can minimize hemorrhagic complications associated with VPS in patients on DAT after treatment with flow diverting stents.

Ultrasound-Guided Posterolateral Approach for Midline Calcified Thoracic Disc Herniation

OBJECTIVE: Symptomatic thoracic disc herniation often requires prompt surgical treatment to prevent neurological deterioration and permanent deficits. Anterior approaches offer direct visualization and access to the herniated disc and anterior dura but require access surgeons and are often associated with considerable postoperative pain and pulmonary complications. A disadvantage with using posterior approaches in the setting of central calcified thoracic disc herniation however, has been the limited visualization of anterior dura and difficulty to accurately assess the extent of decompression. METHODS: We report our experience with intraoperative ultrasound (US) guidance during a modified posterior transpedicular approach for removal of a central calcified thoracic disc herniation with a review of pertinent literature. RESULTS: The herniated thoracic disc was successfully removed with posterior approach with the aid of intraoperative US. The patient had significant neurological improvement at three months follow-up. CONCLUSION: Intraoperative ultrasound is a simple yet valuable tool for real-time imaging during transpedicular thoracic discectomy. Visualization provided by intraoperative US increases the safety profile of posterior approaches and may make thoracotomy unnecessary in a selected group of patients, especially when a patient has existing pulmonary disease or is otherwise not medically fit for the transthoracic approach.

Delayed Vascular Claudication Following Diagnostic Cerebral Angiography: A Rare Complication of the AngioSeal Arteriotomy Closure Device

With rapidly increasing numbers of neuroendovascular procedures performed annually in recent years, use of arterial closure devices after femoral artery access has been exceedingly common secondary to reduced time to hemostasis, decreased patient discomfort, earlier mobilization, and shortened hospital stay. Although uncommon, use of these devices can lead to a different spectrum of complications, as compared to manual compression. Ischemic symptoms following the use of these devices can have unexpected clinical sequelae and can occur in a delayed fashion. Awareness and recognition of such complications is important with the dramatically increased use of these devices in recent years. We report on a case of delayed vascular complication manifesting as vascular claudication following use of the AngioSeal closure device.

Symptomatic Cerebral Air Embolism During Stent-assisted Coiling of an Unruptured Middle Cerebral Artery Aneurysm: Intraoperative Diagnosis and Management of a Rare Complication

Symptomatic cerebral air embolism during cerebral angiography is extremely rare. We report on the case of a 69-year-old woman undergoing elective stent-assisted coiling of an unruptured right middle cerebral artery (MCA) bifurcation aneurysm, who was found to have severe attenuation of somatosensory evoked potential (SSEP) and electroencephalography (EEG) during the procedure. Intra-operative DynaCT showed hypodense cortical vessels consistent with cerebral air embolism. Diagnostic and management strategies for this rare complication are reviewed.

Treatment of a Ruptured Vertebrobasilar Fusiform Aneurysm Using Pipeline Embolization Device

Treatment options of ruptured vertebrobasilar fusiform aneurysms (VFA) are limited and often carry significant mortality and morbidity. We report the use of Pipeline Embolization Device (PED) to successfully treat a patient with a ruptured vertebrobasilar fusiform aneurysm (VFA) who presented with subarachnoid hemorrhage (SAH). A 73 year-old man with a history of cardiac stent placement seven days earlier presented with Hunt-Hess II SAH. He was taking aspirin and clopidogrel. Computed tomography angiogram revealed a large vertebrobasilar fusiform aneurysm. Microsurgical treatment options are technically challenging and carry high risk. He underwent endovascular treatment of the ruptured VFA using overlapping PEDs. Five PEDs were placed in a telescoping fashion to reconstruct the affected portions of the left vertebral and basilar arteries. An additional 2-mm blister aneurysm in the right vertebral artery was also discovered during the conventional cerebral angiography and was treated with one additional PED. The patient remained neurologically intact after the procedure. He was continued on aspirin and clopidogrel. Follow-up magnetic resonance imaging at three months demonstrated patency of the stents without any evidence of ischemic change. Follow-up conventional cerebral angiogram at six months demonstrated thrombosis of the VFA and reconstruction of the vertebrobasilar system. The patient remained clinically well. An endovascular approach using PEDs can be a safe and effective treatment option for ruptured VFA in selected cases.