Presence of intra-aneurysmal thrombi with delayed coil migration after embolization of an aneurysmal subarachnoid hemorrhage: illustrative case.

BACKGROUND: Coil migration is a rare, but notable complication of endovascular treatment. Risk factors include communicating segment aneurysms, aneurysmal shape, and technical factors. Although cerebral blood flow obstruction caused by early coil migration requires urgent coil removal, delayed coil migration is often asymptomatic, making it difficult to determine a treatment strategy. OBSERVATIONS: A 47-year-old woman was referred to the institute with acute-onset headache. She was diagnosed with subarachnoid hemorrhage due to rupture of the right internal carotid artery-posterior communicating artery aneurysm and underwent endovascular coil embolization. Following the procedure, the patient showed no obvious complications; however, 14 days later, images showed coil migration to the distal side, leading to surgical removal. Right frontotemporal craniotomy was performed, and the remaining coil was removed. The aneurysm was clipped again, and blood flow was confirmed. The patient was discharged 12 days after the craniotomy with transient oculomotor nerve palsy. At the 15-month follow-up, there was no aneurysm recurrence and the oculomotor nerve palsy showed improvement. LESSONS: Retrieval of the migrated coil by craniotomy is an effective remedial measure; however, intraoperative complications are common. Early detection, established protocols, and prompt treatment decisions are important for preventing undesirable outcomes.

Disappearance of a moyamoya-related distal anterior cerebral artery aneurysm after target bypass revascularization: illustrative case.

BACKGROUND: Aneurysm formation is a complication of moyamoya disease (MMD). Distal anterior cerebral artery (ACA) aneurysms account for approximately 1% of MMD-related aneurysms. We report a case of target bypass for adult patients with MMD who presented with intracranial hemorrhage due to rupture of a distal ACA aneurysm, whose disappearance was confirmed postoperatively. OBSERVATIONS: A 45-year-old woman presented with sudden-onset headache and loss of consciousness. Head computed tomography showed hemorrhage in the genu of the corpus callosum with intraventricular extension. Digital subtraction angiography (DSA) revealed Suzuki stage III MMD and a left A3 segment aneurysm. Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and STA-ACA target bypass were performed to reduce hemodynamic stress on the left ACA. DSA 6 months after surgery showed patency of both bypasses and disappearance of the aneurysm. At the 20-month follow-up, the patient was asymptomatic and neurologically intact. LESSONS: Bypass revascularization may be an effective treatment to reduce hemodynamic stress and eliminate MMD-related aneurysms.

Pooled blood volume measured by final flat-panel detector computed tomography predicts outcome after endovascular thrombectomy for acute ischemic stroke.

Background: Pooled blood volume (PBV), measured in real-time in the angiography room using an angiography system, correlates with cerebral blood volume (CBV). We examined the usefulness of PBV in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Methods: EVT for AIS in the anterior circulation (internal carotid artery (ICA) and middle cerebral artery (MCA)) was performed in 31 cases (13 males, 18 females, average age 75.7 years). PBV was acquired using a biplane flat-panel detector (FD) angiographic system. Then, we measured the average PBV value in the M1-6 regions similar to the Alberta Stroke Program Early CT score (ASPECTS) before and after EVT. We investigated factors associated with favorable outcome at 90 days after EVT. Results: There were 13 patients (41.9%) in the good outcome group (mRS (modified Rankin Scale) ≦2) and 18 patients (58.1%) in the poor outcome group (mRS>2). In univariate analysis, NIHSS (National Institutes of Health Stroke Scale) (odds ratio [OR] 0.74, 95% CI 0.57-0.87, p < 0.0001) and post PBV value (odds ratio [OR] 1.13, 95% CI 1.03-1.29, p = 0.0086) were significantly associated with good outcome. The good outcome group had significantly higher post-thrombectomy PBV value (3.69 ± 0.32 ml/100 g versus 2.78 ± 0.93 ml/100 g, P = 0.002) compared to that of the poor outcome group. The relationship between pre-thrombectomy PBV value and outcome at 90 days was not significant. Conclusions: Post-operative PBV value measured by FD-CT (computed tomography) correlated with 90-day outcome after EVT for AIS. FD-CT-PBV would be one of the good predictors of clinical outcome.

Case report: isolated trochlear nerve palsy associated with posterior cerebral artery aneurysm.

We describe a case of isolated trochlear nerve palsy caused by an unruptured posterior cerebral artery (PCA) aneurysm in an 82-year-old male who consulted an ophthalmologist after developing diplopia. Magnetic resonance angiography showed a left PCA aneurysm in the ambient cistern, and T2WI showed an aneurysm compressing the left trochlear nerve to the cerebellar tentorium. Digital subtraction angiography revealed that the lesion was located between the left P2a segment. We attributed this isolated trochlear palsy to left PCA unruptured aneurysm pressure. Thus, we performed stent-assisted coil embolization. The aneurysm was obliterated, and trochlear nerve palsy improved completely.

Manual superficial temporal artery compression using a circular plastic material for embolization of meningioma: illustrative case.

BACKGROUND: In meningiomas that occur in the high-convexity region, the superficial temporal artery (STA) frequently feeds the tumor, and when embolizing from the middle meningeal artery (MMA), the embolic material may not reach the tumor vessels because of the pressure gradient resulting from the STA blood flow, resulting in inadequate embolization. In this case, a circular plastic material was used to apply circumferential pressure around the parietal foramen to control blood flow to the tumor. OBSERVATIONS: A 45-year-old male underwent head magnetic resonance imaging that revealed a 2.2-cm meningioma in the right high-convexity region. Preoperative embolization was performed. When N-butyl-2-cyanoacrylate was injected from the right MMA while using a circular plastic material to compress the skin around the parietal foramen through which the bilateral STAs (the tumor feeders) flow, it was able to fully penetrate the tumor vessel and occlude the other feeders in a retrograde manner. The patient underwent tumor removal after embolization uneventfully. LESSONS: Manual compression of the STA using a circular plastic material is useful when the tumor is fed by the STA through the parietal foramen and is also applicable to transarterial embolization of dural arteriovenous fistulas fed by the STA or occipital artery.

Target Embolization of Complex Vertebral Artery Dissecting Aneurysm with Endovascular Reconstructive Technique Using Cone-Beam Computed Tomography Angiography: Technical Note.

OBJECTIVE: Detailed vasculature of vertebral artery dissecting aneurysms (VADAs) is often complicated owing to the irregular structure with the intimal flap/double lumen. Our aim was to present an endovascular reconstructive technique with assessment of detailed vasculature and the relationship between dissection and surrounding vessels using cone-beam computed tomography angiography (CBCT-A). METHODS: The study included 6 cases with complex vertebral artery dissecting aneurysm. Selective digital subtraction angiography initially identified the location and shape of dissection. CBCT-A was then performed with selective injection into the affected vertebral artery. Luminal morphology of the dissection and surrounding arterial anatomy were assessed using CBCT-A. RESULTS: CBCT-A clearly demonstrated luminal morphology of the intimal flap/double lumen, the entrance into the pseudolumen, and the entire dissecting segment. Tiny perforator arteries were also identified. In all 6 cases, target coil embolization for the pseudolumen and stent placement using an LVIS stent for the entire dissecting segment were successfully performed with the aid of information obtained from CBCT-A. No complications occurred in the perioperative period, and improvement of dissection was identified in the follow-up period. CONCLUSIONS: Target embolization of complex vertebral artery dissecting aneurysm with endovascular reconstructive technique with special reference to the detailed anatomy of dissection using CBCT-A would be useful for safe and effective treatment results.

The usefulness of temporary balloon occlusion during transarterial embolization for scalp arteriovenous fistula.

BACKGROUND: We present two cases of scalp arteriovenous fistula (sAVF) treated by transarterial embolization with the aid of a temporary balloon occlusion (TBO) to detect precise vasculature. CASE DESCRIPTION: Case 1: A 59-year-old woman noticed a sudden onset of pulsating bruits. sAVF was fed by the right superficial temporal artery (STA) and drained to the right superficial temporal vein. We performed feeder occlusion using coils after the recognition of a single feeder and a single fistula using TBO. Case 2: A 42-year-old woman noticed a pulsating subcutaneous mass. sAVF was fed by the right occipital artery (OA) and drained to the right occipital vein (OV). We could detect another feeder of the right STA after the TBO of the OA. We performed transarterial feeder occlusion for STA and OA using coil and N-butyl-2-cyanoacrylat including OV and shunt point, because this case was a single fistula with multiple feeders. CONCLUSION: sAVFs are a relatively rare disease with a complex vascular structure. For the adequate transarterial approach, TBO was useful for detecting the precise vasculature of sAVF.

Usefulness of Adjunctive Technique with a TACTICS Catheter for Coil Embolization of Cerebral Aneurysms.

Objective: We report the usefulness of the adjunctive technique using a 3.4-Fr TACTICS catheter, which is a distal access catheter (DAC) for coil embolization. Methods: Patients who underwent coil embolization with an adjunctive technique using a TACTICS catheter between October 2018 and May 2019 were retrospectively analyzed. Results: In all, 64 aneurysms in 51 patients were treated. Among them, 18 aneurysms in 15 patients (4 ruptured aneurysms and 14 unruptured aneurysms) required an adjunctive technique using a TACTICS catheter. The methods of embolization were the double catheter technique (DCT) for five aneurysms, stent-assisted coiling (SAT) for seven, DCT + SAC for one, and balloon-assisted technique (BAT) for five aneurysms. Aneurysms were located in the anterior communicating artery (Acom A) in three cases, distal anterior cerebral artery (dACA) in one, middle cerebral artery (MCA) in five, internal carotid artery (ICA) in six, basilar artery (BA) in one, and vertebral artery (VA) in two cases. It was easy to access distal intracranial vessels using the TACTICS catheter. In all cases, guiding of the microcatheter, coiling, and stent placement were improved. There were no complications associated with using the TACTICS catheter. Conclusion: Compared with conventional DACs, distal intracranial vessels were more easily accessed using the TACTICS catheter. A TACTICS catheter is useful because DCT and SAC require sufficient operability of the microcatheter.

Endovascular Treatment of Ruptured Kissing Aneurysms Arising From the Origin of the Anterior Choroidal Artery and an Aberrant Origin of the Premamillary Artery.

BACKGROUND: The premamillary artery (PMA) usually arises from the posterior communicating artery. Thus, an internal carotid artery (ICA) origin for PMA is rare. We report a rare case of a patient who presented with subarachnoid hemorrhage resulting from kissing aneurysms arising from the origin of the anterior choroidal artery and the aberrant origin of PMA and was successfully treated with coil embolization. CASE DESCRIPTION: A conscious and alert 36-year-old woman arrived at our hospital with a severe headache. Computed tomography (CT) of the head showed a thin subarachnoid hemorrhage. CT angiography revealed kissing aneurysms arising from the ICA. Digital subtraction angiography showed that these kissing aneurysms had arisen from the anterior choroidal artery and the aberrant origin of the PMA. Endovascular coil embolization was performed for both aneurysms. Her clinical course was good, and she was discharged from our hospital 20 days after admission. CONCLUSIONS: To the best of our knowledge, the present study is the first report of a ruptured saccular PMA aneurysm arising from ICA that was successfully treated with coil embolization. Three-dimensional digital subtraction angiography and cone-beam CT were useful for confirming the precise vasculature of the PMA.

[Cervical Myelopathy Caused by Chronic and Intermittent Cord Compression by Tumors upon Neck Rotation:A Case Report].

A 35-year-old man with neurofibromatosis type I presented with right arm weakness and gait disturbance that had developed gradually. MR imaging revealed bilateral intra-and extradural tumors at the C1-2 level. Although the adjacent spinal cord was narrowed, there was no evident contact between the tumors and the spinal cord. Computed tomography myelography revealed that the tumors compressed the cord only during neck rotation. The tumors were resected to make an abundant subdural space around the affected cord. The patient's neurological symptoms improved postoperatively. Because contact between the masses and spinal cord only occurred upon neck rotation, we believe it is important to consider the possibility of intermittent compression, termed dynamic rotational canal stenosis, in patients with masses at the C1-2 level, even when such masses are not seen to be in contact with the cervical cord on routine radiological examination.