Transarterial and Transvenous Coil Embolization of Direct Carotid-Cavernous Fistulas.

Objective: Transvenous embolization (TVE) is typically used in combination with the residual shunt of transarterial embolization (TAE) for the treatment of direct carotid-cavernous fistulas (direct CCFs). This report is about our additional embolization method using combination therapy. Case Presentation: Five consecutive cases of direct CCF were presented; two were caused by aneurysms and three by head injuries. The treatment for each was started with TAE, with the addition of TVE if a shunt remained. At the time of TVE, a microcatheter positioned in the internal carotid artery passing from the cavernous sinus through the aneurysm neck or fistula was pulled back (pull-back method). It was then placed in the coil mass with TAE, and additional coils were filled. In two cases, the shunt disappeared by using only TAE, whereas it disappeared after being additionally embolized by the pull-back method in the remaining cases. All patients recovered with no postoperative complications. Conclusion: The TAE and TVE combination therapy with the pull-back method could efficiently embolize the residual shunt after TAE.

Urgent Carotid Artery Stenting for Carotid-Related Stroke-in-Evolution.

BACKGROUND: Stroke-in-evolution (SIE) is a major outcome determinant in patients with acute ischemic stroke. The benefit of surgery for treatment of carotid artery-related SIE remains controversial. OBJECTIVE: To retrospectively evaluate the use of carotid artery stenting (CAS) as a possible alternative treatment in patients with carotid-related SIE. METHODS: Ten patients with carotid-related SIE were treated with CAS from May 2005 to December 2014. The mean initial National Institutes of Health Stroke Scale (NIHSS) score was 5.4 ± 4.4. Two patients had total occlusion of the internal carotid artery, and 8 had severe stenosis. The mean interval from symptom onset to clinical deterioration was 2.9 ± 2.9 d. The mean NIHSS score after deterioration was 14.3 ± 4.5. In the hemodynamic assessment using perfusion imaging, the ipsilateral cerebral hemodynamics was impaired in 7 of 8 patients. RESULTS: All patients underwent urgent CAS in the acute phase of SIE. Seven patients underwent CAS using flow reversal with or without distal protection. No procedure-related complications occurred in any patients, although 1 patient developed aspiration pneumonia. The mean NIHSS score 7 d after CAS was 4.8 ± 2.3. Six patients (60%) had a modified Rankin scale score of 0 to 2 at discharge. CONCLUSION: Urgent CAS for carotid-related SIE with hemodynamic impairment appears to be an effective method for achieving good clinical outcomes.

Long-term follow-up for ossification of autologous bone plug and skin sinking after periosteum-preserved burr hole surgery.

BACKGROUND: The demand of a burr hole surgery for chronic subdural hematoma (CSDH) is increasing in the global aging society. Burr hole-derived autologous bone dusts are not associated with extra costs compared with other commonly used synthetic materials. In addition, postoperative calvarium ossification requires periosteum-mediated blood supply, which is lacking after using avascular synthetic materials. Based on these findings, we hypothesized that the combination of the bone plugs and the preserved periosteum during burr hole surgeries for CSDH would induce efficient calvarium ossification. METHODS: We evaluated the long-term effects of bone plugs on the degree of ossification and cosmetic appearance of the skin covering the burr hole sites. We included 8 patients (9 burr holes) who received the autologous bone dust derived from burr holes. As the control group, 9 burr holes that did not receive any burr hole plugs were retrospectively selected. These burr holes were evaluated by computed tomography (CT) scan for the calvarium defect ratios, CT value-based ossification, and the degree of skin sinking. RESULTS: Ossification was observed in all the bone plugs by the bone density CT scans; they maintained their volume at 12 months after the surgeries. The calvarium defect ratios (volume ratios of the unossified parts in the burr holes) gradually increased during the first 6 months and reached 0.44 at 12 months. The mean CT values also increased from 527 HU to 750 HU for the first 6 months and reached 905 HU at 12 months. The degrees of skin sinking at the burr hole sites with the bone plugs were 1.24 mm whereas those without the bone plugs were 2.69 mm (P = 0.004). CONCLUSION: Application of burr hole-derived autologous bone dust is associated with better ossification and objective cosmetic result following burr hole surgery after CSDH.

Transfemoral Stenting of Stenoses at the Common Carotid Artery Origin Using an Anchoring Technique With a Balloon Protection Device.

BACKGROUND: Transfemoral stenting of stenoses at the common carotid artery (CCA) origin is technically difficult because of poor stability of the guiding catheter. OBJECTIVE: To describe an anchoring technique using a balloon protection device that provides excellent stability of the guiding catheter. METHODS: Four patients (5 stenotic lesions) with stenosis of the CCA origin underwent transfemoral stenting with a balloon protection device (PercuSurge GuardWire; Medtronic, Santa Rosa, California). These 5 stenotic lesions of the CCA origin included 1 on the right side and 4 on the left side. Two of the stenoses were symptomatic, and 3 were asymptomatic. A balloon-expandable stent (Express LD stent; Boston Scientific, Natick, Massachusetts) was used in all patients. RESULTS: All stenoses were successfully dilated. With the balloon protection device as an anchor in all patients, the guiding catheter was highly stable during the procedure. There were no intraprocedural or periprocedural ischemic complications in any patients. None of the patients developed a stroke during a mean follow-up period of 8.4 months. CONCLUSION: The anchoring technique using a balloon protection device is useful for transfemoral stenting of stenoses at the CCA origin. ABBREVIATIONS: CCA, common carotid arteryECA, external carotid arteryICA, internal carotid arteryPTA, percutaneous transluminal angioplasty.

Safe and accurate sylvian dissection with the use of indocyanine green videoangiography.

BACKGROUND: Sylvian dissection is an essential microneurosurgical skill for neurosurgeons. The safe and accurate opening of the sylvian fissure is desirable for a good prognosis. METHODS: The aim of this report is to demonstrate the use of indocyanine green (ICG) videoangiography to recognize the superficial sylvian vein (SSV) and thus enable a wide opening of the sylvian fissure, especially in patients with subarachnoid hemorrhage (SAH). RESULTS: The small tributary flowing into the SSV was distinguishable from a passing one, which deeply entered the insula. In addition, an entering point of a tributary to the SSV, which ran perpendicular to the insula, was occasionally determined. SSV, which was barely discernable in a reddish SAH involving the sylvian fissure, was clearly demarcated using ICG videoangiography. Two representative cases of sylvian dissection are herein presented. CONCLUSION: The performance of ICG videoangiography before sylvian dissection is a simple and useful method for identifying a vital approach route for safe and accurate sylvian dissection, and it reduces the risk of causing any accidental injury to the veins in the sylvian fissure.

A novel technique for identifying the fistulous point in a direct carotid-cavernous fistula.

The fistulous point in a direct carotid-cavernous fistula (CCF) can often be difficult to identify because of high-flow shunting. A novel technique that is useful for identifying the fistulous point is reported. A 71-year-old woman underwent endovascular therapy for a left direct CCF that presented with sudden diplopia and tinnitus. To identify the fistulous point, vertebral angiography with manual compression of the left carotid artery was attempted, as was slow injection of a contrast agent from a balloon guiding catheter, closing off the left internal carotid artery; however, the shunt flow was very rapid, and identification was not possible. Therefore, three-dimensional digital subtraction angiography of the vertebral artery was performed while also performing manual aspiration from the balloon guiding catheter, closing off the left internal carotid artery. This reduced early visualization of the cavernous sinus and enabled an aneurysm in the cavernous sinus to be clearly visualized. Embolization was performed transarterially and transvenously, and the shunt flow disappeared completely. Vertebral angiography combined with manual aspiration from a balloon guiding catheter closing off the internal carotid artery is useful for identifying the fistulous point in a direct CCF.

A case of angiographically occult, distal small anterior inferior cerebellar artery aneurysm.

BACKGROUND: A small aneurysm at an unusual location, such as a distal anterior inferior cerebellar artery (AICA) aneurysm, may conceal as a computed tomography angiography (CTA) and digital subtraction angiography (DSA)-occult aneurysm. CASE DESCRIPTION: We herein present the case of a patient suffering from a subarachnoid hemorrhage (SAH) with two aneurysms in which the AICA aneurysm was negative by CTA and DSA. CTA demonstrated a right anterior choroidal artery aneurysm, which was revealed to be an unruptured aneurysm after surgical exploration. A small distal AICA aneurysm was detected by 3D rotational angiography (3DRA). The patient fully recovered except for left-side hearing loss four months after the second operation. CONCLUSION: We recommend a meticulous diagnosis by 3DRA in patients with SAH in which the distribution is not coincident with a typical aneurysmal location.

Measuring platelet aggregation in dialysis patients with a whole blood aggregometer by the screen filtration pressure method.

A semi-automatic, whole-blood aggregometer based on the screen filtration pressure (SFP) method is now widely used clinically and in research, but has not been used with hemodialysis (HD) patients. We measured whole-blood platelet aggregation in HD patients by the SFP method. This retrospective cross-sectional study included 62 HD patients, of whom 47 were non-diabetic and 15 were diabetic; we also included a control group of healthy, non-uremic subjects. With the t-test, we examined differences in the platelet aggregation threshold index (PATI) in meaningful sub-groupings of the HD patients, depending on whether or not they had diabetes, and whether or not they had been given antiplatelet agents. Considering the non-diabetic HD patients first, their PATI values were significantly higher than those values in the control subjects (3.1 [1.0-5.2] vs. 1.8 [1.3-2.3] µM, P<0.001). The non-diabetic HD patients taking antiplatelet agents showed significantly (1.9 times) higher PATI values than the non-diabetic HD patients without antiplatelet agents (4.4 [1.8-7.0] vs. 2.3 [1.3-3.3] µM, P=0.003). We observed similar trends among diabetic HD patients. Whole-blood analysis by the SPF method seems to be a promising way of monitoring platelet function for HD patients.