Mechanical Thrombectomy Using a Large Dual-Layer Stent Retriever for Near-Occlusion of the Common Carotid Bifurcation Caused by a Giant Free-Floating Thrombus.

Objective: We report a case of near-occlusion of the common carotid bifurcation caused by a giant free-floating thrombus (FFT) successfully treated with mechanical thrombectomy using a large dual-layer stent retriever. Case Presentation: A 51-year-old man presented to our hospital with dysarthria, right hemiparalysis, and paresthesia. MRI revealed an acute infarction of the left cortical watershed zone, and MRA revealed decreased signals in the left common carotid bifurcation. Carotid ultrasonography demonstrated a giant FFT in the left common carotid bifurcation. Angiography revealed a giant thrombus extending from the left common carotid artery (CCA) to the internal carotid artery (ICA) and the external carotid artery. As direct aspiration from both a balloon-guided catheter (BGC) and an aspiration catheter (AC) was ineffective, we deployed a large dual-layer stent retriever from the ICA to the CCA with an AC-connected aspiration pump and retrieved it under manual aspiration through the BGC. The giant thrombus was successfully removed, and complete recanalization was achieved without distal embolisms. Conclusion: Although there is no established treatment for giant thrombi in the carotid artery, mechanical thrombectomy using a large dual-layer stent retriever may be an effective treatment option.

Endovascular coil embolization of proximal middle cerebral artery aneurysms has better outcomes than other middle cerebral artery aneurysms: A retrospective study.

PURPOSE: Although some authors proposed that coil embolization in middle cerebral artery (MCA) aneurysms is a useful and effective alternative, the characteristics of the aneurysms may be different at each location. We compared the results of coil embolization of proximal middle cerebral artery aneurysms with those of other middle cerebral artery aneurysms. METHODS: Data from 46 patients with 50 aneurysms were retrospectively evaluated. We defined the aneurysms inside of the insular cortex as proximal MCA (pMCA) aneurysms and those outside of the insular cortex as non-proximal MCA (npMCA) aneurysms. The results of the occlusion were divided into classes 1, 2, and 3 of the Raymond scale. We collected the results of the occlusion from the operative notes supplied by a neuroendovascular specialist. RESULTS: Univariate analysis identified favorable results for pMCA aneurysms (class 1: pMCA = 22 npMCA = 11; P < 0.01). In the radiological follow-up results, we achieved class 1 in 29 patients (69%; pMCA = 21 and npMCA = 8; P < 0.01). Side wall type aneurysms (pMCA = 14, npMCA = 2; P < 0.01) and the number of branches from the neck of ≤1 (pMCA = 14, npMCA = 2; P < 0.01) were significantly recognized at the pMCA. CONCLUSIONS: Proximal middle cerebral artery aneurysm clipping is difficult because the origin of the lenticulostriate arteries is often hidden behind the aneurysmal dome. In the present study, endovascular coil embolization for pMCA aneurysms obtained better results than that for npMCA aneurysms because of the morphological characteristics. Endovascular coil embolization seems to be efficacious for pMCA aneurysms as compared with npMCA aneurysms.

Flow-Diverter Stent for an Unruptured Aneurysm at the Junction of the Internal Carotid Artery and Persistent Primitive Trigeminal Artery: Case Report and Literature Review.

BACKGROUND: Persistent primitive trigeminal artery (PPTA), which is a fetal carotid-basilar anastomosis, is the most common embryologic vascular remnant persisting in adults. Aneurysms can arise between the internal carotid artery (ICA) and PPTA. Here we present a case of ICA-PPTA aneurysm treated with a flow-diverter stent. CASE DESCRIPTION: A 52-year-old woman had left abducens nerve palsy. Imaging detected a large left ICA-PPTA aneurysm, which we chose to treat with a flow-diverter stent after embolizing the PPTA with a coil. Although the abducens nerve palsy did not change, there were no signs of cerebral infarction, and no new symptoms appeared postoperatively. Blood flow in the aneurysm had disappeared on digital subtraction angiography after 6 months. CONCLUSIONS: This is the first case report of ICA-PPTA aneurysm successfully treated with a flow-diverter stent. We could stop blood flow from the posterior circulation by embolizing the PPTA with a coil, allowing the use of a flow-diverter stent. This report can be used as a reference for the procedure in future work.

Progressive edematous lesions in subacute phase after neuroendovascular therapy.

BACKGROUND: The appearance of edematous lesions in the subacute phase is a rare complication following neuroendovascular therapy. Effective management of these lesions remains unclear. In this report, a case with progressive edematous lesions in the subacute phase after neuroendovascular therapy was described, and the clinical features and therapeutic strategies were discussed. CASE DESCRIPTION: A 54-year-old female with a large, right cavernous internal carotid artery aneurysm was treated with a flow diverter. Left hemiparesis developed 15 days after the procedure, and multiple edematous lesions in areas of prior catheter procedures were revealed on radiological findings. Steroid pulse therapy was employed, and the lesions were gradually reduced without any additional neurological deficits. No recurrence was recognized in the follow-up study. CONCLUSION: In some reports, pathological findings indicate that these lesions result from the presence of foreign bodies, and emboli could be caused by cotton fibers or hydrophilic polymers used as surface coatings on endovascular catheters. In this case, the edematous lesions were most likely caused by hydrophilic polymer emboli. Steroid pulse therapy had a beneficial effect on the lesions. It is important to effectively manage prescribed periods after the procedure to avoid such a rare complication.

3D-FIESTA Magnetic Resonance Angiography Fusion Imaging of Distal Segment of Occluded Middle Cerebral Artery.

Middle cerebral artery (MCA) occlusion was examined with basi-parallel anatomical scanning (BPAS) using three-dimensional fast imaging employing steady-state acquisition (3D-FIESTA), and 3D-FIESTA and magnetic resonance angiography (MRA) fusion images were created. We expected that an incidence of hemorrhagic complications due to vessel perforations would be decreased by obtaining vascular information beyond the occlusion and thus acute endovascular revascularization could be performed using such techniques. We performed revascularization for acute MCA occlusion for five patients who were admitted in our hospital from October 2012 to October 2014. Patients consisted of 1 man and 4 women with a mean age of 76.2 years (range: 59-86 years). Fusion images were created from three-dimensional time of flight (3D-TOF) MRA and 3D-FIESTA with phase cycling (3D-FIESTA-C). Then thrombectomy was performed in all the 5 patients. Merci retriever to 1 patient, Penumbra system to 1, urokinase infusion to 2, and Solitaire to 1 using such techniques. In all cases, a 3D-FIESTA-MRA fusion imaging could depict approximately clear vascular information to at least the M3 segment beyond the occlusion. And each acute revascularization was able to perform smoothly using these imaging techniques. In all cases, there was no symptomatic hemorrhagic complication. It showed that 3D-FIESTA MRA fusion imaging technique could obtain vascular information beyond the MCA occlusion. In this study, no symptomatic hemorrhagic complications were detected. It could imply that such techniques were useful not only to improve treatment efficiency but also to reduce the risk of development of hemorrhagic complications caused by vessel perforations in acute revascularization.

Usefulness of acellular dermal graft as a dural substitute in experimental model.

BACKGROUND: Friction injury of cortical surface or cerebrospinal fluid leakage are the major complications of polytetrafluoroethylene (ePTFE) duraplasty because of their strong surface tension and lesser adaptability. Autologous duraplasties are also accompanied by potential donor-site complications and are inappropriate for large defects. Acellular Dermal Graft (ADG), prepared from cadaver human skin, does not have the above-mentioned drawbacks because of its human nature. Moreover, the dermal basement membrane and supporting tissues remain intact, so the rate of cellular migration and transformation to the surrounding host tissue is supposed to be excellent. We studied ADG in canine model to observe the rate of transformation into the surrounding dura mater via collagen synthesis from the invaded fibroblasts to evaluate its usefulness as a duraplasty. METHODS: Dural grafting surgery was performed on 6 adult mongrel dogs weighing from 8 to 12 kgs under general anesthesia. Three dogs were sacrificed after 1 month (acute) of surgery and the other three (chronic) were sacrificed after 3 months with overdose of pentobarbital sodium. Transcardiac perfusion-fixation with 4% paraformaldehyde was done. Hematoxylin-eosin and trichrome masson stains were performed to see the graft cellularity. Thickness of grafts was also assessed along the length of the histologic sections. RESULTS: Duralization, which was microscopically characterized by infiltration with regular array of collagen fibers, was observed at a few places in every high-power field in acute group. But in chronic animals, where dermal side of ADG was facing towards cranium, duralization was excellent. CONCLUSIONS: Our result suggests that ADG can be considered as a useful dural substitute.

A case of definitely congenital glioblastoma manifested by intratumoral hemorrhage.

BACKGROUND: A female infant was born with a left-sided glioblastoma that manifested clinically with weakened crying and feeding on day 1 of life, fever and bulging anterior fontanel on day 4, and right hemiparesis by day 10. METHODS: Preoperative magnetic resonance imaging showed hemosiderin intensity indicating that hemorrhage had occurred during the prenatal period. Radical surgical removal of the tumor was performed on the 22nd postnatal day. RESULTS: Postoperatively, the right hemiparesis did not worsen and the patient did not have any new neurological deficits. The right hemiparesis gradually improved after her initial surgery, and she was able to stand by herself at 18 months of age. Adjuvant chemotherapy and radiation were administered. This patient survived for 27 months following birth, which is a relatively long time for glioblastoma cases. Radical removal at the first operation with reliance on the plasticity of infant cerebral function was the key point in the long survival.

Phenotypic modulation of smooth muscle cells and vascular remodeling in intraparenchymal small cerebral arteries after canine experimental subarachnoid hemorrhage.

Cerebral microcirculatory changes are an important factor regulating cerebral blood flow. The aim of this study was to investigate the possibility of phenotypic modulation of smooth muscle cell (SMC) and vascular remodeling of intraparenchymal small cerebral arteries after subarachnoid hemorrhage (SAH). Seven to 14 days after canine experimental SAH, in intraparenchymal perforating arteries, the amount of beta-actin mRNA evaluated by Northern blot analysis increased, the structural change of the 3' untranslated region of beta-actin mRNA detected by polymerase chain reaction analysis was enhanced, and immunohistochemistry showed marked induction of the embryonal isoform of myosine heavy chain accompanied by decreased expression of smooth muscle myosin heavy chain (SM2). Histological morphometric analysis showed an increase in the area of the arterial wall without changes in the number of nuclei of SMC. This is the first report suggesting that vascular remodeling accompanied by phenotypic modulation occurs in intraparenchymal small arteries. These changes may affect cerebral blood flow after SAH by inducing increased cerebrovascular resistance.

Pituitary abscess showing high uptake of thallium-201 on single photon emission computed tomography--case report.

A 32-year-old female presented with a rare case of pituitary abscess manifesting as homonymous hemianopsia. Serum prolactin level was slightly high (40.8 ng/ml). Magnetic resonance (MR) imaging showed the content of the lesion as homogeneously isointense on the T1-weighted images and hyperintense on the T2-weighted images. The capsule of the lesion, which appeared thin and smooth, was enhanced by gadolinium. Dural enhancement around the sella turcica was also recognized. Thallium-201 single photon emission computed tomography (201Tl SPECT) showed homogeneous high accumulation in the pituitary region on both the early and delayed images. The lesion was treated via a transnasaltranssphenoidal approach. The cystic lesion contained pus and the capsule consisted of normal pituitary gland with inflammatory changes. The patient was treated with antibiotics for 3 weeks and the pituitary abscess was cured completely. Pituitary abscess can be differentiated from pituitary adenoma as lesion with a homogeneous high uptake on 201Tl SPECT on both the early and delayed images, and no enhancement of the central portion on MR images.

Role of basic fibroblast growth factor in the course of cerebral vasospasm in an experimental model of subarachnoid hemorrhage.

The goal of this study was to investigate the relationship between basic fibroblast growth factor (bFGF) and the course of cerebral vasospasm after subarachnoid hemorrhage (SAH), using an immunohistochemical method. Female Sprague-Dawley rats were sacrificed by perfusion fixation 10 min, 6 h, 1, 2, 3, 4, 7 or 14 days after a single intracisternal injection of fresh autologous arterial blood. Morphometric analysis of lumen cross-sectional areas of blood vessels were determined by computerized image analysis. Results were expressed as percent lumen patency, defined as the ratio of the area of vessel patency in SAH rats to the area of patency in control rats. An immunohistochemical analysis against bFGF was performed using the avidin-biotin-peroxidase technique. The immuno-reactivity of bFGF was observed with the aid of a light microscope and semiquantitatively graded. Basilar arterial spasm was greatest 10 min after SAH (mean decrease: 67.1% of the control values; p < 0.001). Subsequently, there was a significant degree of spasm of the artery for three days after SAH, followed by full recovery at day 4. A slight increase in immunoreactivity was observed in the intima only at 10 min and one day after SAH. In the media, immunoreactivity showed a biphasic pattern; a significant increase in immunoreactivity was observed at 10 min that persisted for two days after SAH. At three days after SAH, immunoreactivity in the media returned to the control level, but then gradually increased significantly to reach a maximum at 14 days after SAH while the vascular dimensions were normal. Immunohistochemical analysis failed to show a direct relationship between bFGF and the course of cerebral vasospasm in this rat single-hemorrhage model. However, the late phase upregulation of bFGF might lead to the vascular angiopathy, fibrosis or hyperplasia during the chronic stage of SAH.

Dissecting aneurysms of intracranial carotid circulation.

BACKGROUND AND PURPOSE: Clinical features of nontraumatic dissecting aneurysms of intracranial carotid circulation remain unclear because investigation of this disease has been limited to case reports. The aim of this study was to investigate the clinical features of this disease through the use of cooperatively collected cases. METHODS: The cases diagnosed as dissecting aneurysms of intracranial carotid circulation on the basis of clinical signs and neuroradiological findings in 46 stroke centers from 1995 through 1999 were collected, and their clinical features were analyzed. RESULTS: Forty-nine cases of dissecting aneurysms of intracranial carotid circulation were collected. Thirty-two patients presented with subarachnoid hemorrhage (SAH), and 17 presented with cerebral ischemia. The ratio of this disease to all intracranial dissecting aneurysms treated in the same institutes for the same period was 19.1%, and the ratio of SAH resulting from this disease to SAH of unverified origin treated in the same institutes for the same period was 6.2%. The predominant site of lesion was the internal carotid artery in 18 of 32 patients (56%) with SAH and the anterior cerebral artery in 13 of 17 patients (76%) with cerebral ischemia. The predominant angiographic findings were that stenosis with dilatation occurred in 20 of 32 patients (63%) with SAH and stenosis without dilatation was seen in 11 of 17 patients (65%) with cerebral ischemia. Poor prognosis was seen in 21 of 32 patients (66%) with SAH, which was due largely to rebleeding seen preoperatively, during operation, and even postoperatively when clipping or wrapping of the aneurysmal bulge was performed. CONCLUSIONS: Nontraumatic dissecting aneurysm of intracranial carotid circulation is not as rare as expected. It seems to be one of the important causes of SAH of unverified origin.