Ruptured proximal middle cerebral artery traumatic pseudoaneurysm treated with bypass-assisted trapping surgery: A case report.

Background: Traumatic pseudoaneurysms are rare but have a high mortality rate; therefore, immediate diagnosis is vital. Most pseudoaneurysms are in the internal carotid artery or peripheral arteries, while proximal middle cerebral artery pseudoaneurysms have rarely been reported. We present a case of ruptured traumatic pseudoaneurysm located at the M1-M2 bifurcation. Case Description: A 42-year-old man was injured in a motorcycle accident and his Glasgow coma scale score on admission was 7 (Eye opening1, Verbal response2, Motor response4 [E1V2M4]). Head computed tomography (CT) showed thick subarachnoid hemorrhage (SAH). We suspected a ruptured aneurysm, but three-dimensional CT angiography (3D-CTA) did not detect any vascular defects. Head magnetic resonance angiography showed progressive right M1 stenosis suggesting arterial dissection. 3D-CTA on day 20 showed a small aneurysm in the proximal portion of the M2. Although surgery was scheduled for day 26, suddenly left hemiparesis appeared on day 24. Head CT detected fresh SAH and emergency surgery was performed on day 25. We dissected around the ruptured point under M1 temporary occlusion with superficial temporal artery-M2 assist bypass. Contrary to our expectations, there was only a small laceration in the right M2 superior trunk. We trapped the laceration and the proximal portion of the M2 superior trunk while preserving antegrade blood flow from the M1 to the M2 inferior trunk. On the 5-month follow-up, the patient was able to walk independently. Conclusion: Unreasonably thick traumatic SAH or spastic stenosis after head injury may indicate a traumatic pseudoaneurysm and require repeated neurovascular evaluation. If a pseudoaneurysm is detected, immediate surgical intervention is mandatory.

A case of middle cerebral artery large circumferential aneurysm treated with bypass-assisted trapping surgery.

M1 large circumferential aneurysms are clinically challenging because they cannot be treated by simple neck clipping and they may involve the lenticulostriate arteries (LSAs). Although some reports have described endovascular and direct surgical treatment of these aneurysms, the optimal treatment approach remains uncertain. We report a case involving a ruptured large M1 circumferential aneurysm that was treated with bypass-assisted trapping surgery and showed favorable outcomes. The patient was a 47-year-old man presenting with subarachnoid hemorrhage. Digital subtraction angiography revealed a large circumferential aneurysm in the right middle cerebral artery M1 segment with involvement of the lateral and medial LSAs. We successfully performed trapping surgery with the assistance of a superficial temporal artery (STA)-M2 bypass while preserving the medial and lateral LSAs. Although left hemiparesis caused by medial LSA thrombosis appeared in the early postoperative period, the patient showed good recovery from symptoms with rehabilitation and could independently perform daily activities at the five-month follow-up. The treatment of M1 large circumferential aneurysms should involve considerations for prevention of rebleeding, blood supply to the distal area, and preservation of perforating arteries. The treatment strategy for this challenging aneurysm should be planned based on the patient's condition and individual anatomy.

Catastrophic Propeller Brain Injury with Large Scalp Defect Treated with Omental Flap.

In this study, we report a case of catastrophic propeller brain injury with large scalp defect treated with omental flap reconstruction. A 62-year-old man was accidentally caught in a powered paraglider propeller during maintenance. The rotor blades impacted the left part of his head. On arrival at the hospital, he presented with a Glasgow Coma Scale score of E4V1M4. On some areas on his head, skin was noticeably cut off, and the brain tissue out-slipped through an open skull fracture. Continuous bleeding from the superior sagittal sinus (SSS) and the brain surface was observed during emergency surgery. Massive bleeding from the SSS was controlled using a number of tenting sutures and hemostatic agents. We evacuated the crushed brain tissue and coagulated the severed middle cerebral arteries. Dural plasty using the deep fascia of the thigh was performed. The skin defect was closed using an artificial dermis. The administration of high-dose antibiotics has failed to prevent meningitis. Moreover, the severed skin edges and fasciae were necrotic. Plastic surgeons performed debridement and vacuum-assisted closure therapy to promote wound healing. Follow-up head computed tomography revealed hydrocephalus. Lumbar drainage was performed; however, sinking skin flap syndrome was observed. After removing the lumbar drainage, cerebrospinal fluid leakage occurred. We then performed cranioplasty with a titanium mesh and omental flap on day 31. After the surgery, perfect wound healing and infection control were achieved; however, severe disturbance of consciousness remained. The patient was transferred to a nursing home. Primary hemostasis and infection control are mandatory. An omental flap has been determined to be effective in controlling infection by covering the exposed brain tissue.

Rare Dilated Collateral Circulation from Accessory Meningeal Artery to Inferolateral Trunk: A Case Report.

The accessory meningeal artery (AMA) demonstrates various potential anastomoses with the external (ECA) and internal (ICA) carotid arteries. However, rarely does the AMA markedly dilate and compensate for ICA blood flow. A 52-year-old woman with nonspecific symptoms was diagnosed with multiple cerebral aneurysms and abnormal blood vessels observed on magnetic resonance angiography. Digital subtraction angiography revealed four aneurysms and anastomoses between the left AMA and inferolateral trunk (ILT). In addition, two sequential severe flexions were observed in the cervical portion of the left ICA. No ischemic lesions were detected on magnetic resonance imaging. In conclusion, we experienced a rare case in which the AMA-ILT anastomosis was highly developed. This case also presented with the unusual characteristics of an anomaly in the extracranial ICA and multiple aneurysms.

Abnormal foreshortening of a Flow Re-Direction Endoluminal Device caused by in-stent thrombosis immediately after deployment.

Thromboembolic complications are a concern in the treatment of cerebral aneurysms using a flow diverter. In this study, we report a case of abnormal foreshortening of a Flow Re-Direction Endoluminal Device (FRED) caused by in-stent thrombosis immediately after its deployment. A 72-year-old woman had a large cavernous carotid aneurysm, which caused ptosis and diplopia. FRED deployment was planned, and dual antiplatelet therapy was initiated 2 weeks before the procedure. Under systemic heparinization, FRED was deployed with local compaction over the aneurysm orifice. Cone-beam computed tomography subsequently revealed slightly poor wall apposition at the proximal side. While the balloon catheter was prepared for angioplasty, the stent became abnormally foreshortened, the proximal side slipped into the aneurysm, and the internal carotid artery became occluded. FRED was removed using a snare wire, and recanalization was obtained. The lumen of the removed FRED was filled with thrombus. The antiplatelet therapy was changed to triple regimen, and a Pipeline Flex embolization device was placed 1 month later. At that time, no thromboembolic complications were noted. It was considered that thrombotic occlusion was followed by foreshortening of FRED on the distal side because of antegrade blood flow. Multiple factors, such as increased mesh density by locally compacted stent deployment, slightly poor wall apposition, clopidogrel resistance, and the dual-layer structure of FRED, may have been involved in thrombus formation.

A case of symptomatic carotid artery occlusion after aortic arch replacement treated with carotid-carotid crossover bypass.

Background: Symptomatic common carotid artery (CCA) occlusion is rare and its treatment remains unestablished. Although cases of subclavian-to-carotid bypass have been reported, very few cases of carotid-tocarotid crossover bypass have been reported, despite its advantages. We report a case of Riles type 1A symptomatic CCA occlusion after aortic arch replacement that was treated with carotid-to-carotid crossover bypass with favorable outcomes. Case Description: A 65-year-old woman with a history of hypertension, hyperlipidemia, diabetes, and total arch replacement for thoracic aortic aneurysm was admitted to our hospital with a complaint of the right hemiparesis and motor aphasia. Head magnetic resonance imaging revealed a fresh infarction in the left cerebral hemisphere. Cervical computed tomography (CT) angiography revealed left CCA occlusion. Thoracic CT angiography showed severe stenosis of the left subclavian artery. SPECT showed a general decrease in blood flow in the left cerebral hemisphere. We performed a carotid-to-carotid crossover bypass with a synthetic graft that was passed through the subcutaneous tunnel. First, the right carotid artery-synthetic graft end-to-side anastomosis was performed. Subsequently, we performed synthetic graft-left CCA end-to-side anastomosis. The postoperative course was uneventful. Cervical computed tomography angiography showed perfect patency of the crossover bypass. The patient recovered almost completely and was independently performing daily activities. Conclusion: Carotid-to-carotid crossover bypass is a durable treatment for symptomatic CCA occlusion. Further studies are needed to compare its outcomes with those of other methods and to confirm our findings with larger sample size.

A Case of Proximal Posterior Inferior Cerebellar Artery (PICA) Aneurysm Treated with PICA-to-PICA Bypass and Trapping Surgery: Comparison with Occipital Artery-PICA Bypass.

Posterior inferior cerebellar artery (PICA) aneurysms often require cerebral vascular reconstruction for surgical treatment because of their characteristic morphology. Despite its potential complications, the occipital artery-to-posterior inferior cerebellar artery (OA-PICA) bypass is a typical treatment because of its versatility. Although a few cases of intracranial-to-intracranial bypass have been reported, this type of vascular reconstruction is only regarded as an alternative to the OA-PICA bypass because of the uncertainty of bypass feasibility and potential risk of ischemic complications. In this article, we report a case of proximal PICA ruptured aneurysm that was treated with a PICA-to-PICA (PICA-PICA) bypass. A 79-year-old man presented with a chief complaint of sudden, severe headache and disturbances in consciousness. Radiological examination revealed a right proximal PICA fusiform aneurysm. The patient had many systemic disorders such as microscopic polyangiitis and steroid-induced diabetes mellitus that could have caused wound dehiscence and cerebrospinal fluid (CSF) leakage. We performed the PICA-PICA bypass and trapping surgery rather than the OA-PICA bypass to avoid skin problems and CSF leakage. The postoperative course was uneventful, and the patient was discharged on day 64 without any neurological disorders. In comparison with the OA-PICA bypass, the PICA-PICA bypass is less likely to cause CSF leakage and skin complications, although it carries the risk of specific ischemic complications and requires advanced surgical techniques. For some patients with systemic disorders, the PICA-PICA bypass could be an optimal treatment option for proximal fusiform PICA aneurysms rather than as an alternative to the OA-PICA bypass.

Evaluation of the differences in pressure applied to the vessel wall by different types of balloon remodeling microcatheters in an experimental model.

BACKGROUND: We examined compliance differences among balloon remodeling microcatheters, which have not been established previously. METHODS: Straight and 120° angulated vascular models were created in a 3 mm diameter tube with 3 mm hole (vascular model A), a tube with a 4 mm hole (vascular model B), and a 4 mm diameter tube (vascular model C). We compared the pressure exerted when each balloon was herniated 1 or 2 mm between three compliant balloons (SHOURYU SR, TransForm C, and Scepter C) and four super-compliant balloons (HyperForm, SHOURYU HR, TransForm SC, and Scepter XC). RESULTS: In vascular model A, there was a significant difference in the pressure exerted by compliant balloons and super-compliant balloons in both the straight and angulated models. In the straight model (1 and 2 mm), the lowest pressure was exerted by HyperForm (super-compliant balloons group) and SHOURYU SR (compliant balloons group). The lowest pressure was exerted in the angulated model by HyperForm (super-compliant balloons group) and Scepter C (compliant balloons group). The Scepter balloon exerted higher pressure in the straight model than other balloon remodeling microcatheters but less in the angulated model. In vascular model B, the pressure decreased in all balloons compared with model A. In vascular model C, the pressure increased in all balloons compared with model A. CONCLUSIONS: Pressure differed across balloon remodeling microcatheters. In addition, vessel shape and diameter, and hole size, affected the results. Our findings can help select balloon remodeling microcatheters.

Anterior Communicating Artery Aneurysm with a Peculiar Angiographic Appearance: A Case Study.

We describe a case of pulsatile anterior communicating artery aneurysm (A-com AN) with a peculiar angiographic appearance. An 81-year-old man was referred to the department of neurosurgery for a large A-com AN artery aneurysm, which was detected incidentally. The patient hoped not to be treated but to be followed up. After 4 months, magnetic resonance imaging (MRI) revealed the presence of a cerebral edema and hematoma around the aneurysm, and partial thrombus in the upper wall of the aneurysm was suspected. Based on these findings, the patient underwent an immediate coil embolization a day after admission. However, the portion of the neck remnant increased in size after the first procedure. Therefore, 8 months after the initial procedure, he was treated with stent coil embolization. Contrary to the first procedure, angiographic evaluation revealed an active pulsating aneurysm. Moreover, MRI revealed the presence of a partial thrombus in the upper neck segment of the aneurysm, with an intensity that changed over time. The patient underwent cautious treatment and was discharged without any symptoms. This is the first case study to reveal an A-com AN with active pulsation and the relationship between the pulsatile portion of the aneurysm and thrombosed portion by MRI.

Analysis of relationship between superior hypophyseal artery visualization and preservation and postoperative visual field deficit in paraclinoid aneurysm.

Direct surgery for paraclinoid aneurysms can result in visual field deficit owing to compromised blood flow to the superior hypophyseal artery (SHA). However, it is rarely visualized in angiography, and discussions regarding its preservation in the field of neuro-endovascular treatment are limited. Biplane angiographic suite with high spatial resolution has been used at our institution since 2014. Since then, there were a few cases where SHAs could be visualized via digital subtraction angiography. We retrospectively analyzed the relationship between the presences and abscence of SHAs in paraclinoid aneurysms and post-procedural visual field deficit. Sixty-three paraclinoid aneuryms treated by neuro-endovascular procedure in 2014-2018 at our neurosurgery department were analyzed. Pre- and post-procedural multiplanar reconstruction imagings of three-dimensional rotation angiography were analyzed to retrospectively investigate the SHAs. SHAs were visualized in 26 patients (41%) and the median number of pre-procedurally visualized SHAs was 0 (interquartile range 0-1). Their origins were the aneurysmal necks in 11 patients (42%). In two of the 11 cases, they were noticed before coil embolization and were able to be preserved after the procedure. In the remaining nine cases, they were not pre-procedurally detected, and coiling was normally conducted. Visual field deficit occurred in one of these nine cases, but symptoms were transient, and the patient fully recovered. Because SHAs could be visualized in >40% cases and no visual field defects occurred in cases that SHAs could be identified and preserved preoperatively, we recommend their preservation during coil embolization for paraclinoid aneurysms.

Management of Asymptomatic Vertebral Artery Injury Caused by a Cervical Pedicle Screw Malposition: Two Case Reports.

Iatrogenic vertebral artery (VA) injury in cervical fusion is an extremely rare complication but can lead to serious sequelae. We present two successful cases of internal trapping for preventing delayed-onset ischemic stroke after iatrogenic VA stenosis caused by a cervical pedicle screw. A 34-year-old female underwent posterior cervical fusion for C4/C5 dislocation fracture. No neurological deficits were observed after the operation. However, the postoperative images revealed that the left C5 pedicle screw perforated the transverse foramen, and the left VA was suspected to be occluded at the screw insertion site. Before revision surgery, we tried to embolize the injured VA with coils. A microcatheter could be navigated from the ipsilateral VA to the distal of the screw, and internal trapping was performed with coils. Another case is that of a 50-year-old male with cervical spondylosis, who underwent posterior decompression and cervical fusion. The neurological symptoms did not deteriorate after the operation. However, the postoperative computed tomography images revealed the perforation of the right C3 transverse foramen by the pedicle screw. In right vertebral angiography, about 70% stenosis was observed at the screw insertion site. Although revision surgery was not planned due to good stability, we embolized the right VA after balloon occlusion test, to prevent the delayed-onset thromboembolic complications. Both the patients recovered without any neurological deficits. Iatrogenic VA injuries, even if asymptomatic immediately after surgery, can lead to serious sequelae in case of delayed-onset ischemic stroke. Therefore, careful attention should be paid when the screw perforates the transverse foramen.

Results of Mechanical Thrombectomy in Patients Aged ≥80 Years.

Objective: The effectiveness of mechanical thrombectomy (MT) for anterior circulation large vessel occlusion (LVO) is controversial in elderly patients. The aim of this study was to evaluate the efficacy of MT in octogenarians. Methods: One hundred and sixty-five patients who underwent MT for anterior circulation LVO between May 2014 and August 2019 at our institution were evaluated. Patients were divided into two groups, the elderly group (≥80 years) and non-elderly group (<80 years), and we compared the effective recanalization rate (Thrombolysis in Cerebral Infarction 2b-3), good outcome rate (modified Rankin Scale 0-2 at 90 days), time from groin puncture to recanalization (P to R), symptomatic intracranial hemorrhage (sICH), and mortality rate between them retrospectively. Eligible patients for MT were judged using the Japanese stroke guidelines, and the selection criteria were more carefully applied to elderly patients. Results: MT was performed on 48 elderly patients (29.1%) and 117 non-elderly patients (70.9%). On the other hand, 10 elderly patients (19.6%) and 5 non-elderly patients (5.4%) did not undergo MT even though they met the inclusion criteria. There were significantly fewer male patients and smokers in the elderly group, but other baseline and clinical characteristics were not significantly different between the groups. Effective recanalization (elderly 93.8% vs non-elderly 91.5%), good outcome (45.8% vs 60.7%), P to R (33.5 minutes vs 33.5 minutes), sICH (2.1% vs 4.3%), and mortality (8.3% vs 2.6%) were not significantly different between the two groups. Conclusion: When recanalization was achieved by strict preoperative evaluation of clinical conditions and imaging, MT may be safe and effective even for octogenarians or older patients.

Efficacy of Respiratory Control under Local Anesthesia during Endovascular Therapy in the Tortuous Vertebral Artery with the Use of Respiratory Dislocation of the Aortic Arch.

Purpose: Endovascular therapy (EVT) through the tortuous access route is increasingly performed in neurovascular procedures. In the posterior circulation through the vertebral artery (VA), ischemic complications, including vessel dissection and cerebral vessel infarction, are sometimes observed, especially during navigation of the guiding catheter, because of small vessel diameter and tortuous origin. We describe an adjunctive technique for passing the guiding catheter safely to the tortuous VA and reducing ischemic complication using respiratory displacement of the aortic arch. Case Presentations: The guidewire is advanced to the origin of the VA until it is caught in the tortuosity. Then we instruct the patient to take a maximum deep inspiration and hold his or her breath. In this manner, the aortic arch and side branches are dislocated to the caudal direction, which reduces the tortuosity of the VA origin and facilitates passage of the guidewire. Here, we discuss three representative cases which demonstrate that our techniques are effective in navigating the catheter to the tortuous VA. Conclusion: In the EVT of a patient who has a tortuous VA, respiration control under local anesthesia, maximum deep inspiration, and breath holding induce the respiratory dislocation of the aortic arch. This enables safe navigation of the guiding catheter, reduces the likelihood of interruption in blood flow, and helps avoid dissection and ischemic complications during EVT.

Direct Vertebral Artery Puncture During Open Surgery for the Endovascular Treatment of a Recurrent Vertebro-Vertebral Arteriovenous Fistula.

BACKGROUND: Vertebro-vertebral arteriovenous fistula (VVAVF) is a condition in which there is an arteriovenous shunt directly connecting the extracranial vertebral artery to the vertebral venous plexus. Many reports have described fistula occlusion or vertebral artery trapping as treatments for VVAVF. Here, we describe a case in which endovascular treatment for recurrent VVAVF using a transfemoral approach was unsuccessful; thus, the vertebral artery (VA) was directly punctured during open surgery and the treatment was successful. CASE DESCRIPTION: The patient was a 47-year-old female who had undergone endovascular treatment for VVAVF. The patient developed subarachnoid hemorrhage. Digital subtraction angiography revealed a left VVAVF. The left VA was trapped with coils at the C2 and C3 levels and an arteriovenous shunt formed from the VA between the 2-coil mass to the vertebral venous plexus. In addition, reflux was observed in the spinal vein. Endovascular treatment was attempted with a transfemoral approach, but we could not reach the shunt. Five days post-treatment, the patient had a second subarachnoid hemorrhage and surgery was performed to occlude the radiculomedullary vein; however, residual reflux went into the spinal vein from another spinal level. Later, the VA was directly punctured and treated with N-butyl cyanoacrylate, and the shunt disappeared. CONCLUSIONS: Direct puncture of the vertebral artery was useful in this case, where it was difficult to reach the lesion. Although direct VA puncture is associated with more complications than the transfemoral or transbrachial approach, it may be an option when other methods are difficult.

A case of internal trapping to a thrombosed giant rapidly growing aneurysm at the posterior cerebral artery.

We describe a case of internal trapping including the vasa vasorum for a thrombosed giant rapidly growing posterior cerebral artery aneurysm and performing a detailed analysis. A 48-year-old woman was followed up in our hospital for a thrombosed large posterior cerebral artery aneurysm located in the P2 segment. She initially presented after experiencing a sudden headache on two occasions. Head computed tomography and magnetic resonance imaging indicated a larger aneurysm than before. Digital subtraction angiography with balloon occlusion test was assessed, and internal trapping was sequentially conducted. We detected that the vasa vasorum originated from the posterior temporal artery. Therefore, we embolized the posterior temporal artery including the vasa vasorum using N-butyl-2-cyanoacrylate and Lipiodol. Next, the anterior temporal artery was embolized with N-butyl-2-cyanoacrylate and Lipiodol, posterior temporal artery P3 segment and the aneurysm and finally the proximal P2 segment were embolized with coils. Final vertebral and internal carotid angiography showed complete obliteration of the aneurysm. On the day after the procedure her paresis worsened and she developed left upper quadrantanopia, however was finally discharged with no hemiparesis. We reported a case of a rapidly growing thrombosed giant posterior cerebral artery aneurysm treated by parent artery occlusion including the vasa vasorum with detailed image analysis.

Cardiac Arrest Induced by Carotid Sinus Reflex Activation During Flow-Diverter Stent Deployment.

BACKGROUND: A 60-year-old female with multiple carotid aneurysms underwent endovascular treatment with a Pipeline Flex embolization device (PED) under local anesthesia via femoral puncture. CASE DESCRIPTION: Cardiac arrest occurred when the delivery systems were pushed to promote adequate opening and apposition of the PED against the vessel wall and was recovered to sinus rhythm in approximately 30 seconds by pulling down the microcatheter. The carotid sinus reflex was suspected as the cause of this temporary asystole. Delivery of the PED was accompanied by application of forward pressure on the delivery system. This resulted in buckling of the delivery systems in the neck and likely excessive pressure on the carotid sinus. The procedure was continued and successfully completed with care not to excessively push the system and with the additional use of atropine. CONCLUSIONS: Although it was a rare complication, the phenomenon and its mechanisms were known in the carotid artery stenting procedure. To the best of our knowledge, this is the first report of cardiac arrest induced by a carotid sinus reflex during PED deployment. It is important for an operator of PED deployment to recognize its possibility. Vital signs should be closely checked during PED deployment, particularly while pushing the catheter.