Coil Embolization for Asymptomatic Low-grade Vertebral Artery Injury which Worsened after Cervical Decompression Surgery: A Case Report.

Introduction: Blunt cervical injuries rarely cause vertebral artery injuries (VAIs), such as vertebral artery (VA) dissection or occlusion. To prevent subsequent embolic infarction, embolization of the injured VA is needed before surgical fixation of the cervical spine. However, evidence on endovascular treatment for asymptomatic low-grade VAIs with blunt traumatic cervical injury is insufficient. Case Report: In the present case, a 79-year-old Japanese man presented tetraparesis after falling while walking. Digital subtraction angiography showed no intimal flap and only slight stenosis of the right VA. Embolization was not performed before spinal decompression surgery for this low-grade injury. However, on the 3rd day after surgery, diffuse-weighted imaging showed dot-like high signal intensity in the right thalamus and right posterior lobe, and magnetic resonance angiography (MRA) showed near occlusion of the right VA. 8 days after surgery, MRA showed recanalization of the right VA flow. We performed VA embolization to prevent emboli scattering to the distal region during recanalization of the intracranial blood flow. Conclusion: According to the relevant literature, prophylactic embolization may be indicated to prevent the embolic infarction not only in cases of VA occlusion requiring fixation of the cervical spine but also in cases of low-grade VAIs in which fixation is not required. Embolization of the VA before spinal surgery might be an aggressive treatment strategy that avoids serious embolic infarction disorder after VAIs.

Mixed Germ Cell Tumor with a Yolk Sac Tumor Component in the Medulla Oblongata of a 50-year-old Patient: A Case Report and Literature Review.

Yolk sac tumor (YST) is a rare primary brain tumor that occurs almost exclusively in patients under 30 years old. Intracranial germ cell tumors are most frequently located in the pineal and suprasellar region. Medulla oblongata YSTs are particularly rare. Extragonadal YSTs may be difficult to diagnose because of their characteristics, such as the rarity and variety of growth patterns. Furthermore, they are known to have a very poor prognosis. We herein report a case of YST of the medulla oblongata in a 50-year-old woman. She was followed up for 18 months without any tumor recurrence.

Expression of Angiopoietins and Angiogenic Signaling Pathway Molecules in Chronic Subdural Hematomas.

Chronic subdural hematoma (CSDH) is an angiogenic disease that is involved with many inflammatory mediators. Tie2 is predominantly expressed in the embryonic endothelium and plays an important role in the maturation and stabilization of the vasculature. Angiopoietin (Ang)1 and Ang2 are well-known ligands of the Tie2 receptor. We examined the expression of Ang1 and Ang2 in CSDH fluid and the expression of Tie-2 receptor and components of the angiogenic signaling pathways in the outer membrane of CSDH. Twenty-five samples of CSDH fluid and eight samples of outer membrane of CSDH were included. The concentrations of Ang1 and Ang2 in the CSDH fluid were measured using enzyme-linked immunosorbent assay (ELISA) kits. The expression of Tie2, phosphoinositide 3-kinase (PI3K), protein kinase B (Akt) mechanistic target of rapamycin (mTOR), GßL, 70 kDa ribosomal protein S6 kinase (p70S6K), eukaryotic initiation factor 4E (eIF-4E), and ß-actin was examined by a Western blot analysis. The expression of Tie2, Akt, and mTOR was also examined by immunohistochemistry. The concentration of Ang2 in CSDH fluid was significantly higher than that in the serum or cerebrospinal fluid (CSF), and also higher than that of Ang1 in CSDH fluid. Tie2, PI3K, Akt, mTOR, GßL, p70S6K, and eIF-4E were detected in all cases. In addition, Tie2, Akt, and mTOR were localized in the endothelial cells of vessels in the CSDH outer membrane. Our data suggest that Ang2, although not Ang1, in CSDH fluid promotes angiogenesis in endothelial cells through the Tie2 receptor. The Ang2/Tie2 signaling pathway might therefore be a useful therapeutic target for treating the growth of intractable CSDH.

Spinal Subdural Hematoma owing to the Removal of Cerebrospinal Fluid Drainage Tube During Thoracic Endovascular Aortic Repair.

BACKGROUND: Cerebrospinal fluid (CSF) drainage during the treatment of aortic disease is commonly performed to prevent spinal cord ischemia. Spinal subdural hematoma (SDH) has never been reported after CSF drainage during thoracic endovascular aortic repair (TEVAR). We present a case of concurrent intracranial subarachnoid hemorrhage (SAH) and spinal SDH after CSF drainage tube removal in a patient with TEVAR. CASE DESCRIPTION: A 73-year-old man was hospitalized to undergo TEVAR. The day before the procedure, a lumbar CSF drainage tube was inserted. Continuous CSF drainage was performed only during the procedure, and the tube was removed the following day. The patient complained of mild back pain on postoperative day 2; headache, bilateral lower limb paresis, and bladder and rectal disturbances developed on postoperative day 5. Brain and spinal magnetic resonance imaging revealed spinal subdural or subarachnoid hematoma and intracranial SAH. Lumbar laminectomies for spinal SDH removal were performed; lower limb strength improved immediately after surgery. At postoperative 2 years, the patient returned to his preoperative activity level; only mild right lower limb numbness persisted. CONCLUSIONS: We present a rare case of intracranial SAH and spinal SDH that developed after CSF drainage tube removal in a patient with TEVAR. CSF drainage should be carefully considered in patients undergoing aortic procedures, as SAH and spinal SDH may occur in addition to spinal cord ischemia.

Efficacy of Endovascular Proximal Occlusion before Direct Reposition Surgery of Blunt Cervical Fracture with Unilateral Vertebral Injury.

Cerebral infarction related to traumatic vertebral artery (VA) injuries is not common. However, if VA injuries cause ischemic and/or hemorrhage stroke, these subsequent problems can result in severe residual impairment and mortality. Herein, we present five patients with cervical vertebra fractures due to blunt cervical trauma who underwent preoperative endovascular therapy. Between June 2010 and April 2018 in our hospital, five patients with traumatic occlusion of a unilateral VA underwent coil embolization to prevent post-surgical stroke due to reperfusion in the VA. Because of cervical instability or subluxation, all of the patients received endovascular therapy before surgery for their cervical fracture. None of the patients presented with stroke after presurgical embolization and direct surgery. When stagnated blood, including thrombi, in the occluded VA is released during cervical surgery, brain embolism may occur. Therefore, early cerebrovascular vessel assessment and presurgical endovascular treatment must be considered to prevent stroke after direct surgery.

Efficacy of three-dimensional rotational fluoroscopic unit guidance for lumbar cerebrospinal fluid drainage among patients with unsuccessful initial attempt at bedside.

Lumbar cerebrospinal fluid drainage has been widely performed in patients at the bedside; however, technical failure can occasionally occur as a result of blind maneuvering. Herein, we present the use of rotational fluoroscopic unit-guided lumbar drainage for patients with an unsuccessful initial attempt at bedside. In four of the 24 patients with aneurysmal subarachnoid hemorrhage, initial lumbar drainage could not be performed at bedside. Thus, a three-dimensional rotational technology guided by a high-quality fluoroscopic unit was used. After a cone-beam computed tomography scan was performed, an accurate puncture point and a target thecal sac were identified using the software. The fluoroscopic unit helped us to identify the puncture point and trajectory with a laser pointer on the patient. A needle was inserted along the tract until the cerebrospinal fluid was collected. The lumbar drainage tube was successfully inserted with a single puncture in all four patients. Rotational fluoroscopic technology helps to identify a suitable puncture point, trajectory and target site for lumbar spinal drainage. Our technique is considerably useful in an era wherein minimally invasive procedures are preferred.

Bilateral Vertebral Artery Dissection and Unilateral Carotid Artery Dissection in Case of Ehlers-Danlos Syndrome Type IV.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a rare genetic connective tissue disorders, but the vascular type (type IV) typically poses the greatest risk to patients. We report a case of multiple cranial artery dissection, which was successfully treated with carotid artery stenting. CASE DESCRIPTION: A 50-year-old woman presented with recurrent severe headaches caused by bilateral vertebral artery dissections that were treated conservatively at our hospital. However, she developed right cervical pain and dizziness at 3 days after admission, and a magnetic resonance angiogram revealed dissection of the right internal carotid artery. Because the dissected portion of the artery had narrowed, a stent was placed. The pearl and string formations in the bilateral vertebral arteries then improved spontaneously. Subsequently, the patient was diagnosed with EDS type IV via a skin biopsy, and review of her family history revealed that multiple family members had suffered from subarachnoid hemorrhages. No neurologic deficits were observed, and the patient was discharged without further events at 30 days after admission. CONCLUSIONS: It is extremely rare for multiple artery dissections to occur at the same time. EDS type IV should be considered as an important differential diagnosis in similar cases, even in adult patients without a known history of connective tissue disease or vascular complications.

Novel Technique for Rapid and Accurate Insertion of a Microguidewire Tail Into Low-Profile Devices During Endovascular Procedures: The Paper Rail Method.

PURPOSE: To report a novel technique ("paper rail") to facilitate inserting the tail of a microguidewire into the tip of a low-profile device during endovascular procedures. TECHNIQUE: A sterilized nonwoven fabric tape with a smooth glossy paper backing is used. The tape has several linear folds ideal for a paper rail. Holding each piece of equipment about 5 cm from its respective tip, both the tail of the guidewire and the tip of the catheter are navigated at a 30° angle toward each other in the crease until the guidewire enters the catheter. The paper rail technique was compared with the conventional freehand method under varying luminosities found in an operating room. The paper rail technique was most effective in suboptimal lighting, where the mean time was reduced from 83 seconds with the conventional method to 20 seconds with the paper rail maneuver. The times required to insert the wire with the paper rail method were comparable (~22 seconds) at all light levels. CONCLUSION: The paper rail method may help improve the speed and accurate insertion of the tail of a microguidewire into the tip of low-profile devices during endovascular procedures. It may be particularly useful for physicians in a low-light environment or trainees.

Treatment of Ruptured Vertebral Artery Dissection and Abdominal Hemorrhage Associated with Segmental Arterial Mediolysis Using Endovascular Coil Embolization.

BACKGROUND: Segmental arterial mediolysis is a rare disease characterized by idiopathic noninflammatory vasculopathy involving small to medium arteries. Here, we report a case of ruptured cerebral and abdominal aneurysms, which were successfully treated using emergency endovascular coil embolization. CASE DESCRIPTION: A 45-year-old male suffered subarachnoid hemorrhage caused by the rupture of the right vertebral artery dissecting aneurysm, which was treated using emergency endovascular coiling. Iatrogenic dissection of the left vertebral artery occurred during the procedure. A stent was placed, and antivasospasm therapy was initiated after operation. Eight days after admission, the patient experienced sudden hypovolemic shock because of an abdominal hemorrhage, which was diagnosed as the rupture of an aneurysm in the accessory middle colic artery and treated with urgent coil embolization. CONCLUSIONS: It is extremely rare for a subarachnoid and an abdominal hemorrhage to occur simultaneously during hospitalization. Here, owing to the vulnerability of the unaffected vertebral artery during the initial procedure, segmental arterial mediolysis was diagnosed.

Novel Vertebral Artery Flow Reversal Method for Preventing Ischemic Complication during Endovascular Intervention.

BACKGROUND AND PURPOSE: We report a secure endovascular approach for the treatment of vascular lesions of the posterior circulation. Even if a large profile guide catheter is wedged in the unilateral vertebral artery (VA), our VA flow reversal method can prevent ischemic complications, including the spinal cord infarction. CASE PRESENTATION: The patient was a 64-year-old woman who had been followed up for arteriovenous malformation (AVM) and an unruptured aneurysm of the basilar artery-superior cerebellar artery bifurcation. Endovascular treatment was performed because minor bleeding occurred from the AVM. When a 6-French guide catheter was navigated into the right VA, the guide catheter became completely wedged, and blood flow between the tip of the catheter and the VA union was fully stagnated. Because ischemia of the anterior spinal artery and right posterior inferior cerebellar artery could persist for a few hours during the endovascular procedure, we built a continuous reversal circulation from the guiding catheter tip to the femoral vein. The flow stagnation disappeared immediately. There was no complication during embolization of both the AVM and aneurysm. CONCLUSIONS: The VA flow reversal method was secure in this case in which the tip of the guide catheter became wedged in the VA during the endovascular procedure.

Efficacy of the proximal balloon flow control method for endovascular coil embolisation as a novel adjunctive technique: A retrospective analysis.

Background and purpose In our previous study, we established the utility of 8-F balloon guide catheters for anterior circulation aneurysms. This study aims to assess the efficacy of the proximal flow control method using 8-F balloon guide catheters for coil deployment into the aneurysms as a novel adjunctive technique for aneurysmal coil embolisation along with local balloon neck remodeling, stent assist and double catheter techniques. Materials and methods We retrospectively analysed patients who underwent endovascular coiling of anterior circulation aneurysms between August 2013 and December 2017. Results Of 206 patients enrolled in this study, the balloon of the guiding catheter was inflated to assist coil deployment in 43 patients (20.9%). In addition, the proximal flow control method found utility in cases with small aneurysms and relatively narrow-necked internal carotid artery. We observed no intraprocedural complications in this study. Conclusion This technique enabled secure coil deployment without navigating another microcatheter or balloon catheter around the aneurysms.

Posterior inferior cerebellar artery with an extradural origin from the V3 segment: higher incidence on the nondominant vertebral artery.

OBJECTIVE The posterior inferior cerebellar artery (PICA) and the vertebral artery (VA) often exhibit anatomical variations at the craniovertebral junction (CVJ). An example of this is the PICA originating extradurally from the V3 segment of the VA. To date, some cadaveric investigations have been reported, but the incidence and relationship of this variation to the VA and the atlas as observed on clinical imaging have not been discussed. This study evaluated the prevalence of PICAs originating from the V3 on CT scanning. Other variations of the atlas and VA were also analyzed. METHODS CT images from a series of 153 patients who underwent 3D CT angiography (CTA) were analyzed, and variations of the PICA, VA, and atlas were investigated. RESULTS A total of 142 patients (284 sides) were analyzed; 11 patients (7.2%) were excluded due to poor image quality. The most common VA variation was the PICA originating from V3 (9.5% of 284 sides), which was more frequently observed on the nondominant VA than the dominant VA (22.5% vs 6.25%, p = 0.0005). A VA with a PICA end was identified in 4 sides (1.4%), which is the same incidence as observed in the persistent first intersegmental VA (1.4%). VA fenestration was only found in 1 side (0.35%). Regarding the atlas, ponticulus posticus was observed in 24 sides (8.5%). There was no relationship between the incidence of ponticulus posticus and the variations of the VA. CONCLUSIONS A PICA originating from V3 was the most common VA variation at the CVJ and was more common on the nondominant VA. Three-dimensional CTA is useful for the evaluation of this variance. Surgeons should be mindful of this variation during operations.

[Multi-Layered Closure of Transorbital Penetrating Brain Injury without Bone Reconstruction: A Case Report].

A 26-year-old man was injured in a motor vehicle accident. He sustained a compound orbital fracture with brain contusion. The brain tissue protruded through the orbit. Computed tomography showed a long contusion with a moderate amount of hematoma in the right frontal lobe. No foreign body was observed in the cranium. On 3D CTA, the major cerebral vessels were found to be intact. An urgent surgery was first performed by neurosurgeons and subsequently by ophthalmologists. The periosteum was left on the skull. A frontal periosteal, a right temporal fascial, and a right temporal muscular flap were prepared. After debridement and irrigation, the dural tear was closed with the right periosteal and fascial flaps. Finally, the frontal fascia was used to cover the orbital defect. The patient's clinical course was favorable. The patient was able to walk when discharged 46 days after the surgery. A penetrating brain injury through the orbit is rare, and its treatment is not established. A key to successful management of this injury is immediate assessment. Foreign bodies in the cranium, especially metal, should be checked for immediately. The cerebral vessels should also be evaluated. Usually, a surgical intervention is necessary. Since bone reconstruction can be associated with a risk of infection, a multi-layered closure, as described in this report, could prevent leakage of cerebrospinal fluid and subsequent meningitis.