Mobile endovascular therapy for acute treatment of ruptured vertebral artery dissecting aneurysm in multiple hospitals.

BACKGROUND: The patients with ruptured vertebral artery dissecting aneurysm (rVADA) should be treated as early as possible because VADA carries extremely high risk of rebleeding in the acute phase. We have established a mobile endovascular strategy for the patients with rVADA between our flagship center and its affiliated local hospitals. We introduced and reviewed our mobile endovascular therapy in this study. METHODS: We retrospectively evaluated 98 consecutive patients who underwent endovascular surgery for rVADA from 2000 to 2018 at our institution or five affiliated hospitals. When each patient was initially transported to the local affiliated hospitals, neuroendovascular surgeons traveled directly to the affiliated hospital from the flagship center in order to treat the patient there. Clinical outcomes using modified Rankin Scale at 6 months after treatment, radiological results, and procedure-related complications were reviewed to justify our mobile endovascular strategy. RESULTS: All aneurysms were cured successfully by internal trapping. Favorable outcome was achieved in 61 patients (62.2%) even though 53 patients (54.1%) had presented with severe subarachnoid hemorrhage. Overall mortality rate, treatment-related mortality rate, and treatment related complication rate were 18.4% (18/98), 0%, and 16% (16/98), respectively. There were no differences in clinical and radiological outcomes between the patients treated in the flagship center and those who treated in the affiliated hospitals. Treatment in the affiliated hospital was not a predictive factor of unfavorable outcome in our multivariate analysis, and elderly age (≥ 60) was negatively associated with favorable outcome. CONCLUSIONS: Our results prove the efficacy and safety of mobile endovascular therapy for the treatment of rVADA in the ultra-acute stage. Mobile endovascular therapy may work well in the acute treatment of rVADAs in the certain circumstance.

Mikulicz Disease Mimicking Intraorbital Tumors.

We report a case of Mikulicz disease (MD), an immunoglobulin G4 (IgG4)-related disease that affects the lacrimal and salivary glands. IgG4-related disease is a relatively new clinical entity and is not commonly encountered by neurosurgeons. MD sometimes mimics intraorbital tumors such as malignant lymphoma but responds well to corticosteroid treatment. Thus it is important to recognize the clinical and radiographic features of MD.

[Cavernous sinus dural arteriovenous fistulas treated with percutaneous transvenous embolization using liquid material: two case reports].

INTRODUCTION: Percutaneous transvenous embolization (TVE) using coils is a well-established treatment of cavernous sinus dural arteriovenous fistula (CSdAVF). However, it is sometimes difficult to achieve complete occlusion by coil embolization. In these two cases, we were able to obtain complete angiographic obliteration of the fistulas without complications by means of percutaneous TVE using n-butyl-cyanoacrylate (NBCA) after we failed when TVE using coils. Case 1: An 89-year-old woman presented with double vision. She was diagnosed as Barrow type D right CSdAVF draining only to the cortical vein. We treated the patient by TVE using coils, but the microcatheter was withdrawn before complete occlusion was attained. The repositioning of the microcatheter was difficult, so we used 30% NBCA for TVE, and obtained complete obliteration of the fistula. Case 2: An 87-year-old woman presented with right exophthalmos, and chemosis. She was diagnosed as Barrow type C right CSdAVF draining only to the right superior ophthalmic vein with very slow flow. We planned to treat her, using TVE with coils, but we could place only 3 coils and obtained only partial obliteration of the fistula. So we additionally used 25% NBCA for TVE, and obtained complete obliteration of the fistula. CONCLUSION: Compared to TVE using coils, TVE using NBCA gives rise to many problems, but, we can use NBCA as a second option if TVE using coils results in only partial obliteration as in these cases.

Surgical treatment of a lenticulostriate artery aneurysm. Case report.

A previously healthy 61-year-old man presented with basal ganglia hemorrhage caused by rupture of a small aneurysm arising from the distal lenticulostriate artery associated with moyamoya-like disease and manifesting as left hemiparesis and dysarthria. The patient underwent frontotemporal craniotomy. Neck clipping of the aneurysm was performed through the hematoma cavity. He was transferred for rehabilitation with left hemiparesis. Three-dimensional computed tomography angiography was very useful for preoperative planning and evaluation of the anatomical correlation between the aneurysm and the hemorrhage.

Persistent primitive trigeminal artery-cavernous sinus fistula with intracerebral hemorrhage: endovascular treatment using detachable coils in a transarterial double-catheter technique. Case report and review of the literature.

Intracerebral hemorrhage occurred in this 61-year-old woman with preexisting diplopia and proptosis. Results of angiography demonstrated a persistent primitive trigeminal artery (PPTA)-cavernous sinus fistula with cortical venous reflux. Two microcatheters were introduced transarterially through the PPTA into the two draining pathways in the cavernous sinus. Coils were delivered in both pathways simultaneously to prevent further venous overload on either path. The fistula was successfully occluded without complication while the PPTA was preserved. The authors describe this double-catheter technique for coil embolization of a fistula and review the literature concerning PPTA-cavernous sinus fistulas.

Ruptured vertebral artery dissecting aneurysm associated with parent artery occlusion.

A 63-year-old hypertensive man presented with vertebral artery (VA) dissection manifesting as subarachnoid hemorrhage located mainly in the posterior fossa. Left vertebral angiography on the day of hemorrhage showed complete occlusion of the left VA. Right vertebral angiography showed retrograde filling of the distal portion of the left VA and the left posterior inferior cerebellar artery, and a "double lumen"-like finding in the left VA. He was managed conservatively. Follow-up angiography on Day 29 showed spontaneous recanalization of the occlusive lesion and an almost normal arterial configuration. T2-weighted magnetic resonance (MR) imaging on Day 45 revealed multiple infarctions in the brainstem. T1-weighted MR imaging showed a high intensity area, suggestive of intramural hematoma, in the left VA. He was transferred to another hospital in a persistent vegetative state.