bluuebunny/crossref_metadata_2025 huggingface dataset:
Fatal Hemorrhage in Cerebral Proliferative Angiopathy
Authors: Maekawa H. , Tanaka M. , Hadeishi H.
Published: January 2017

Cerebral proliferative angiopathy (CPA) is a rare vascular abnormality with several angiomorphological features that are distinct from brain arteriovenous malformations (AVMs). The natural history of CPAs indicates a lower risk for hemorrhage compared to brain AVMs. A 62-year-old woman presented with gait instability and dysarthria. MRI and angiography revealed a diffuse vascular network involving the tectum and cerebellar vermis with intermingled brain parenchyma. This lesion had no dominant feeder, high-flow arteriovenous shunt, flow-related aneurysm or highly dilated veins on angiogram. These findings were consistent with a diagnosis of CPA. During follow-up, she developed progressive gait instability and eye movement abnormalities, but no remarkable change was detected on the repeated MRI and angiography. Nine years later, she died of mesencephalic hemorrhage originating from the CPA. To the best of our knowledge, this is the first description of a patient with CPA who died as a result of the initial hemorrhage. It is important to recognize that a part of CPAs is aggressive and can be more vulnerable to critical hemorrhage.
Direct Percutaneous Carotid Artery Stenting for a Patient with Absence of the Common Carotid Artery
Authors: Toyota S. , Wakayama A. , Yoshimine T.
Published: January 2017

A 54-year-old man with symptomatic internal carotid artery stenosis with absence of the common carotid artery (CCA), who had been treated with surgery and postoperative radiotherapy for tonsillar carcinoma, underwent direct percutaneous carotid artery stenting (CAS). To our knowledge, this is the first report of direct percutaneous carotid artery stenting (CAS) for a patient with absent CCA.
Giant Extracranial Aneurysm of the Internal Carotid Artery in Neurofibromatosis Type 1
Authors: Moratti C. , Andersson T.
Published: January 2017

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by cutaneous pigmentations, neurofibromas, Lisch nodules and neuroectodermal tumors. Supra-aortic vessel aneurysms may affect patients with NF-1 and can be associated with rupture, ischemic complications and compression symptoms. We describe a 48-year-old woman with NF-1 and an extracranial 3×5 cm right internal carotid artery aneurysm. After balloon test occlusion the patient was treated with parent artery sacrifice which led to significant shrinkage on follow-up MR and reduction of compression symptoms. The literature concerning internal carotid artery aneurysms associated with NF-1 is reviewed evaluating the possible therapeutic options.
Traumatic Pseudoaneurysms of the Common Carotid and Vertebral Artery in a Four-Year-Old Child
Authors: Mahmoud M. , Roshdi E. , Benderbous D.
Published: January 2017

Pseudoaneurysms of the neck arteries are rare lesions usually traumatic and less frequently infectious in origin. They are often described as case reports. We describe here an unusual occurrence of pseudoaneurysms in the common carotid and vertebral artery in a four-year-old child victim of a stab wound in the neck treated by parent artery occlusion of the vertebral and common carotid arteries.
A 6-Fr Guiding Catheter (Slim Guide®) for Use with Multiple Microdevices
Authors: Kai Y. , Ohmori Y. , Watanabe M. , Kaku Y. , Morioka M. , Hirano T. , Yano S. , Kawano T. , Hamada J-I. , Kuratsu J-I.
Published: January 2017

A modified technique is required in patients with wide-necked aneurysms whose treatment by the single microcatheter technique is difficult. We developed a 6-Fr guiding catheter (Slim Guide®) that features a large lumen (0.072 inch) for performing the modified technique. To evaluate the usefulness of Slim Guide® we carried out experiments using three types of 6-Fr guiding catheter.

In experiment 1, the shaft hardness and kink resistance were compared among three different guiding catheters (Slim Guide®, Launcher®, Envoy®). In experiment 2, we inserted a microballoon catheter and a microcatheter into the three different guiding catheters and recorded the maximal infusion pressure. In experiment 3, we inserted 13 different types of microdevices into the three different guiding catheters and evaluated the resistance of the microdevices.

Although the shaft of the Slim Guide® was softer than that of the other two guiding catheters, its kink resistance was comparable. The maximal infusion pressure was significantly lower than with Launcher® or Envoy® catheters. Furthermore, with Slim Guide®, in 136 of 143 microdevice combinations examined (95.1%) there was no resistance; this was true for 125 (87.4%) and 116 (81.1%) combinations using the Launcher® - and the Envoy® guiding catheters, respectively. There was a significant difference between Slim Guide® and the other two guiding catheters with respect to their accommodation of double microsystems (p<0.05).

Although the inner diameter of Slim Guide® is slightly larger than of the other two guiding catheters, it significantly increased the combination of microdevices that could be used for the coil embolization of difficult aneurysms.
A Technical Note
Authors: Pereira V.M. , Marcos-Gonzalez A. , Radovanovic I. , Bijlenga P. , Narata A.P. , Moret J. , Schaller K. , Lovblad K.O.
Published: January 2017

Ruptured cerebral arteriovenous malformations (AVMs) usually require treatment to avoid re-bleeding. Depending on the angioarchitecture and center strategy, the treatment can be surgical, endovascular, radiosurgical or combined methods. The classic endovascular approach is transarterial, but sometimes it is not always applicable. The transvenous approach has been described as an alternative for the endovascular treatment of small AVMs when arterial access or another therapeutic method is not possible. This approach can be considered when the nidus is small and if there is a single draining vein. We present a technical note on a transvenous approach for the treatment of a ruptured AVM in a young patient.
Taiwan Aneurysm Registry: Multivariate Analysis of Two-Month, One-Year, and Two-Year Outcomes after Endovascular and Microsurgical Treatment of Ruptured Aneurysms
Authors: Liu H-M. , Wong H-F. , Lee K-W. , Tu Y-K. , Yeh Y-S. , Chou C-W. , Wang Y-H. , Chen Y-L. , Lo Y-L. , Hsieh T-C. , Wang Y-C. , Lin T-K. , Lai D-M. , Chen W-L. , Tseng H-M. , Li C-W.
Published: January 2017

We compared the outcomes of endovascular coiling with microsurgical clipping of aneurysms in a Taiwanese population.

In an ambi-directional cohort design, patient baseline characteristics and clinical course after treatment for ruptured subarachnoid aneurysm were abstracted from medical records from three hospitals to examine and compare differences in post-operative outcomes between those treated with endovascular coiling and those treated with microsurgical clipping. Outcomes were measured, using the modified Rankin scale, two months, one year and two years postoperatively.

Of the 642 patients enrolled in the study, 281 underwent endovascular treatment and 361 underwent neurosurgery. The demographics and baseline characteristics of two groups were comparable except for a larger maximum target aneurysm lumen size (p=0.02) in the endovascular group. Patients who underwent the endovascular procedure tended to have a better quality of life than those who had neurosurgery (p<0.01). When the severity of symptom data was pooled into two groups (Rankin values 0–2 and 3–6) a statistically significant relationship was found between the severity of symptoms and age, Hunt and Hess grade, number of target aneurysms detected, and log of maximum target aneurysm lumen size (all p≤0.01). After controlling for potential confounding factors and using the lumped Rankin outcome data, no significant difference in outcome was found between the two procedures at either time point.

Our study indicated that endovascular coiling achieves results comparable to surgical clipping for patients with ruptured subarachnoid aneurysms in a Taiwanese population.
Peri-Procedural Morbidity and Mortality Associated with Stent-Assisted Coiling for Intracranial Aneurysms
Authors: Wang K. , Sun Y. , Li A-M.
Published: January 2017

Despite experience and technological improvements, stent-assisted coiling for intracranial aneurysms still has inherent risks. We evaluated peri-procedural morbidity and mortality associated with stent-assisted coiling for intracranial aneurysms.

Patients with cerebral aneurysms that were broad-based (>4 mm) or had unfavorable dome/neck ratios (<1.5) were enrolled in this study between February and November 2011 at our center. Aneurysms were treated with the self-expanding neurovascular stents with adjunctive coil embolization.

Seventy-two consecutive patients (27 men and 45 women; 22–78 years of age; mean age, 52.8 years) underwent 13 procedures for 13 ruptured aneurysms and 64 procedures for 73 unruptured aneurysms. Nine [11.7%, 95% CI(4.5%–18.9%)] procedure-related complications occurred: one and eight with initial embolization of ruptured and unruptured aneurysms, respectively. Complications included six acute in-stent thromboses, one spontaneous stent migration, one post-procedural aneurysm rupture, and one perforator occlusion. Three complications had no neurologic consequences. Two caused transient neurologic morbidity, two persistent neurologic morbidity, and two death. Procedure-related neurologic morbidity and mortality rates, respectively, were as follows: overall, 5.2% (95%CI, 0.2%–10.2%) and 2.6% (95%CI, 0%–6.2%); ruptured aneurysms, 7.7% (95%CI, 0%–36%) and 0% (95%CI, 0%–25%); unruptured aneurysms, 4.7% (95%CI, 0%–9.9%) and 3.1% (95%CI, 0%–7.3%). Combined procedure-related morbidity and mortality rates for ruptured and unruptured aneurysms were 7.7% (95%CI, 1.7%–13.7%) and 7.8% (95%CI, 1.8%–13.8%), respectively.

Stent-assisted coiling is an attractive option for intracranial aneurysms. However, stent-assisted coiling for unruptured aneurysms is controversial for its comparable risk to natural history.
Management Considerations in Ruptured Isolated Radiculopial Artery Aneurysms
Authors: Van Es A.C.G.M. , Brouwer P.A. , Willems P.W.A.
Published: January 2017

Little is known on the natural history of ruptured isolated aneurysms of the posterior spinal artery (PSA). To date, only a few of such cases have been described in the literature. This paper aims to assess the most appropriate management strategy, based on the available literature and two new cases. In one of these, treatment was postponed until day 33, when angiography showed slight growth of the aneurysm. In the other, conservative treatment, requested by the patient, was successful. From these data, we conclude that treatment strategies for ruptured PSA aneurysms may vary. Aside from the recommendation by others to perform prompt surgical treatment, we suggest an alternative clinical paradigm allowing for the evaluation of the early clinical course. This may preclude the unnecessary treatment of spontaneously regressing lesions and still allows for appropriate treatment for persistent lesions.
Unilateral Rete Mirabile as a Result of Segmental Agenesis of the Ascending Petrous Segment of the Internal Carotid Artery: Embryology, Differential Diagnosis and Clinical Implications
Authors: Lin E. , Linfante I. , Dabus G.
Published: January 2017

We describe an extremely rare case of unilateral rete mirabile in a young woman and discuss its significance in embryological development as well as its radiological aspects, differential diagnosis and potential clinical implications.
Targeted CT-Guided Epidural Blood Patch for Treatment of Spontaneous Intracranial Hypotension Due to Calcified Intradural Thoracic Disc Herniation
Authors: Agarwal V. , Sreedher G. , Rothfus W.E.
Published: January 2017

Calcified thoracic intradural disc herniations have recently been reported as a cause of spontaneous intracranial hypotension (SIH). We report successful treatment of SIH with a targeted CT-guided epidural blood patch.

A 57-year-old man presented to the emergency department with a two-week history of progressively debilitating headache. CT and MRI of the brain showed findings consistent with intracranial hypotension and MRI of the spine showed findings consistent with CSF leak. Subsequent CT myelogram of the thoracic spine confirmed the presence of CSF leak and calcified disc herniations at the T6-7, T7-8 and T8-9 levels indenting the ventral dura and spinal cord. The calcified disc herniation at T6-7 had an intradural component and was therefore the most likely site of the CSF leak. Under CT fluoroscopic guidance, a 20-gauge Tuohy needle was progressively advanced into the dorsal epidural space at T6-7. After confirmation of needle tip position, approximately 18cc of the patient's own blood was sterilely removed from an arm vein and slowly re-injected into the dorsal epidural space. With satisfactory achievement of clot formation, the procedure was terminated. The patient tolerated the procedure well. The next morning, his symptoms had completely resolved and he was neurologically intact. At five-week follow up, he was symptom-free.

Targeted epidural blood patch at the site of presumed CSF leak can be carried out in a safe and effective manner using CT fluoroscopic guidance and can be an effective alternative to open surgical management in selected patients.
A Simplified Pull-Through Angioplasty Technique without a Snare Device
Authors: Matsumoto Y. , Nakai K. , Tsutsumi M. , Iko M. , Oishi H. , Eto H. , Mizokami T. , Nii K. , Aikawa H. , Kazekawa K.
Published: January 2017

The pull-through angioplasty technique allows stable wire tension and stabilization of the device during the procedure. In this technique, a guide wire is passed from one sheath to another, usually with the aid of a snare device. We describe the treatment of occlusive subclavian artery disease and lesion at the origin of the vertebral artery employing a brachiofemoral pull-through technique without using a snare device. In this technique, the guide wire is advanced from the femoral artery to the brachial artery. The guide wire is directly inserted into the sheath placed at the brachial artery. The brachial artery is compressed proximal to the point of sheath insertion to prevent bleeding. The sheath is extracted temporally and the guide wire is caught outside of the body. The sheath is then introduced again through the guide wire. We used the pull-through technique without a snare device in seven cases, and we were able to build the pull-through system in six of these cases without a snare device. This pull-through technique without a snare device is not difficult to use, and may reduce the time and cost of angioplasty procedures.
Evaluation of Operator Radioprotection Using a New Injection Device during Vertebroplasty
Authors: Nguyen-Kim L. , Fargeot C. , Beaussier H. , Payen S. , Chiras J.
Published: January 2017

This study aimed to evaluate the protection granted by a simple device (X'TENS®, Thiebaud, France) and to provide operators with information on the performance of this new device, which has not yet been assessed. Our assumption is that this device efficiently reduces the radiation dose to the operator.

In a prospective clinical study, the radiation dose the operator's hand receives has been assessed using a specific sensor (UNFOR Instrument). Each patient included in the study was to receive at least two injections of cement during the procedure. Exposure was measured with and without the range extender. The data collected were then processed using a Wilcoxon matched pairs test.

During 14 interventions, 20 vertebrae were treated with both procedures. Eleven women and three men were included. Seven patients underwent vertebroplasty for metastatic lesions and seven for osteoporotic lesions, bone fractures or vertebral compressions. The average injection time was 1.35 minutes with the device and 1.20 without (p=0.75). The dose to the hand per ml injected was 111.37 vs. 166.91 (p<0.05).

Theoretically, the protection granted by the range extender depends on the length of the device. Our results are consistent with the inverse-square law. However, the variations in our results indicate that a proper and rigorous use is mandatory for the device to be effective. Given that radioprotection during fluoroscopy procedures is a frequently raised issue, the need for information for a safer practice increases likewise.
Aneurysm Rupture after Endovascular Flow Diversion: The Possible Role of Persistent Flows through the Transition Zone Associated with Device Deformation
Authors: Darsaut T.E. , Rayner-Hartley E. , Makoyeva A. , Salazkin I. , Berthelet F. , Raymond J.
Published: January 2017

Haemorrhagic complications can occur following aneurysm treatment with flow diverters (FD), but the underlying mechanism remains unknown. We describe a case where deformation of the device may have contributed to the complication.

A patient with a giant, previously unruptured cavernous aneurysm that extended intracranially to cause oedema of the internal capsule was treated with flow diversion. Treatment was followed by multiple episodes of peri-aneurysmal haemorrhages within eight days. A deformation of the device which occurred where it curved to cross the aneurysm neck created residual flows which, in the presence of a stent stenosis immediately beyond the neck, may have contributed to the observed ruptures. Following multiple haemorrhages the patient subsequently died.

Autopsy demonstrated early red thrombus partially bridging the struts of the flow diverter, and intra-aneurysmal thrombus of various ages. Microscopic pathology showed an aneurysm wall consisting of collagen infiltrated with neutrophils, but the wall was absent near the cerebral peduncle, adjacent to the brain haemorrhage.

Radiographs of the extracted specimen confirmed deformation of the FD construct, located at the transition zone of the stent, leading to increased pore size and porosity. The site of the deformation correlated with the angiographic presence of a continued blood inflow jet into the aneurysm.

Stent deformation at the transition zone may promote persistent blood entry into the aneurysm, and in turn potentially contribute to haemorrhagic complications.
Endovascular Treatment of Unruptured A1 Segment Aneurysms
Authors: Xiaochuan Huo , Xiaoyun Sun , Youxiang Li , Ning Guan , Wenshi Guo , Junsheng Luo
Published: January 2017

Aneurysms of the A1 segment of the anterior cerebral artery (A1A) are rare and challenging to treat. Less information is available regarding their management by endovascular approach. We evaluated our experience of endovascular treatment in 15 patients with unruptured A1As.

We retrospectively reviewed unruptured A1As treated by embolization at our hospital. The clinical data and angiographic results were reviewed. A special technique involving shaping microcatheter tips was used for catheterization.

From September 2009 to December 2012, 15 patients presenting with unruptured A1As were identified. All the patients were treated by selective embolization including five patients with balloon-assisted coiling (BAC) or stent-assisted coiling (SAC). These adjunctive techniques were used to catheterize the sac safely or to protect a branch at the neck. According to the location and direction of the aneurysm, “Z-shaped”, “S-Shaped” or “U-Shaped” microcatheter tip shaping was used for microcatheter positioning and stabilization. All patients showed an excellent clinical outcome. A complete aneurysm occlusion was obtained in all the patients.

Endovascular treatment of A1As is feasible and associated with good results. Because of their location and close relationship with perforators, endovascular treatment of A1As sometimes requires the use of BAC or SAC. The microcatheter tip shaping technique is very important for coiling. Our results suggest that endovascular treatment is a suitable therapeutic option for unruptured A1As when the aneurysm size is optimal for embolization.
Coil Embolization of Intracranial Aneurysm in Polyarteritis Nodosa
Authors: Gupta V. , Chinchure S.D. , Goel G. , Jha A.N. , Malviya S. , Gupta R.
Published: January 2017

Polyarteritis nodosa (PAN) is a rare multisystem disease characterized by systemic necrotizing arteritis of small and medium size arteries. The skin, joints, kidneys, gastrointestinal tract and peripheral nerves are most commonly involved. Although aneurysms are commonly seen in the visceral vessels, intracranial aneurysms are rare with 15 reported cases. The intracranial aneurysms are usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. The aneurysms were usually small, although large cavernous aneurysms were reported in one case. Treatment guidelines are not clear regarding the management of these cases. Most patients were treated conservatively by medical management with surgical excision performed in only two cases and coiling done in one patient with cavernous aneurysms. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported.

We describe the case of a 22-year-old woman, a known case of PAN who presented with subarachnoid hemorrhage. Cerebral angiogram showed a ruptured right middle cerebral artery bifurcation aneurysm along with unruptured left middle cerebral, right posterior communicating and left posterior inferior cerebellar artery aneurysms. Her previous abdominal angiogram had revealed multiple aneurysms in visceral arteries. Successful coil embolization of the ruptured right MCA bifurcation aneurysm was performed with preservation of the parent vessel. The patient made a complete recovery and was placed on medical treatment for PAN. Follow-up MR angiography at three months revealed stable occlusion of the embolized aneurysm with no change in the unruptured aneurysms.

Although rare, PAN can be associated with intracranial aneurysms which can cause subarachnoid or parenchymal hemorrhage. Selected cases can be treated safely by coil embolization.
Combined Surgical and Endovascular Management of a Giant Fusiform PCA Aneurysm in a Pediatric Patient
Authors: Shin S.H. , Choi I.S. , Thomas K. , David C.A.
Published: January 2017

Treatment of intracranial giant aneurysms presents is challenging. In the case of pediatric giant aneurysm, more challenges arise. We describe our experience with a 17-year-old pediatric patient who presented with severe headache. She was diagnosed as having a giant fusiform aneurysm at the right P1-P2-Pcom junction. The aneurysm was treated with superficial temporal artery-posterior cerebral artery bypass and subsequent coil embolization of the aneurysm with parent artery occlusion. The patient had an excellent outcome at one-year follow-up. Our case suggests a combined approach of surgical and endovascular management may yield a better outcome than surgery or endovascular management alone in the treatment of pediatric giant aneurysm.
Single-Stage Extracranial Carotid Artery Stenting and Intracranial Aneurysm Coiling: Technical Feasibility and Clinical Outcome
Authors: Park J.C. , Kwon B.J. , Kang H-S. , Kim J.E. , Kim K.M. , Cho Y.D. , Han M.H.
Published: January 2017

The coexistence of carotid artery stenosis and cerebral aneurysm in a patient presents challenges for treatment decision-making. The purpose of this study was to evaluate the technical feasibility and clinical outcome after single-stage extracranial carotid artery stenting (CAS) and ipsilateral intracranial aneurysm coiling in a single institution.

From March 2005 to February 2011, 17 patients with 21 aneurysms underwent single-stage CAS and coiling for ipsilateral aneurysms. There were symptomatic atherosclerotic carotid stenoses with unruptured aneurysms in eight, ruptured or symptomatic aneurysms with simultaneous asymptomatic carotid stenoses in two and asymptomatic lesions in seven. CAS was followed by aneurysm coiling in all 17 patients. Clinical and radiological data were reviewed.

There were two procedure-related complications: acute in-stent thrombosis in one and premature aneurysmal rupture in the other. After aneurysm coiling, complete occlusion was demonstrated in 17 aneurysms and near-total occlusion in four. No neurological deficit was found at discharge and follow-up outcomes were excellent in all the patients (mean, 32.9 months). Follow-up imaging studies were performed in all the patients, including neck CT angiography in 14 (mean, 26.1 months), brain MR angiography in 14 (mean, 31.2 months), and conventional angiography in three (mean, 14.7 months). They revealed two asymptomatic, mild carotid re-stenoses and one major aneurysmal recanalization requiring re-coiling.

A single-stage CAS and coiling procedure appears to be feasible and the complication rate seems to be reasonable. We suggest that there is no need for separate therapeutic procedures when a patient has carotid artery stenosis and accompanying ipsilateral intracranial aneurysm.
Percutaneous Thrombin Injection with a Distal Embolic Protection Device for Treatment of a Common Carotid Artery Pseudoaneurysm
Authors: Lee J.H. , Tseng I.K. , Siegel R.L. , Roychowdhury S.
Published: January 2017

Carotid artery pseudoaneurysm is a rare complication from placement of an internal jugular triple lumen catheter. Endovascular stenting is the favored treatment option in the setting of traumatic carotid injury. In other parts of the body, specifically the femoral artery, thrombin injection has become the standard of care. We intend to show that effective management of carotid pseudoaneurysms can also be achieved with thrombin injection after placement of a distal embolic protection device.
Sacroplasty for Symptomatic Sacral Hemangioma: A Novel Treatment Approach
Authors: Agarwal V. , Sreedher G. , Weiss K.R. , Hughes M.A.
Published: January 2017

Painful vertebral body hemangiomas have been successfully treated with vertebroplasty and kyphoplasty. Sacral hemangiomas are uncommon and as such painful sacral hemangiomas are rare entities. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty.

A 56-year-old woman with a history of right-sided total hip arthroplasty and lipoma excision presented to her orthopedic surgeon with persistent right-sided low back pain which radiated into her buttock and right groin and hindered her ability to walk and perform her activities of daily living. MRIs of the thoracic spine, lumbar spine and pelvis showed numerous lesions with imaging characteristics consistent with multiple hemangiomas including a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen. Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient underwent CT-guided sacroplasty for treatment of a painful right sacral hemangioma. Under CT fluoroscopic guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion. Biopsy was then performed and after appropriate preparation, cement was then introduced through the needle using a separate cement filler cannula. Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc of cement, it was felt that there was near complete filling of the right sacral hemangioma. With satisfactory achievement of cement filling, the procedure was terminated. Pathology from biopsy taken at the time of the procedure was consistent with hemangioma.

Image-guided sacroplasty with well-defined endpoints is an effective, minimally invasive and safe procedure. Patients with painful sacral hemangiomas can be treated with this technique with no significant complications.
Local Intraarterial Thrombolysis in the Carotid Territory
Authors: Theron J. , Coskun O. , Huet H. , Oliveira G. , Toulas P. , Payelle G.
Published: January 2017

A new series of 142 patients treated by local intraarterial thrombolysis is presented. After haemorrhage was ruled out by CT, all patients had an emergency angiogram. Patients with occlusion of the lenticulostriate arteries were not treated after the sixth hour (79 cases). Patients without involvement of these arteries were treated up to the 12th hour (61 cases).

This selection led to a dramatic reduction of pos-thrombolysis intraparenchymatous haemorrhage (0.7%) compared to other series. All deaths (7 cases) were related to vasogenic oedema due to incomplete reduction of infarcted cerebral volume, in most cases (4 cases) in intracerebral extension of a cervical internal carotid occlusion.

Digitized parenchymography proved to be a reliable technique to document the exact location and extent of brain ischaemia before and after thrombolysis. It also allows a prognosis of spontaneous recovery without using thrombolysis. By reducing the infarcted cerebral volume, local intraarterial thrombolysis seems beneficial to the patient as long as a strict selection based on the angiographic location of the occlusion and the time delay is respected.
Embolisation of Ruptured Cerebral Aneurysms with Interlocking Detachable Coils in Acute Stage
Authors: Manabe H. , Fujita S. , Hatayama T. , Ohkuma H. , Suzuki S. , Yagihashi S.
Published: January 2017

Twelve cases of ruptured cerebral aneurysm were treated in acute stage with interlocking detachable coils (IDC, Target Therapeutics, Fremont, California) and the outcome was assessed.

IDCs were placed intra-aneurysm for intra-aneurysmal occlusion, or intra-artery for proximal occlusion. Cases: age 36–84 (mean; 60) y.o., 11 females and 1male; 1, 5, 4 and 2 patients were categorised (Hunt and Hess) as grades 1, 2, 3 and 4 respectively. An intra-aneurysmal occlusion in ten cases and a proximal occlusion in two were performed on day 1–11 (mean 4).

On angiograms and CT findings, the ruptured point seemed to have occluded in all cases. The occlusion rate was 100% in five cases, 95% in two, 90% in three, 80% in one, and less than 50% in one.

There were two cases of technical complication, one a coil migration and the other an aneurysmal perforation with IDC.

Their Glasgow Outcome Scale six months after embolisation was graded as good recovery in four cases, moderately disabled state in two, severely disabled state in one, and dead in five. Follow-up angiograms taken four to six months after embolisation showed an intra-aneurysmal coil compaction in five cases. Two of these were treated by a second embolisation or by neck clipping followed by aneurysmal resection, but another two were observed without any treatment and the last one died of rebleeding. Histological examination of the resected embolised aneurysm revealed slight organization around coils but no endothelialisation over the aneurysmal orifice.

In our experience, coil embolisation with IDC for acute ruptured aneurysm is a promising means of preventing rerupture during subacute stage.
Characteristics of a New Liquid Material for Arteriovenous Malformations (HEMA-MMA)
Authors: Kazekawa K. , Tomonaga M. , Iwata H. , Kawano T. , Kawaguchi T. , Honma T. , Kaneko Y. , Dosaka A. , Koizumi T. , Morikawa N. , Matsuda S. , Ikada Y.
Published: January 2017

Characteristics of a newly developed liquid material for embolization of AVM and its clinical experiments are reported.

This liquid is composed of dissolving poly (2-hydroxyethyl methacrylate-co-methyl methacrylate) in Iopamiron with adding a small amount of ethyl alcohol. Thirty-two cases of AVM and 5 cases of spinal AVM were embolized with this liquid with good results.

This liquid material is of low viscosity, not adhesive and not cytotoxic, therefore, it can be easily injected through a microcatheter, and can safely and effectively occlude AVM.
Covered Stent Placement for Artificial Cervical Carotid Aneurysms
Authors: Mase M. , Banno T. , Yamada K. , Katano H. , Sasaki S. , Kitase M. , Matsumoto T.
Published: January 2017

In order to evaluate the midterm patency and the effectiveness of Dacron-covered self-expanding metallic stent in the treatment of cervical carotid aneurysm, we made wide-necked carotid aneurysms with a technique of vein pouch end-to-side anastomosis, and implanted the stents percutaneously to occlude the aneurysms in dogs. The patency was angiographically followed up for 3 months with anticoagulation and antiplatelet medications.

The Dacron-covered stent could make the aneurysms disappear angiographically within ten minutes if it was implanted in the correct place. The acute thrombotic obstruction was seen in one of the five regions. The delayed stenosis was seen in two of the five regions in two weeks. Only one of the five regions was patent three months after the stent placement without stenosis, in this case, no cerebral infarction of the brain was found histologically.

The Dacron-covered stent can make wide-necked aneurysms occlude quickly. However, the short or midterm patency was poor, suggesting that it is not safe enough to be used clinically in carotid lesions. Further study should be needed to improve the materials for a covered stent before clinical applications.
Pitfalls in Endovascular Treatment of Dural Arteriovenous Fistulas Involving the Cavernous Sinus
Authors: Kuwayama N. , Endo S. , Kubo M. , Akai T. , Takaku A.
Published: January 2017

Angiographic changes of the sylvian veins, superior ophthalmic vein (SOV), and superior petrosal sinus (SPS) before and after endovascular treatment were determined for 18 patients with dural arteriovenous fistulas (AVFs) involving the cavernous sinus, and pitfalls of endovascular treatment, especially regarding venous drainage routes, for 3 of the patients were reported.

Case 1: 57-year-old woman who presented with right abducens nerve palsy had a Barrow type D fistula in the right cavernous sinus draining into the bilateral inferior petrosal sinuses (IPS). One of the ipsilateral sylvian veins that had drained antegradely before treatment was occluded, and a small lacunar infarction in the corona radiata developed after transvenous embolization (TVE) of the right cavernous sinus.

Case 2: 72-year-old woman who presented with symptoms of right ocular hypertension had a type D fistula in the right cavernous sinus draining into only the ipsilateral SOV. Conjunctival hyperemia persisted and was aggravated after angioanatomical obliteration of the fistula by transarterial embolization.

Case 3: 55-year-old man who presented with left abducens nerve palsy had a type D fistula in the left cavernous sinus draining into the ipsilateral IPS and sylvian vein. The dural AVF was obliterated once with TVE, but recurred 1 week later with retrograde drainage into the ipsilateral SPS and mesencephalic veins. A second TVE resulted in complete obliteration of the fistula.

In conclusion, detailed analysis of drainage routes is necessary for planning of treatment of patients with dural AVF, and prompt treatment is needed when redistribution of drainage routes develops during or after TVE.
Transvenous Embolizations of Venous Compartments of Dural Arteriovenous Fistulas within Venous Sinus Walls
Authors: Nakamura M. , Hara Y. , Nagashima T. , Morikawa M. , Minami H. , Tamaki N.
Published: January 2017

Transvenous embolization of venous compartments within the venous sinus wall was the method initially attempted for closing dural arteriovenous fistulas in 15 patients (22 sinuses). The venous channel, separate from the sinus lumen and located in the venous sinus wall, could be embolized in 6 lesions (3 patients), including 3 superior sagittal sinus fistulas, 2 transverse sinus fistulas, and 1 straight sinus fistula.

This technique resulted in closure of the fistulas and preservation of sinus patency as well as immediate improvement of clinical symptoms. The embolizable venous compartment of the fistula within the venous sinus wall could be detected by preoperative angiography, magnetic resonance imaging, and intraoperative venography. This unique drainage of dural arteriovenous fistulas may develop concurrently with more obvious portions of the fistula.

Transvenous embolization of these venous compartments can close the fistulas and normalize impaired sinus function.
Intracranial Aneurysm Embolization Using Interlocking Detachable Coils
Authors: Satoh K. , Matsubara S. , Hondoh H. , Nagahiro S.
Published: January 2017

The relationship between volume embolization ratio and coil compaction on the intracranial aneurysm occluded using interlocking detachable coils (IDCs) was determined.

From February 1994 to October 1996, 7 intracranial aneurysms were embolized using IDCs. Aneurysm capacity (volume) was calculated assuming that aneurysms are ellipsoid of the diameter in 3 planes. Coil volume was calculated assuming that IDCs are cylinders of primary coil.

Coil compaction was observed in aneurysms embolized at a volume embolization ratio under 25%. There was no coil compaction in aneurysms embolized at a volume embolization ratio of over 25%.

Measurement of the volume embolization ratio is useful to predict coil compaction. Intracranial aneurysms should be embolized at a volume embolization ratio of 25–33%.
Results of 55 AVM Cases Treated by Embolization and/or Surgery
Authors: Hattori T. , Negoro M. , Bundou M. , Iwakoshi T. , Fukui K. , Fukasaku K. , Takayasu M. , Shibuya M. , Yoshida J.
Published: January 2017

In order to build a data base for future comparison, we summarized the treatment results of cerebral arteriovenous malformation (AVM) patients in our hospital. Fifty five AVM patients who had been treated at Nagoya University Hospital from 1988 to 1995 were enrolled in the study. The patient characteristics were nearly the same as other reported series. Trend of treatment modality was changing in this period and embolization was increasing in its role.

Karnofsky score was used to follow the patients' clinical status. It was useful to assess pretreatment clinical status and post treatment status.

The results showed the improvement of the embolization procedure.
Matters to Be Attended to in Intra-Aneurysmal GDC Embolization for Aneurysms with No Hemorrhage or Hemorrhage in Chronic Stage
Authors: Ezura M. , Takahashi A. , Yoshida M. , Takahashi N. , Nishimura S. , Yoshimoto T.
Published: January 2017

Sixty-two aneurysms with no hemorrhage or hemorrhage in chronic stage were treated by intra-aneurysmal GDC embolization in 69 sessions. The embolizations were performed under local anesthesia, systemic heparinization, 6F introducing catheter and double-markered microcatheter. Systemic heparinization was performed during the procedure and continued 48 hours afterwards except for the first 4 sessions in which only during the procedure. Activating clotting time (ACT) was maintained 2 to 2.5 times as long as base line value.

Angiographic results were complete in 30, neck remnant in 27, and body filling in 12. Symptomatic embolism distal to the aneurysm were observed in two cases out of the first 4 cases without post-embolization heparinization. In the last 65 sessions, persistent symptomatic complications were observed in 4 patients, parent artery occlusion in 1 and embolism distal to the aneurysm in 3. Asymptomatic or transient complication was observed in 7 cases (parent artery occlusion or stenosis).

Complications related to systemic heparinization were observed in 5 cases. Difficulty of complete neck closure and recanalization of aneurysmal cavity mainly due to coil compaction are two main problems on GDC embolization. To avoid these two problems, it is be extremely important for GDC embolization to embolize the aneurysmal cavity as tightly as possible. On the other hand, the more tightly the aneurysmal cavity is embolized, the more frequently thromboembolic complications occur. Thus, systemic heparinization after the embolization is essential.

However, one should been in mind that systemic heparinization itself carries a potential risk of hemorrhage. To overcome this dilemma, we use a special device for immediate and complete closure of the puncture site of the introducing sheath.
Transarterial Embolization of Cerebrospinal Lesions with Liquid Coils
Authors: Hara Y. , Nakamura M. , Ehara K. , Tamaki N.
Published: January 2017

We report our experience with endovascular embolization using liquid coils. Twenty-two transarterial embolization procedures were performed with these coils in 20 patients with cerebrospinal vascular or neoplastic lesions. The coils were delivered into the target vessels under fluoroscopic monitoring through a microcatheter by manual injection and flushing with saline.

Subsequent surgical resections of embolized lesions were performed in 14 cases, and radiosurgery for two. Complete obliteration of the target vessels were accomplished in all cases without complications. Passage through the microcatheter and delivery of the coil was smooth. Proximal protrusion of the coil occurred during the procedure, and a combination of other embolic materials was necessary to completely occlude large vessels in 9 cases.

The embolized lesions were easily resected in the following neurosurgery. Liquid coils were safe and effective as an embolic material in use prior to surgery or radiosurgery.
Embolization of Aneurysms with a Liquid Material: An Experimental Study
Authors: Koizumi T. , Kawano T. , Kazekawa K. , Kawaguchi T. , Honma T. , Kaneko Y. , Dosaka A. , Tabuchi K. , Iwata H. , Morikawa N. , Matsuda S. , Ikada Y. , Inoue T.
Published: January 2017

The authors evaluated the embolization effects on experimental aneurysm models with a liquid material. This material is a mixture of poly (HEMA-co-MMA), Iopamidol, water and a small amount of ethyl alcohol.

We have satisfactorily treated over 30 cases of AVM with this material. Out of four solutions of different viscosity, we used the solution with the highest viscosity to prevent distal migration of the mixture. Glass models of aneurysms of 5 mm in diameter in pulsatile saline flow were embolized with the mixture under various conditions. When an IDC was placed in the aneurysm models, the mixture obliterated them completely and did not migrate out from the aneurysm models.

In this experimental study, it is suggested that the liquid material appears to be useful in embolizing cerebral aneurysms safely.
Investigations of the Dose of Heparin and Whole Blood Coagulation Time during Endovascular Surgery
Authors: Nagai S. , Kurata A. , Tanaka R. , Irikura K. , Miyasaka Y. , Fujii K.
Published: January 2017

We chronologically determined whole blood coagulation time during continuous heparin administration, and investigated optimal doses of heparin in thirty-seven vascular surgery cases.

ACT was determined with Hemochron 401. Heparin (2000 IU) was administered by bolus injection at the beginning of intravascular surgery, which was followed by continuous injection of 20 to 160 IU/kg/h. ACT determined before and 30 minutes after heparin administration were compared.

There were no complications. ACT was maintained at a nearly constant level by continuous heparin administration. The dose of heparin required to maintain ACT at a level 1.5 to 2 times the initial level was 20 to 60 IU/kg/h. ACT was prolonged by more than three times in two of the ten subjects who were given heparin at a dose of 70 IU/kg/h or more.

Continuous administration of heparin allowed maintenance of ACT at a nearly constant level during intravascular surgery. ACT was maintained within the range which is believed to be effective for prevention of thrombus formation (approximately 1.5 to 2.0 times larger than the initial level) by continuous administration of 20 to 60 IU/kg/h of heparin. ACT was, however, prolonged to more than three times the initial level in some subjects who were given 70 IU/kg/h or higher doses, suggesting the risk of a bleeding tendency. Accordingly, it is ideal to continue heparin administration at appropriate doses, while measuring ACT.

The results of our study should serve as a useful standard for meeting this goal.
Assessment of Complication Types and Rates Related to Diagnostic Angiography and Interventional Neuroradiologic Procedures
Authors: Horowitz M.B. , Dutton K. , Purdy P.D.
Published: January 2017

We determined the types and rates of complications related to diagnostic angiography and neuroradiologic interventional procedures at a centre that carries out the full spectrum of angiographic procedures.

The occurrence of immediate and delayed complications in 1929 neuroangiographic procedures (1358 diagnostic and 571 interventional) performed between the years 1993–1996 was prospectively identified and recorded on a daily basis. A retrospective review of all charts of patients having procedures conducted during the study period was also carried out to ensure that no complications were missed.

The overall complication rate for diagnostic cerebral angiography was 2.2%. Puncture site complications ranged from 0 – 0.1%. Vessel injury distal to the puncture site ranged from 0.2 – 0.6%. The temporary neurologic complication rate was 0.3%, while the permanent rate was 0.4%. There were no contrast reactions. The death rate was 0.1%. Interventional procedures had higher incidences of complications with overall rates ranging from 5.3 – 33%. Temporary and permanent neurologic deficits occurred at a rate of 0 – 10.5% depending upon the procedure involved. Individual complication and death rates and complication categories are provided for arteriovenous malformation embolisation, tumour embolisation, temporary balloon occlusion tests, detachable balloon vessel sacrifice, urokinase infusion, angioplasty, papavarine infusion, GDC embolisation, and carotid cavernous fistula embolisation.

When carried out in experienced hands, neuroangiography and neurointervention are relatively safe with low incidences of neurologic and non-neurologic complications. Knowledge of these rates is important when counselling patients prior to treatments or deciding upon the risk-benefit ratio of preoperative procedures.
[O-15]H2O Positron Emission Tomography Determination of Cerebral Blood Flow Reserve after Intravenous Acetazolamide during Balloon Test Occlusion of the Internal Carotid Artery
Authors: Murphy K.J. , Deveikis J.P. , Brunberg J.A. , Jamadar D.A. , Frey K.A.
Published: January 2017

The purpose of this paper was to evaluate the effects of acetazolamide on cerebral blood flow (CBF) measured by [O-15] H2O positron emission tomography (PET) during balloon test occlusion (BTO) of the internal carotid artery (ICA).

[O-15] H2O PET cerebral blood flow studies were completed in 20 patients undergoing BTO. CBF determinations were obtained without carotid occlusion as a baseline, following balloon occlusion, and as a third scan with balloon occlusion after an intravenous acetazolamide bolus.

The balloon was left deflated between scans, and was only inflated immediately before and during the 90 second period of time needed for CBF determination.

Significance was determined at the P<0.05 level. Two of twenty studies were technical failures. Prior to acetazolamide there was a significant decrease in CBF (P<0.0007) ipsilateral to the occlusion.

After acetazolamide administration there was no statistically significant change in flow on the occluded side (P<0.3047); however, there was a significant increase in cerebral blood flow (P<0.0002) on the non-occluded side.

In this patient population, there was no acetazolamide-induced CBF decompensation (steal) phenomenon or haemodynamically significant risk in CBF ipsilateral to the occlusion.