Language：English   Publisher：The Japan Neurosurgical Society  

<p>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.</p>

DOI： 10.2176/jns-nmc.2022-0308

CiNii Research

Language：English   Publishing type：Research paper (scientific journal)  

PURPOSE: Artificial intelligence (AI)-based three-dimensional angiography (3D-A) was reported to demonstrate visualization of cerebral vasculature equivalent to that of three-dimensional digital subtraction angiography (3D-DSA). However, the applicability and efficacy of the AI-based 3D‑A algorithm have not yet been investigated for 3D-DSA micro imaging. In this study, we evaluated the usefulness of the AI-based 3D‑A in 3D-DSA micro imaging. MATERIALS AND METHODS: The 3D-DSA micro datasets of 20 consecutive patients with cerebral aneurysm (CA) were reconstructed with 3D-DSA and 3D‑A. Three reviewers compared 3D-DSA and 3D‑A in terms of qualitative parameters (degrees of visualization of CA and the anterior choroidal artery [AChA]) and quantitative parameters (aneurysm diameter, neck diameter, parent vessel diameter, and visible length of AChA). RESULTS: Qualitative evaluation of diagnostic potential revealed that visualization of CA and the proximal to middle parts of the AChA with 3D‑A was equal to that with conventional 3D-DSA; in contrast, visualization of the distal part of the AChA was lower with 3D‑A than with 3D-DSA. Further, regarding quantitative evaluation, the aneurysm diameter, neck diameter, and parent vessel diameter were comparable between 3D‑A and 3D-DSA; in contrast, the visible length of the AChA was lower with 3D‑A than with 3D-DSA. CONCLUSIONS: The AI-based 3D‑A technique is feasible and evaluable visualization of cerebral vasculature with respect to quantitative and qualitative parameters in 3D-DSA micro imaging. However, the 3D‑A technique offers lower visualization of such as the distal portion of the AChA than 3D-DSA.

DOI： 10.1007/s00062-023-01325-8

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PubMed

Language：English   Publishing type：Research paper (scientific journal)  

We conducted a study to understand the characteristics of the finishing coils to select the appropriate coil for the final stage of embolization. Consequently, experimental embolization was performed on a 10 mm spherical silicone aneurysm filled with radiolucent coils, which simulated a volume embolization ratio of 20%. Nine different coils (i-ED complex ∞ SilkySoft, SilkySoft, ExtraSoft, V-Trak HyperSoft helical, Barricade 10 complex finishing, Optima complex 10 soft, Target 360 Ultra, Galaxy G3 mini, and Axium prime 3D ExtraSoft) were analyzed six times at random. After each coil insertion, indices that include area, Feret diameter, circularity, and centroid center of mass were calculated using biplane x-ray images. Furthermore, these data were analyzed using the spring constant k, which represents the stiffness of the coil. In multiple comparisons, a significant difference was observed in the area analysis. The i-ED complex ∞ SilkySoft was more widespread than Target 360 Ultra (p < 0.05). However, no significant differences were observed in the other indices. The spring constant k value of Target 360 Ultra was 2.5 times larger than that of the i-ED complex ∞ SilkySoft, and it negatively correlated with the area index rather than with the other indices. Notably, it was suggested that the smaller the spring constant k, the wider the distribution of the finishing coils. Although there was little difference between the coils, some coils had characteristics suggesting that good embolization could be expected using appropriate finishing coils.

DOI： 10.18999/nagjms.85.4.725

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Language：English   Publisher：Scientific Reports  

Genetic factors alone cannot explain the pathophysiology of moyamoya disease (MMD), and environmental factors such as an immune response are thought to be involved. Oral and gut microbiomes have attracted attention as environmental factors in the pathophysiology of some vascular and autoimmune diseases. However, the relationship between MMD and these microbiomes is yet to be thoroughly investigated. This prospective case–control study aimed to compare the microbiomes of Japanese patients with MMD with those of healthy individuals to identify the specific bacteria involved in MMD. Saliva and fecal samples were collected from 16 patients with MMD who had not undergone revascularization surgery. Fifteen healthy individuals were matched for age, sex, and body mass index. The microbiomes were determined using 16S rRNA sequencing and analyzed using QIIME2. Differentially abundant microbes were identified using LEfSE and ANCOM-BC. In the oral microbiome, the two analytical methods showed that Campylobacter was more abundant in patients with MMD than in healthy individuals. Differences in the gut microbiome were smaller than those in the oral microbiome. In conclusion, the oral microbiome profiles of patients with MMD significantly differ from those of healthy individuals. Campylobacter spp. could be a substantial environmental factor in the pathophysiology of MMD.

DOI： 10.1038/s41598-023-45755-3

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DOI： 10.7759/cureus.45326

PubMed

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR) carry a high risk for neurological sequelae or death. Recently, transverse-sigmoid sinus DAVFs were shown as good indications for transarterial embolization (TAE) with ONYX. Here, we compared the effectiveness and safety of conventional transvenous embolization (TVE) with those of TAE with ONYX for transverse-sigmoid sinus DAVFs with CVR. METHODS: Sixty-one patients with transverse-sigmoid sinus DAVFs were treated from April 2013 to May 2020. Among them, 37 patients with CVR were included. Transarterial embolization and TVE were compared in terms of complete occlusion and residual CVR immediately after treatment, complications with worsening modified Rankin Scale (mRS) ≥ 1, amount of contrast media used during treatment, radiation exposure, and surgical procedure time. RESULTS: Ten patients were treated with 10 TAEs using ONYX and 27 patients with 29 TVEs. Transarterial embolization and TVE showed no differences in the overall complete occlusion rate (80% [8/10 patients] vs. 80% [23/27], respectively), whereas the residual rate of existing CVR was 10% (1/10 patient) vs. 3.4% (1/27) in the TAE and TVE groups, respectively. No complications with worsening mRS ≥1 occurred in either group. Among the parameters of amount of contrast media, radiation dose, and operative time, only radiation dose in the TAE group was lower than that in the TVE group (median: 2239 mGy vs. 3268 mGy, respectively; p = 0.07). CONCLUSION: For transverse-sigmoid sinus DAVFs with CVR, TAE treatment reduced radiation exposure. However, both TAE and TVE achieved high complete occlusion rates and low complication rates.

DOI： 10.1177/15910199231195135

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BACKGROUND: In this study, we propose a butterfly needle tap and suction (BTS) technique for recurrent chronic subdural hematoma (CSDH) as an alternative to reoperation with burr hole craniostomy (BHC) and investigate its efficacy and safety. The procedure involves percutaneous puncture through the burr hole created during the previous surgery and subsequent hematoma evacuation using a butterfly needle. METHODS: This retrospective study included patients who underwent BTS for CSDH at Ogaki Municipal Hospital between January 2017 and December 2020. The follow-up CT scans were reviewed after several weeks. We evaluated the number of percutaneous punctures required to resolve CSDH during the BTS technique, the volume of the evacuated hematoma, and procedure-related complications. RESULTS: Twenty-six patients were enrolled in the study, 21 of whom achieved resolution of the hematoma using punctures with the BTS technique alone (mean, 2.2 ± 1.5). Five patients had a recurrence of hematoma after one or more punctures during the BTS technique, and they underwent reoperation with BHC according to the surgeon's decision or patient requests. Among the 55 punctures, 43.0 ± 16.0 ml of hematoma was evacuated per puncture. The evacuated hematoma volume was 41.9 ± 16.4 ml in the BTS-alone group and 49.4 ± 12.9 ml in the reoperation group, with no significant difference (p = 0.25). Three patients complained of a headache during the puncture procedure, and no other complications, including intracranial hemorrhage or infection, were reported therein. CONCLUSIONS: The BTS technique is an effective alternative to reoperation with BHC.

DOI： 10.1007/s00701-023-05543-4

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OBJECTIVE: The protocol for antiplatelet therapy after stent-assisted coil embolization (SACE) for intracranial aneurysms is not well established. In particular, the indications for single antiplatelet therapy (SAPT) discontinuation remain controversial. The authors investigated the long-term outcomes of SAPT discontinuation after SACE among patients at a single institution. METHODS: Patients who underwent SACE during the period from 2010 to 2020 and who were followed up for > 1 year were included in this study. The delayed ischemic and hemorrhagic complication rates were examined during follow-up. Moreover, the risk factors of antiplatelet therapy reduction or discontinuation and the outcomes of SAPT discontinuation were examined. RESULTS: In total, 240 patients were included in the analysis. The average patient age was 60.3 years, and the average follow-up period was 46.7 months. Nine (3.8%) patients presented with symptomatic delayed ischemic complication, and 3 (1.3%) patients experienced a decline in modified Rankin Scale score. The stent configuration (T- or Y-stent) was the only risk factor associated with delayed ischemic complication (p < 0.001). SAPT was discontinued in 147 (71.7%) of 205 patients who were followed up for > 2 years, and no ischemic complications were observed. CONCLUSIONS: It is safe to discontinue SAPT in patients without ischemic complications and with stable intraaneurysmal signals on MRA 2 years after SACE. The T- or Y-stent is a high-risk factor for delayed ischemic complications, and antiplatelet therapy reduction or discontinuation should be cautiously considered.

DOI： 10.3171/2022.6.JNS22815

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OBJECTIVE: To evaluate the static and dynamic features of blood blister-like aneurysms (BBAs) using cerebral angiography to identify characteristic features to improve the diagnosis of these uncommon aneurysms. METHODS: Digital subtraction angiography (DSA) images were compared between patients with BBAs (n = 12, group A) and patients with unruptured paraclinoid aneurysms ≤ 5 mm in size treated by endovascular procedures (n = 12, group B). DSA images were assessed for irregularities in the diameter of the parent artery and delayed inflow and outflow of contrast medium in the aneurysm. Enlargement of the aneurysm and morphological changes from the first assessment were also evaluated in patients with BBAs. RESULTS: Compared to the group B, group A had a higher proportion of irregular vessel diameter (p = 0.013) and the delayed contrast medium outflow (p = 0.014). As well, stagnation of contrast medium along the aneurysm wall was a characteristic finding of BBAs, even for small aneurysms. CONCLUSION: Irregular morphological features of the parent artery and delayed contrast medium outflow as characteristic findings of ruptured BBAs may improve the diagnosis of these uncommon aneurysms, which remains challenging in practice.

DOI： 10.1016/j.clineuro.2022.107583

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Digital subtraction angiography (DSA) is the most useful technique for diagnosing spinal arteriovenous malformations (AVM). In recent years, with the improvement of imaging capabilities, the usefulness of three-dimensional (3D) imaging by fusing various modalities has been recognized. The use of 3D fusion imaging with a workstation connected to an angiography system has been reported in many cases of intracranial disease, but less frequently for spinal AVM. In this article, we describe two illustrative cases of spinal AVM in which 3D fusion imaging was useful for treatment. Although 3D fusion images using the system have the disadvantage that only a maximum of two images can be fused, it provides spinal surgeons with useful information for preoperative evaluation in a small amount of time.

DOI： 10.18999/nagjms.85.1.127

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In the neuroendovascular field, the training of operators has become an important issue. Recently, eye-tracking technology has been introduced into various fields of medical education. This study aimed to apply eye-tracking technology to the training of neuroendovascular therapy. Six neurosurgeons, including three neuroendovascular specialists and three trainees, at our institution and related facilities participated in the study. Eye movement was recorded by the eye-tracking device during the microcatheter navigation and coil placement into the silastic aneurysm model under biplane X-ray fluoroscopy. Eye-tracking analysis during neuroendovascular therapy was feasible in all six subjects. In microcatheter navigation, specialists tended to more frequently switch their attention between frontal and lateral images than trainees. In coil embolization, the overall gaze frequency tended to increase, and the average fixation duration tended to decrease as the number of experienced cases increased. Inexperienced operators tend to fix their gaze when they are operators than when they are assistants. More experienced operators tended to look at the microcatheter longer in the coil insertion task. The eye-tracking analysis may be useful for operator training in neuroendovascular therapy. Experts may have moved their eyes more frequently than trainees to gaze at the right place. In the future, it will be necessary to collect gaze data for more operators in various tasks.

DOI： 10.18999/nagjms.85.1.50

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Language：English   Publisher：The Japan Neurosurgical Society  

<p>Intracranial aneurysms (IA) in infants are reportedly rare at 0.5% to 4.5% of all aneurysms. Furthermore, subarachnoid hemorrhage in infants younger than three months are even rarer as it has been reported in approximately 20 cases only till date.</p><p>A 3-month-old infant with seizures and impaired consciousness was admitted to our hospital. Three-dimensional computed tomography angiography (3D-CTA) revealed a dissecting aneurysm with a maximum diameter of 13 mm in the right M2. Internal trapping using detachable coil were successfully performed, following which he was discharged without significant neurological deficit after one month of onset. Thus, we have reported a rare case of a large ruptured dissecting IA in a 3-month-old infant, in the right middle cerebral artery (MCA), successfully treated with an endovascular therapy, along with a literature review.</p>

DOI： 10.2176/jns-nmc.2022-0369

PubMed

CiNii Research

Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective</b>: We verified the usefulness of patient management using a balloon-pressurized belt (Stanch Belt Plus) to prevent puncture site hematomas, which can occur at a specific rate even with hemostatic devices after endovascular neurosurgery.</p><p><b>Methods</b>: A total of 113 patients who underwent endovascular surgery with a femoral puncture from April 2019 to September 2020 were divided into two groups: 31 cases using a traditional compression belt and 82 cases using a newly introduced balloon-pressurized belt during this period. The clinical data were analyzed retrospectively. The chi-square test and Mann–Whitney U test were used to test for significant differences.</p><p><b>Results</b>: There were no significant differences in treatment procedures or frequency of hemostatic device use, but the balloon-pressurized belt group had a significantly lower incidence of hematomas (2.4% vs 12.9%, p <0.05) and a significantly lower incidence of moderate or higher lumbago (22.0% vs 41.9%, p <0.05). The incidence of epidermal detachment tended to be low; however, no significant difference was observed (3.7% vs. 12.9%, n.s.).</p><p><b>Conclusion</b>: Patient management with the newly introduced balloon-pressurized belt may decrease the occurrence of groin hematoma and lumbago among complications after endovascular neurosurgery.</p>

DOI： 10.5797/jnet.oa.2023-0053

PubMed

CiNii Research

Language：English   Publisher：The Japan Neurosurgical Society  

<p>A 61-year-old man presented with massive epistaxis, amaurosis, nausea, and severe headache. A detailed examination revealed a subarachnoid hemorrhage and prolactinoma. Angiography showed a small internal carotid artery pseudoaneurysm and inadequate collateral circulation; thus, uncomplicated coil embolization was performed. Considering the side effects of medication, such as cerebrospinal fluid rhinorrhea, the patient was followed up for asymptomatic prolactinoma without medication after discharge. At 40 months later, aneurysm recurrence was confirmed. Flow diverter device placement was performed, and the outcomes were excellent. In the present report, we described a rare case of a ruptured internal carotid artery aneurysm in an untreated prolactinoma and discussed the literature.</p>

DOI： 10.2176/jns-nmc.2022-0355

PubMed

CiNii Research

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Two-dimensional digital subtraction angiography (2D-DSA) and conventional three-dimensional digital subtraction angiography (3D-DSA) are used for the detailed analysis of dural arteriovenous fistula (DAVF). Recently, four-dimensional digital subtraction angiography (4D-DSA), a novel technology, has been attracting attention. The current study aimed to evaluate the capability of 4D-DSA in assessing anatomical angioarchitecture in DAVF. METHODS: In total, 10 consecutive patients with DAVF who underwent 3D-DSA and 4D-DSA at a single institution were included in the analysis. Initially, one-slice multiplanar reconstruction (MPR) images obtained via 4D-DSA and 3D-DSA were compared to investigate the visibility of the feeding artery, fistulous point, and draining vein. Next, 4D-DSA images alone were compared and evaluated with and the MPR images of conventional 3D-DSA in terms of diagnosis of the angioarchitecture. RESULTS: In total, six men and four women (with a mean age of 65.6 ± 10.0 years) were included in the study. The MPR image obtained via 3D-DSA had a significantly better visibility of the feeding artery and fistulous point than that acquired via 4D-DSA (p < 0.05). As for the draining vein, the score was equivalent and not significant. The diagnosis of the vascular architecture of only 4D-DSA images was nearly equivalent to that of MPR images of 3D-DSA. There were no inter-rater differences. CONCLUSION: The MPR images obtained via 4D-DSA may be slightly inferior to those acquired via 3D-DSA in identifying fine angioarchitecture in DAVF. However, they were comparable in terms of diagnostic accuracy.

DOI： 10.1177/15910199221145526

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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.

DOI： 10.18999/nagjms.84.4.884

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Language：English   Publishing type：Research paper (scientific journal)  

This study sought to establish an experimental aneurysm model of visualizing coil insertion using radiolucent nylon coils. Moreover, this study aimed to clarify the characteristics and differences of each coil and use them clinically as indices of coil selection. The coil insertion test was performed on the 10 mm spherical silicone aneurysm model filled to a nylon coil volume embolization ratio of 11.8%. Five types of coil were randomly tested six times, and the distribution of the coils was analyzed by fluoroscopy imaging. Indices of "Area (mm2)," "Feret's diameter (mm)," and "Circularity" were calculated from the fluoroscopic images. Among the indices, only "Area" showed a significant difference between coils (p = 0.002). On multivariate analysis, "Area" of the ED Infini was larger than those of Target XL soft and Galaxy G3 (p = 0.018 and 0.026, respectively). Furthermore, the area of the 360 soft was larger than that of G3 (p = 0.049). Analysis of the correlation between these values and the coil configuration showed that "Area" was negatively correlated with the stock-wire diameter (r = -0.50; p = 0.004) and primary coil configuration (r = -0.65; p < 0.001). When inserting the coils in the early stage, although the difference between each coil is relatively difficult to obtain, knowledge on the proper use of the coils with differences in characteristics can help in selecting the coil most appropriate for the conditions.

DOI： 10.18999/nagjms.84.4.762

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Language：Japanese   Publisher：(NPO)日本脳神経血管内治療学会  

Language：English   Publishing type：Research paper (scientific journal)  

OBJECTIVE: After revascularization surgery in pediatric patients with moyamoya disease (MMD), resting and avoiding crying is important. However, this inaction is often difficult because of pain or anxiety. Dexmedetomidine (DEX), which has sedative and analgesic properties, may be useful in reducing those uncomfortable conditions; however, its common side effects include bradycardia and hypotension, which have a risk of decreasing the cerebral blood flow. The aim of this study was to investigate the efficacy and safety of using DEX for pediatric patients with MMD in the acute period after revascularization surgery. METHODS: This retrospective study included pediatric patients with MMD who underwent revascularization surgery. Based on whether DEX was used for light sedation during postoperative days (PODs) 0-1 after extubation, the patients were divided into DEX or control groups. For neurological outcomes, the incidence of symptomatic cerebral infarction and transient neurological events (TNEs) during PODs 0-1 and the entire hospitalization were investigated. In addition, the Richmond Agitation-Sedation Scale (RASS) was used to assess the effect of DEX, and bradycardia and hypotension were evaluated as side effects. RESULTS: A total of 84 surgical procedures were included in this study (27 in the DEX group and 57 in the control group). During PODs 0-1, symptomatic infarction was not observed in either group. The incidence of TNEs was almost the same in both groups: 2 (7.4%) of the 27 procedures in the DEX group and 4 (7.0%) of the 57 procedures in the control group (p > 0.99). Moreover, the incidences of symptomatic infarction and TNEs during the entire hospitalization did not differ significantly (symptomatic infarction, p > 0.99; TNEs, p = 0.20). Regarding the DEX effect, the median RASS scores during PODs 0-1 were -1.0 (drowsy) in the DEX group and +1.0 (restless) in the control group, showing a significant difference (p < 0.01). Regarding side effects, bradycardia was observed only in 3 (11.1%) of the 27 procedures in the DEX group (p = 0.03), and hypotension was not observed in any of the cases. CONCLUSIONS: In pediatric patients with MMD who are extubated after revascularization surgery, DEX produced appropriate light sedation and analgesia. The risk for symptomatic infarction is almost the same in cases in which DEX is used and those in which it is not; however, neurosurgeons should be cautious of bradycardia and TNEs as potential side effects.

DOI： 10.3171/2022.6.PEDS2241

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OBJECTIVES: Congenital afibrinogenemia is an autosomal recessive inherited disorder that can cause thrombotic as well as hemorrhagic events. We describe a case of repeated mild ischemic strokes due to a mural thrombus in the carotid artery and our medical treatment. CASE DESCRIPTION: A 49-year-old woman with congenital afibrinogenemia developed two minor ischemic strokes in two months. Clinical images revealed scattered fresh infarcts in the right middle cerebral artery region and mild cervical carotid artery stenosis. The risk for surgical treatment was considered to be extraordinarily high. The patient was treated with 100 mg/day of aspirin and 3 g fibrinogen infusion every two weeks. After the one-year course of medication, the mural thrombus gradually decreased, and there were no bleeding or ischemic stroke events. CONCLUSION: This case report highlights the successful treatment of an ischemic stroke in a patient with a congenital afibrinogenemia with an antiplatelet agent and fibrinogen replacement. There are no guidelines for managing ischemic stroke in patients with congenital afibrinogenemia, and further studies are needed.

DOI： 10.1016/j.jstrokecerebrovasdis.2022.106526

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Language：English   Publishing type：Research paper (scientific journal)  

The purpose of this study was to examine the effects of combined revascularization for ischaemic-onset moyamoya disease (MMD) on cerebral haemodynamics by comparing cerebral blood flow (CBF) during the postoperative chronic phase with preoperative CBF. A retrospective cohort of 24 MMD patients (representing 31 surgeries) who received single photon emission computed tomography (SPECT) before and more than 6 months after surgery was investigated. The CBF value of each vascular territory was extracted from SPECT data, and the value relative to the ipsilateral cerebellar value (relative CBF, or RCBF) was calculated. The correlation between the revascularization effect and the proportional change in RCBF before and after surgery (calculated as post-RCBF/pre-RCBF ("post/pre-RCBF")) was analysed. Furthermore, the relationships between changes in neurological symptoms and post/pre-RCBF were investigated. Preoperative and postoperative mean RCBF values were 0.92 ± 0.15 and 0.96 ± 0.13 (p = 0.619) in the anterior cerebral artery territory, 0.99 ± 0.17 and 1.01 ± 0.17 (p = 0.598) in the middle cerebral artery territory and 1.15 ± 0.22 and 1.14 ± 0.19 (p = 0.062) in the posterior cerebral artery territory, respectively. No significant correlation was found between the revascularization score and post/pre-RCBF. The revascularization score and post/pre-RCBF were not significant predictors of worsening neurological symptoms postoperatively. No significant change in RCBF was observed in any vascular territory in the chronic phase after revascularization. Combined revascularization may assist in the redirection of blood flow from the internal to the external carotid system and contribute to CBF maintenance.

DOI： 10.1007/s10143-022-01774-8

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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.

DOI： 10.1177/15910199211031765

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Balloon test occlusion (BTO) is an angiographic test to evaluate ischemic tolerance after permanent occlusion of an internal carotid artery (ICA). BTO can simulate ischemia caused by parent artery occlusion and can be used to select a suitable bypass surgery using specific criteria. On the other hand, a postoperative thrombus can form despite proper case selection, optimal radiological evaluation, and an appropriate surgical strategy. Postoperative ischemic complications related to perforating branches are clinically significant. This simulation study aimed to analyze postoperative flow characteristics and elucidate the cause of ischemic complications related to the perforating branch using computational fluid dynamics (CFD). An unexpected postoperative thrombus formation related to the perforating branch occurred after treating a giant aneurysm in the cavernous portion of the ICA in a patient. Three-dimensional digital subtraction angiography was used to acquire flow data and set up the CFD simulation. The flow simulations were performed at various bypass flow rates. The CFD analysis indicated flow stagnation in the ICA only when surgical treatment using a low-flow bypass graft was performed. Thrombus formation may lead to ischemic complications related to the perforating branch, such as the anterior choroidal artery. BTO did not reflect the influence of bypass blood flow. Therefore, recognizing that blood flow stagnation may occur and comprehensively deciding on the surgical strategy by CFD analysis can be helpful to prevent ischemic complications in patients with giant aneurysms.

DOI： 10.1038/s41598-022-11321-6

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Publisher：Journal of Neurosurgery: Case Lessons  

BACKGROUND Symptomatic hyperperfusion after cerebral revascularization for pediatric moyamoya disease (MMD) is a rare phenomenon. The authors report a series of patients with this condition. OBSERVATIONS In all three patients in this case series, the combined revascularization was on the left side, the patency of bypass grafts was confirmed after surgery, and focal hyperemia around the anastomotic site was observed on single photon emission computed tomography (SPECT). On the first to eighth days after surgery, all of the patients developed neurological manifestations, including motor aphasia, cheiro-oral syndrome, motor weakness of their right upper limbs, and severe headaches. These symptoms disappeared completely approximately 2 weeks after surgery, and all patients were discharged from the hospital. Quantitative SPECT was performed to determine the proportional change in cerebral blood flow (DRCBF) (to ipsilateral cerebellar ratio (denoted DRCBF) in the region of interest around the anastomoses, and the mean value was 1.34 (range, 1.29–1.41). LESSONS This rare condition, which develops soon after surgery, requires an accurate diagnosis by SPECT. One indicator is that the DRCBF has risen to 1.3 or higher. Subsequently, strategic blood pressure treatment and fluid management could prevent the development of hemorrhagic stroke.

DOI： 10.3171/CASE2274

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: In patients with moyamoya disease (MMD) who receive superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, hypoperfusion remote from the anastomosis site rarely occurs. Watershed shift due to direct bypass has been proposed as the mechanism; however, no report has confirmed this phenomenon using angiography. OBSERVATIONS: A 48-year-old man presented with transient weakness in his left arm. Angiography revealed severe bilateral stenosis of the MCAs and moyamoya vessels. The right anterior cerebral artery (ACA) had short stenosis at A2 but ample blood supply to the cortical area of the right ACA and MCA regions. The patient was diagnosed with MMD and received a single STA-MCA bypass. The next day, he had difficulty communicating, and a cerebral infarction away from the anastomosis site was identified. Perfusion examination revealed hyperperfusion around the direct bypass and hypoperfusion away from the anastomosis site. Angiography revealed bypass patency; however, the original anterograde flow of the right ACA decreased significantly at the stenosed point, indicating an improper watershed shift. LESSONS: STA-MCA bypass for patients with MMD can cause an improper watershed shift decreasing cerebral flow. Donor flow should be prepared based on each angiographic characteristic, and the risk of the improper watershed shift should be considered.

DOI： 10.3171/CASE22104

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PubMed

Language：English   Publishing type：Research paper (scientific journal)  

OBJECTIVE: Cerebral revascularization is necessary for pediatric patients younger than 5 years with moyamoya disease (MMD). However, they have a high risk of developing cerebral infarction early after surgery. This study aimed to analyze the risk factors for developing cerebral infarction among these patients. METHODS: The charts of 21 consecutive patients with MMD (39 surgeries) younger than 5 years who had undergone revascularization at our hospital were retrospectively analyzed. Because cerebral infarction occurring within 1 month after surgery was the primary end point, other clinical information was evaluated, including each surgical procedure. Multivariate analysis of the risk factors for postoperative cerebral infarction was performed. RESULTS: Cerebral infarction occurred after 7 of 39 surgeries (17.9%). Of the 39 surgeries, 23 (59%) included direct and indirect combined revascularization. The incidence of cerebral infarction did not differ significantly between the combined (21.7%) and indirect (12.5%) groups (P = 0.46). Logistic regression showed no association between the revascularization procedure and the occurrence of cerebral infarction after surgery (P = 0.3). However, younger age at surgery was correlated with a higher risk of developing cerebral infarction in the early postoperative period (P = 0.05). CONCLUSIONS: No differences were found in the risk of developing cerebral infarction early after surgery as a result of surgical procedures. However, younger patients had higher postoperative risk. Further multicenter research should examine this issue for young pediatric patients with moyamoya at high risk of developing cerebral infarction.

DOI： 10.1016/j.wneu.2021.12.115

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Language：English   Publishing type：Research paper (scientific journal)  

Cerebral revascularization for moyamoya disease (MMD) is an effective treatment for improving cerebral ischaemia and preventing rebleeding. Although direct bypass surgery is commonly performed on older children and adults, it is challenging in very young children due to the high difficulty level of the procedure. The subjects were MMD patients under 3 years of age on whom surgery was performed by a single surgeon (Y.A.). Preoperative clinical findings, information related to direct bypass surgery, bypass patency, and the incidence of postoperative stroke were investigated. Combined revascularization, including direct bypass surgery, was performed on 3 MMD patients (3 sides) under 3 years of age. The average diameter of the grafts used in direct bypass was 0.8 mm. The average recipient diameter was 0.8 ± 0.17 (range 0.6-1) mm. In all cases, the anastomotic procedure was completed using 11-0 monofilament nylon thread, and patency was confirmed. Direct bypass for MMD patients under 3 years old is technically challenging. However, despite the anatomical differences between very young children and elderly individuals, direct bypass surgery could certainly be completed. In addition, a rapid recovery from cerebral blood flow insufficiency could yield a promising neurological outcome.

DOI： 10.1007/s10143-021-01685-0

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Language：English   Publishing type：Research paper (scientific journal)  

Superficial temporal artery (STA) to superior cerebellar artery (SCA) bypass is usually performed via the subtemporal approach (StA), anterior transpetrosal approach (ApA), or combined petrosal approach (CpA), but no study has yet reported a quantitative comparison of the operative field size provided by each approach, and the optimal approach is unclear. The objective of this study is to establish evidence for selecting the approach by using cadaver heads to measure the three-dimensional distances that represent the operative field size for STA-SCA bypass. Ten sides of 10 cadaver heads were used to perform the four approaches: StA, ApA with and without zygomatic arch osteotomy (ApA-ZO- and ApA-ZO+), and CpA. For each approach, the major-axis length and the minor-axis length at the anastomosis site (La-A and Li-A), the major-axis length and the minor-axis length at the brain surface (La-B and Li-B), the depth from the brain surface to the anastomosis site (Dp), and the operating angles of the major axis and the minor axis (OAa and OAi) were measured. Shallower Dp and wider operating angle were obtained in the order CpA, ApA-ZO+, ApA-ZO-, and StA. In all parameters, ApA-ZO- extended the operative field more than StA. ApA-ZO+ extended La-B and OAa more than ApA-ZO-, whereas it did not contribute to Dp and OAi. CpA significantly decreased Dp, and widened OAa and OAi more than ApA-ZO+. ApA and CpA greatly expanded the operative field compared with StA. These results provide criteria for selecting the optimal approach for STA-SCA bypass in light of an individual surgeon's anastomosis skill level.

DOI： 10.1007/s10143-021-01686-z

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Remote cerebral infarction after combined revascularization of the middle cerebral artery (MCA) territory is rare in patients with moyamoya disease (MMD) with a fetal-type posterior communicating artery (PCoA). OBSERVATIONS: A 57-year-old woman developed numbness in her right upper limb and transient motor weakness and was diagnosed with MMD. She also had a headache attack and a scintillating scotoma in the right visual field. Preoperative magnetic resonance angiography (MRA) showed stenosis of the left posterior cerebral artery (PCA). Combined revascularization was performed for the left MCA territory. No new neurological deficits were observed for 2 days after the operation, but right hemianopia, alexia, and agraphia appeared on postoperative day (POD) 4. Magnetic resonance imaging showed a new left occipitoparietal lobe infarction, and MRA showed occlusion of the distal left PCA. After that point, the alexia and agraphia gradually improved, but right hemianopia remained at the time of discharge on POD 18. LESSONS: Cerebral ischemia in the PCA territory may occur after combined revascularization of the MCA territory in patients with fetal-type PCoA. For these cases, a double-barrel bypass or indirect revascularization to induce a slow conversion could be considered on its own as a treatment option.

DOI： 10.3171/CASE21704

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PubMed

Language：English   Publishing type：Research paper (scientific journal)   Publisher：Journal of Neurosurgery Publishing Group (JNSPG)  

OBJECTIVE

De novo aneurysms generally develop in healthy vessels after parent artery occlusion for large internal carotid artery (ICA) aneurysm, possibly owing to increased hemodynamic stress in the remaining vessels. In recent years, there has been a shift toward flow diverter stent treatment. However, there is a lack of direct evidence and data that prove this change in hemodynamic stress in healthy vessels after parent artery occlusion and flow diverter stent treatment. The authors compared hemodynamic stress in healthy-side vessels before and after parent artery occlusion and flow diverter treatments.

METHODS

The authors included patients who underwent 3D cine phase-contrast MRI before and after large ICA aneurysm treatment. Spatially and temporally averaged volume flow rates and spatially averaged systolic wall shear stress (WSS) in healthy-side ICA distal to the posterior communicating artery (C₁ segment according to Fisher’s classification) were measured before and after parent artery occlusion and flow diverter treatments.

RESULTS

Seventeen patients were included (5 patients in the parent artery occlusion group and 12 in the flow diverter group). At 1–2 months after treatment, median volume flow rate in healthy-side ICA increased from 5.36 ml/sec to 6.28 ml/sec (total increase 117%, p = 0.04) in the parent artery occlusion group and from 4.65 ml/sec to 4.93 ml/sec (total increase 106%, p = 0.02) in the flow diverter group. In the parent artery occlusion group, median WSS in the C₁ segment of the healthy-side ICA increased from 3.91 Pa to 5.61 Pa (total increase 143%, p = 0.08); however, no significant increase was observed in the flow diverter group (4.29 Pa to 4.57 Pa [total increase 107%, p = 0.21]).

CONCLUSIONS

Postoperatively, volume flow rate and WSS in the C₁ segment of the healthy-side ICA significantly increased in the parent artery occlusion group. Therefore, the parent artery occlusion group was more prone to de novo aneurysm than the flow diverter group.

DOI： 10.3171/2021.2.JNS204185

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Other Link： https://thejns.org/downloadpdf/journals/j-neurosurg/136/3/article-p619.xml

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Transient neurological deficits (TNDs) develop after cerebral revascularization in patients with moyamoya disease (MMD). The authors report a rare pediatric MMD case with extensive decreased cerebral blood flow (CBF) and prolonged TNDs after combined revascularization. OBSERVATIONS: A 9-year-old boy presented with transient left upper limb weakness, and MMD was diagnosed. A right-sided combined surgery was performed. Two years after the surgery, frequent but transient facial (right-sided) and upper limb weakness appeared. The left internal carotid artery terminal stenosis had progressed. Therefore, a left combined revascularization was performed. The patient's motor aphasia and right upper limb weakness persisted for approximately 10 days after surgery. Magnetic resonance angiography showed that the direct bypass was patent, but extensive decreases in left CBF were observed using single photon emission tomography. With adequate fluid therapy and blood pressure control, the neurological symptoms eventually disappeared, and CBF improved. LESSONS: The environment of cerebral hemodynamics is heterogeneous after cerebral revascularization for MMD, and the exact mechanism of CBF decreases was not identified. TNDs are significantly associated with the onset of stroke during the early postoperative period. Therefore, appropriate treatment is desired after determining complex cerebral hemodynamics using CBF studies.

DOI： 10.3171/CASE21628

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Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective</b>: Owing to the limited time since the introduction of the PulseRider (PR), inconsequential or rare complications that clinicians should be aware of remain unreported yet. Here, we report a rare complication of incomplete detachment.</p><p><b>Case Presentation</b>: A 50-year-old male underwent PR-assisted coil embolization for a basilar tip aneurysm. Coiling was completed, and the detachment procedure was performed using a detachment machine; the success signal was observed. The delivery microcatheter was subsequently advanced back up to the proximal markers, and no reapproximation of the proximal markers, which indicates successful detachment, was observed. However, only one of the proximal markers returned to the microcatheter, and incomplete detachment of only one leg was detected. Ultimately, electrical detachment was not possible, and physical separation by tension was achieved.</p><p><b>Conclusion</b>: Our case report presents a rare case of a detachment problem in the PR. The PR could not be detached, although the signal revealed successful detachment. Therefore, careful withdrawal of the delivery wire by checking not only the proximal markers but also the behavior of the entire PR and coil complex is important.</p>

DOI： 10.5797/jnet.cr.2021-0095

PubMed

CiNii Research

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: The aim of this study was to investigate the association between early postoperative slow flow in bypass grafts and preoperative focal cerebral blood flow (CBF) in patients who underwent combined surgery for moyamoya disease (MMD). METHODS: The subjects were 18 patients (22 surgeries) who underwent single photon emission computed tomography (SPECT) before surgery. The CBF value of the middle cerebral artery territory was extracted from the SPECT data, and the value relative to the ipsilateral cerebellar CBF (relative CBF, or RCBF) was calculated. The association between RCBF and early postoperative slow flow in the bypass graft was investigated. In addition, the correlation between the revascularization effect and preoperative RCBF was analyzed. RESULTS: In four of 22 surgeries (18.2%), slow flow in the bypass graft was identified in the early postoperative period. Preoperative RCBF in the slow flow and patent groups was 0.86 ± 0.15 and 0.87 ± 0.15, respectively, with no significant difference (P = 0.72). The signal intensity of four slow-flowed bypasses was improved in all cases on magnetic resonance angiography images captured during the chronic phase (mean of 3.3 months postoperatively). The revascularization scores were 2 ± 0.82 and 2.1 ± 0.68 in the slow flow and patent groups, respectively, and did not differ significantly (P = 0.78). A significant correlation was not observed between preoperative RCBF and the revascularization effect. CONCLUSION: No significant association was observed between preoperative RCBF and early postoperative slow flow in bypass grafts in patients with MMD undergoing combined surgery. Given the high rate of improved depiction of slow-flowed bypass in the chronic postoperative phase, the conceptual significance of an opportune surgical intervention is to maintain CBF by supporting the patient's own intracranial-extracranial conversion function.

DOI： 10.25259/SNI_772_2022

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Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective</b>: Superior petrosal sinus dural arteriovenous fistula (SPS-DAVF) is a rare subtype of intracranial DAVF that sometimes leads to hemorrhagic symptoms following deep venous drainage. Here we report the case of SPS-DAVF with retrograde venous reflux to the cerebellar vein. Preoperative contrast-enhanced MRI was a decisive factor in a safe and effective treatment.</p><p><b>Case Presentation</b>: A 37-year-old woman was referred to our hospital with abnormal MRI findings, which was performed when she had a mild headache during her check-up. DSA revealed left-sided SPS-DAVF, which was diagnosed as Cognard type IIb. Both CTA and DSA could not detect the whole SPS but only the shunt pouch. Using contrast-enhanced MRI, we were able to visualize the presence of the SPS and its continuity within the shunt pouch. 3D-T1 turbo spin echo (SPACE) showed a low-intensity area in the SPS, which was not seen in the 3D-T1 fast field echo (FFE). During the procedure, there was a point where it was difficult to advance the microcatheter, which coincided with the low-intensity area. We achieved effective transvenous embolization from the occluded venous access by devising a surgical technique.</p><p><b>Conclusion</b>: In addition to the contrast-enhanced 3D-T1 FFE, 3D-T1 SPACE might provide beneficial information for endovascular therapy in the evaluation of venous sinuses, which could not be detected by standard examinations.</p>

DOI： 10.5797/jnet.cr.2021-0029

PubMed

CiNii Research

Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

<p>In this article, we report a case wherein a brain tumor was suspected based on computed tomography and magnetic resonance imaging findings. We made an initial diagnosis of malignant brain tumor based on methionine-positron emission tomography (PET) findings, but the correct diagnosis was dural arteriovenous fistula (DAVF). The patient was a 45-year-old man with DAVF who developed headache. Methionine-PET imaging showed high methionine uptake in the lesion. Although the tumor was strongly suspected from the findings of methionine-PET, the diagnosis of DAVF could be made correctly only by interpreting digital subtraction angiography and computed tomographic angiography. The findings of methionine-PET, which is considered useful in the diagnosis and denial of brain tumors, made the diagnosis of DAVF more difficult. The increased uptake of methionine-PET in DAVF is an important finding because, to our knowledge, this study is the first to report such finding. The results of this study might be useful for differential diagnoses when the diagnosis is uncertain.</p>

DOI： 10.2176/jns-nmc.2022-0055

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CiNii Research

Language：English   Publishing type：Research paper (scientific journal)  

Stroke and neurological outcomes in the early phase following revascularization for moyamoya disease (MMD) may depend on the patient's age. In this study, an age-stratified comparative analysis was performed to clarify this issue. We reviewed 105 MMD patients who underwent 179 revascularization surgeries. The demographic characteristics were collected in four age groups (≤ 5 and 6-17 years for pediatric patients and 18-49 and ≥ 50 years for adults). Additionally, we assessed the incidence of subsequent stroke and deterioration of modified Rankin Scale (mRS) score. Then, we evaluated predictors of postoperative stroke and mRS deterioration using logistic regression. The mean patient age was 26.2 ± 18.5 years. No significant difference in the incidence of postoperative stroke was observed between age groups; however, the incidence tended to be increased among patients aged ≤ 5 years (17.9%) and patients aged ≥ 50 years (16.7%). Deterioration of mRS scores was significantly associated with ages ≤ 5 years (17.9%) and ≥ 50 years (11.1%). Logistic regression showed that posterior cerebral artery involvement (odds ratio [OR], 4.6) and postoperative transient neurological events (TNEs) (OR, 5.93) were risk factors for postoperative stroke. Age ≤ 5 years (OR, 9.73), postoperative TNEs (OR, 7.38), and postoperative stroke (OR, 49) were identified as predictors of unfavorable neurological outcomes. The novel feature of this comparative analysis by age group is that membership in the early-childhood MMD patient group (under 5 years old) was an independent risk factor for unfavorable short-term neurological outcomes and was mainly associated with the incidence of postoperative severe cerebral infarction.

DOI： 10.1007/s10143-020-01459-0

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

<p>The carotid sinus reflex (CSR) is a rare complication of the Pipeline Embolization Device (PED) deployment. No study has assessed the potential risk factors in a case series. The purpose of this study was to examine CSR triggering during PED deployment. Thirty-seven consecutive patients who underwent PED deployment were included. All procedures were performed under local anesthesia with mild sedation. We retrospectively analyzed patient characteristics, PED deployment time, and vital signs during the procedure. The vital signs included the pulse rate (PR) and systolic blood pressure (SBP) obtained at three timepoints (pre-deployment, during deployment, post-deployment). We examined the triggering of the CSR during PED deployment by comparing the vital signs at the three timepoints. Moreover, risk factors for CSR were analyzed with univariate analysis. The patients’ average age was 66.3 years. The average size of the aneurysm was 18.0 mm. Six patients (16.2%) showed a decline in the SBP or PR defined as CSR. One patient had a transient cardiac arrest and two had severe transient bradycardia. Deployment into the ophthalmic segment of the internal carotid artery (C2 segment) aneurysm (p = 0.022), prolonged PED deployment time more than 14.5 minutes (p = 0.005), and an acute angle of the anterior genu less than 51.5 degrees (p = 0.005) were risk factors in triggering CSR. CSR may be triggered during PED deployment under local anesthesia with mild sedation. Deployment to the C2 segment aneurysm, prolonged PED deployment time, and an acute angle of the anterior genu were associated with CSR triggering.</p>

DOI： 10.2176/nmc.oa.2021-0049

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CiNii Research

Language：Japanese   Publisher：(NPO)日本脳神経血管内治療学会  

【目的】多発硬膜動静脈瘻(dural arteriovenous fistula:DAVF)の症例において,左上錐体静脈洞部(superior petrosal sinus:SPS)のシャントを右SPS経由で塞栓した症例を報告する.【症例】60歳女性,意識障害の精査にて深部静脈逆流を伴う多発DAVFを認めた.逆流に最も関与する左横静脈洞部DAVFに対して経静脈的塞栓術を施行した.術後症状改善が乏しく,再度DSAを行うと,左SPSへのシャントと深部静脈への逆流が明らかとなった.左横静脈洞と両側下錐体静脈洞は閉塞していたため,右SPSと両側海綿静脈洞を経由してマイクロカテーテルをシャント部へ誘導し,左SPSを塞栓し,逆流の消失を得た.【結論】対側SPSを経由したSPSへのアクセスは,同側からのアクセスが困難な症例において,有効な選択肢になり得る.(著者抄録)

Other Link： https://search.jamas.or.jp/default/link?pub_year=2021&ichushi_jid=J06751&link_issn=&doc_id=20211027220008&doc_link_id=%2Fcf5nokec%2F2021%2F000603%2F008%2F0161-0168%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fcf5nokec%2F2021%2F000603%2F008%2F0161-0168%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

<p>Cone beam computed tomography (CBCT) images are degraded by artifacts due to endovascular implants. We evaluated the use of streak metal artifact reduction technique (SMART) in non-contrast CBCT images after endovascular neurosurgery obtained from 148 patients (125 with aneurysm and 23 with dural arteriovenous fistula [dAVF]). Three neurosurgeons evaluated the cistern and brain surface visibility in CBCT images with and without SMART correction based on a 4-point scale (1, excellent; 2, good; 3, limited; and 4, insufficient). Significant improvement in visibility was achieved when the median scores improved from 4 or 3 to 2 or 1 or from 2 to 1. Metal artifact reduction in adjacent slices without metal and new artifacts after SMART correction was also examined. A significant improvement was achieved regarding the visibility of the cistern in 90 (60.8%) images and of the brain surface in 108 (73.0%) images. Metal size (cistern: odds ratio [OR], 0.91 per 1 mm increase; 95% confidence interval [CI], 0.83–0.99), irregular metal shape (cistern: OR, 0.18; 95% CI, 0.05–0.60 and brain surface: OR, 0.15; 95% CI, 0.05–0.45), and infratentorial lesions (cistern: OR, 0.37; 95% CI, 0.14–0.96 and brain surface: OR, 0.30; 95% CI, 0.11–0.80) were negatively correlated with improved visibility. Metal artifact reduction in adjacent slices without metal was obtained in 25.6% and 34.8% of images with aneurysm and dAVF, respectively. New artifacts after SMART correction were found in 4.8% and 13.0% of images with aneurysm and dAVF, respectively. SMART is especially effective for supratentorial small aneurysms.</p>

DOI： 10.2176/nmc.oa.2021-0014

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CiNii Research

Language：English   Publishing type：Research paper (scientific journal)  

In superficial temporal artery to middle cerebral artery anastomosis with indirect revascularization for patients with moyamoya disease, the optimal method for selecting the most appropriate cortical artery for the recipient in anastomosis has not been established. We investigated the relationship between the fluorescence emission timing of the recipient artery in the preanastomosis indocyanine green videoangiography and operative outcomes. This retrospective study included 51 surgical revascularization procedures for 39 moyamoya disease patients. The enrolled surgical procedures were classified into three groups based on the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography: the EARLIEST, the INTERMEDIATE, and the LATEST. Clinical characteristics and operative outcomes were also collected. The occurrence of white thrombus at the anastomosis site and symptomatic hyperperfusion showed significant differences between the groups classified by the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography (white thrombus, p = 0.001; symptomatic hyperperfusion, p = 0.026). The development of white thrombi was significantly higher in the LATEST group, and all symptomatic hyperperfusion was observed in the EARLIEST group. These results indicated that the LATEST group had a significantly higher risk for developing white thrombus, and the EARLIEST group was prone to occur symptomatic hyperperfusion. Selecting the recipient artery based on evaluating the fluorescence emission timing in preanastomosis indocyanine green videoangiography may be useful in reducing perioperative complications.

DOI： 10.18999/nagjms.83.3.523

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

<p>The straightening phenomenon is known as a cause of catheter kickback in the late phase of coil embolization. The mechanism is supposed to be the relative shortage of the stretch resistance (SR) line, and it occurs when a coil is folded too small. Among many SR coils available, there should be a coil-specific tendency to cause this phenomenon. Here, we conducted an in-vitro experiment to know which coil is the most resistant to the straightening phenomenon. We developed an experimental model to reproduce the straightening phenomenon. Five different coils (Axium Prime, ED Coil, Hypersoft, SMART Coil, and Target 360 nano) of the same size (3 mm × 6 cm) were investigated for five times each. Resistance to the straightening phenomenon, which is represented by the insertion length at the onset of the phenomenon, was compared among coil types. The straightening phenomenon was successfully observed in all insertions. Insertion lengths were significantly different among coil types (p = 0.013). The insertion length of ED was the longest (mean ± SD, 27.0 ± 8.3 mm), which means the most resistant to the phenomenon. Axium was second (21.6 ± 7.0 mm), followed by Target (15.8 ± 6.9 mm), Hypersoft (13.8 ± 5.8 mm), and SMART (12.4 ± 4.7 mm). Difference between ED and Hypersoft (p = 0.037) and difference between ED and Smart (p = 0.018) were significant. ED coil was the one with the most resistance to the straightening phenomenon. Selecting the optimal coil is the key to avoid the phenomenon.</p>

DOI： 10.2176/nmc.oa.2020-0348

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CiNii Research

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: When superficial temporal artery-middle cerebral artery bypass is combined with indirect methods (e.g., revascularization surgery) to treat Moyamoya disease (MMD), antiplatelet treatment can impact bypass patency, infarction, or hemorrhage complications. Recently, heparin has been proposed as an anticoagulant treatment against white thrombus at the anastomosis site. The study aims to evaluate the effect of aspirin on the perioperative outcomes and investigate the results of heparin treatment for white thrombus. METHODS: This retrospective study included 74 procedures of combined revascularization surgery for MMD patients who either received or did not receive aspirin. Perioperative outcomes were compared between the two groups. In addition, the effects of heparin treatment for white thrombus were evaluated. RESULTS: The rate of white thrombus at the anastomosis site was significantly higher in the non-aspirin medication group (univariate: p = 0.032, multivariate: p = 0.044) and, accordingly, initial bypass patency was lower in the non-aspirin medication group (p = 0.049). Of the 17 patients with white thrombus development, five received heparin injections, and all white thrombi disappeared; however, there was one case of epidural hematoma and another of subdural hematoma. The risk of hemorrhagic complications was significantly higher in the surgical procedures that received heparin injections (p = 0.021). CONCLUSIONS: In MMD patients who received combined revascularization surgery, aspirin medication lowered the occurrence of white thrombus. Heparin injections help to treat white thrombus but can enhance the risk of hemorrhagic complications.

DOI： 10.1007/s00701-020-04668-0

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Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Ipsilateral late stroke events occurring after cerebral revascularization for Moyamoya disease (MMD) and their risk factors have not been fully investigated. METHODS: We retrospectively analyzed 123 patients with MMD who underwent 212 revascularizations. We investigated preoperative demographic data, surgical procedures, and ipsilateral stroke events occurring more than 1 month after surgery. The effect of revascularization and the residual Moyamoya vessel (MMV) score were examined using magnetic resonance angiography (MRA). Then, predictive factors for postoperative late stroke occurrence were evaluated by logistic regression. RESULTS: The mean age was 26 ± 18.4 years (range 1 to 66 years). Ipsilateral late stroke events were present in 11 of 123 (9%) patients. Stroke occurred in 11 out of 212 surgeries (5.2%) on a hemispheric basis. During the 1300.1 hemisphere-years of follow-up more than 1 month after surgery, the annual stroke rate was 0.84%. The postoperative MRA time-of-flight image showed a mean revascularization score of 1.82 ± 0.6 and a mean residual MMV score of 1.91 ± 0.83. Postoperative strokes occurring within 1 month after cerebral revascularization (36.4%, p = 0.0026) and lower revascularization scores (1.82 ± 0.6 vs 2.51 ± 0.59, p = 0.0006) were significant factors related to the presence of ipsilateral late stroke. Logistic regression showed that stroke events within 1 month after revascularization (odds ratio [OR], 9.79; 95% confidence interval [CI], 0.02-0.57; p = 0.0103), low revascularization score (OR, 0.15; 95% CI, 0.001-0.37; p = 0.0069), and high residual MMV score (OR, 16.2; 95% CI, 1.88-187.4; p = 0.0107) were risk factors for ipsilateral stroke more than 1 month after revascularization. CONCLUSIONS: MMD patients who have a stroke within 1 month after cerebral revascularization are at high risk for late strokes. Less effective revascularization or remarkable residual MMV are risk factors for late stroke events. Additional revascularization may be considered for patients in such situations. CLINICAL TRIAL REGISTRATION: This study was approved by the Bioethics Review Committee of Nagoya University Hospital for the treatment and prognosis of Moyamoya disease (2016-0327).

DOI： 10.1007/s00701-021-04773-8

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Language：Japanese   Publisher：(NPO)日本脳神経血管内治療学会  

【目的】ステント留置後妊娠において,抗血栓療法に関する明確な基準は認めない.われわれは破裂大型脳底動脈瘤に対してステント支援コイル塞栓術を施行し,2度の出産を経験した症例を報告する.【症例】27歳女性.脳底動脈瘤破裂によるくも膜下出血を発症し,ステント支援コイル塞栓術を施行した.33歳時に体外受精にて妊娠した.抗血小板剤は治療3年後に中止となっていたが,妊娠時の過凝固を考慮しアスピリンを開始,28週からヘパリン皮下注射へ切り替え,帝王切開で児を分娩した.母子共に合併症なく経過した.35歳時の妊娠も同内容の抗血栓療法を行い,合併症なく経過した.【結論】周産期抗血栓療法によって合併症なく2度の分娩を経験した.(著者抄録)

Other Link： https://search.jamas.or.jp/default/link?pub_year=2021&ichushi_jid=J06751&link_issn=&doc_id=20210527200004&doc_link_id=%2Fcf5nokec%2F2021%2F000601%2F004%2F0024-0029%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fcf5nokec%2F2021%2F000601%2F004%2F0024-0029%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japan Neurosurgical Society  

<p>Internal trapping with coils is an established treatment of symptomatic large non-branching thrombosed fusiform vertebral artery aneurysms (VAA). However, when perforators arise near the aneurysm neck, parent artery occlusion has a high risk of causing medullary infarction. As an alternative treatment, we performed short-segment internal trapping of the artery using n-butyl-2-cyanoacrylate (NBCA) and coils (bird’s nest trapping). Before treatment, perianeurysmal perforators are carefully detected using high-resolution three-dimensional rotational angiography (3DRA). Double microcatheters are advanced to the distal portion of the aneurysm through a balloon guiding catheter where coils are deployed without tight packing. Then, NBCA is injected into the coil mass, taking care to preserve perforators and significant branches. The same maneuver is repeated in the proximal portion of the aneurysm. Coil placement is avoided within the middle of the aneurysm; however, if necessary, only a small number of coils are placed to prevent worsening of mass effect. Two quinquagenarian males presented with a large thrombosed fusiform VAA that caused symptoms due to mass effect. In each case, perforators arose from the parent artery and short-segment internal trapping with NBCA and coils was performed. Symptoms improved after treatment and follow-up imaging confirmed aneurysm shrinkage with no long-time recurrence. In symptomatic large fusiform VAAs where the distance from the lesion to important perforators is extremely short, internal trapping using a combination of NBCA and coils can be more useful than conventional internal trapping.</p>

DOI： 10.2176/nmc.tn.2020-0329

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CiNii Research

Language：English   Publishing type：Research paper (scientific journal)  

PURPOSE: In endovascular neurosurgery, the operator often acquires three-dimensional (3D) images of the cerebral vessels. Although workstation reoperation is required in some situations during treatment, it leads to time loss because a sterile condition cannot be maintained and treatment must be temporarily interrupted. Therefore, a workstation reoperating system is required while maintaining the desired sterility. METHODS: A contactless operating interface using Kinect to control 3D images was developed via gesture recognition for endovascular neurosurgery and was applied to a 3D volume rendering technique (VRT) image reconstructed at the workstation. The left-hand movement determines the assigned functions, whereas the right-hand movement is used like a computer mouse to pan and zoom in/out. In addition to the interface, voice commands were used and assigned to digital operations, such as image view changes and mode signal changes. RESULTS: This system was used for the actual endovascular treatment of cerebral aneurysms and cerebral arteriovenous malformations. The operator and gesture were recognized without any problems. Using voice operation, it was possible to expeditiously set the VRT image back to the reference angle. Furthermore, it was possible to finely adjust gesture operations, including mouse operation, and treatment was completed while maintaining sterile conditions. CONCLUSION: A contactless operating interface was developed by combining the existing workstation system with Kinect and voice recognition software, allowing surgeons to perform a series of operations, which are normally performed in a console room, while maintaining sterile conditions.

DOI： 10.1007/s11548-021-02330-3

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DOI： 10.2176/nmccrj.cr.2020-0036

PubMed

Language：English   Publishing type：Research paper (scientific journal)  

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.

DOI： 10.18999/nagjms.83.1.21

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Elsevier {BV}  

DOI： 10.1016/j.wneu.2020.10.156

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Nagoya Journal of Medical Science  

Puncture site hemorrhage following femoral artery catheterization is a significant cause of morbidity. The aim of this case-control study was to identify predictors of postprocedural arterial hemorrhage at the puncture site. We retrospectively reviewed 255 patients who underwent endovascular treatment at our institution over a 23-month period and classified them into a hemorrhage group and a non-hemorrhage group. Puncture site hemorrhage occurred in 15 patients (5.9%). Clinical factors associated with a significantly increased risk of puncture site bleeding included patients whose postoperative activated clotting time of ≤300 seconds before removal of the sheath (9 patients, 11.8%; P<0.05), those who received triple antiplatelet therapy (n<4, 17.4%; P<0.05) and the group administered heparin postoperatively (7 patients, 13.2%; P<0.05). The effects of low on-treatment platelet reactivity, i.e., P2Y12 reaction units <95%, sheath size, hemostasis method used, and operating time were not clinically significant. Our findings suggest an increased risk of puncture site hemorrhage in patients who either had an activated clotting time ≤300 seconds before the postoperative removal of the sheath, had received triple antiplatelet therapy, or were administered heparin postoperatively

DOI： 10.18999/nagjms.83.1.125

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Language：English   Publisher：The Japan Neurosurgical Society  

<p>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.</p>

DOI： 10.2176/nmccrj.cr.2021-0062

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CiNii Research

Language：English   Publisher：The Japan Neurosurgical Society  

<p>Aneurysms of the large basilar artery (BA) occasionally cause cranial nerve palsy and motor disorder through mass effect. Since 1967, five cases of cerebral aneurysm leading to parkinsonism have been reported. Herein, we describe a rare case of progressive parkinsonism caused by the recurrence of a large aneurysm of the basilar tip after stent-assisted coil embolization. A 66-year-old man visited our hospital with an asymptomatic large aneurysm (maximum diameter, 21 mm) of the BA tip. Magnetic resonance imaging (MRI) revealed no perianeurysmal edema. Coil embolization with a Y-configuration stent with cross-placement was performed. Although thrombus formation occurred and the perforator infarction was complicated, complete occlusion was achieved. Three months later, the patient developed progressive and severe parkinsonism. MRI revealed mild enlargement of the aneurysm and perianeurysmal mesencephalic edema with minor neck recurrence. A trial administration of levodopa and additional stent-assisted coil embolization were performed. Levodopa dramatically improved parkinsonism; thus, the patient’s symptoms were controlled by a continuous levodopa regimen. In a large BA-tip aneurysm patient, moderate regrowth and minor neck recurrence occurred after initial treatment, and chronic compression of the midbrain caused secondary parkinsonism. In such cases, it is important to consider levodopa administration and therapeutic strategies to prevent recurrence or regrowth.</p>

DOI： 10.2176/nmccrj.cr.2020-0023

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CiNii Research

Language：English   Publisher：The Japan Neurosurgical Society  

<p>In cases of a dural arteriovenous fistula (AVF) with a pial arterial supply, postoperative hemorrhagic complications occur frequently. Six cases in which patients were diagnosed with a coexisting dural AVF and pial arteriovenous malformation (AVM) sharing a common drainer are presented. These cases were initially thought to be dural AVFs with pial arterial supplies, but careful examination of preoperative images showed that a pial AVM coexisted near the dural AVF, and that both shared a common drainer. The coexistence of a pial AVM is difficult to notice during surgery; for this reason, determining the presence of a pial AVM on preoperative imaging is essential to safely treat a dural AVF with a pial arterial supply. The details of each case, specifically, the diagnostic evidence for this condition (coexisting dural AVF and pial AVM sharing a common drainer), as well as imaging findings that should be noted, are presented.</p>

DOI： 10.2176/nmccrj.cr.2020-0349

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CiNii Research

Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Purpose:</b> 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.</p><p><b>Case Presentations:</b> 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.</p><p><b>Conclusion:</b> 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.</p>

DOI： 10.5797/jnet.tn.2020-0109

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CiNii Research

Language：Japanese   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective:</b> With the widespread use of endovascular treatment for cerebral aneurysms, women of childbearing age may also undergo this treatment. We report the case of a patient who underwent stent-assisted coil embolization for a ruptured large basilar artery aneurysm after two successful subsequent childbirths.</p><p><b>Case Presentation:</b> A 27-year-old woman developed a subarachnoid hemorrhage due to a ruptured basilar artery aneurysm (maximum diameter, 24 mm). We performed stent-assisted coil embolization. She became pregnant through in vitro fertilization (IVF) at age 33 years when she was already off the antiplatelet medication. She resumed taking aspirin when she found out that she was pregnant and switched to subcutaneous injection of heparin for 28 weeks. She gave birth by cesarean section at 37 weeks, without complications. She became pregnant through IVF again at age 35 years, received the same antithrombotic treatment, and gave birth without complications.</p><p><b>Conclusion:</b> There are no clear criteria for antithrombotic treatment in pregnant patients after the implantation of a cerebral aneurysm-assisted stent. However, the patient in this reported case passed the perinatal period with antithrombotic therapy without complications.</p>

DOI： 10.20626/nkc.cr.2020-0019

CiNii Research

Language：Japanese   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective</b>: Herein, we report a case of multiple dural arteriovenous fistulas (DAVFs) in the left superior petrosal sinus (SPS) successfully treated by transvenous embolization via the right SPS.</p><p><b>Case Presentation</b>: A 60-year-old woman was diagnosed with multiple DAVFs with deep venous reflux to evaluate consciousness disturbance. We performed packing of the left transverse sinus, which was chiefly involved in reflux to the straight sinus. However, consciousness continued to be mildly disturbed, and DSA was performed again. A shunt was inserted into the left SPS, and the subsequently occurring deep venous reflux was clearly revealed. Because the ipsilateral transverse sinus and both inferior petrosal sinuses were already occluded and unavailable as access routes, we used the contralateral SPS and both cavernous sinuses to navigate the microcatheter into the shunt. We achieved occlusion of the SPS and stopped the reflux by inserting the intermediate catheter firmly into the bilateral SPS.</p><p><b>Conclusion</b>: An access route through the contralateral SPS might successfully enable transvenous embolization of DAVF cases without an ipsilateral access route.</p>

DOI： 10.20626/nkc.tn.2021-0009

CiNii Research

Language：English   Publishing type：Research paper (scientific journal)   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective:</b> Mechanical thrombectomy in acute ischemic stroke (AIS) has become popular in recent years. Our affiliated institutes without neuro-endovascular specialists call our department to come to assist and perform thrombectomy (Drip and Go). In this study, the effectiveness of this inter-hospital cooperative system was evaluated.</p><p><b>Methods:</b> Between January 2016 and December 2018, “Drip and Go” was performed in a total of 29 patients (20 males, average age of 75 years) from four hospitals located within a 1-hour drive, that frequently called for AIS assistance. The background and outcomes of such cases were then retrospectively collected and evaluated.</p><p><b>Results:</b> The median National Institutes of Health Stroke Scale (NIHSS) and diffusion-weighed image-Alberta Stroke Programme Early CT Score (DWI-ASPECTS) were 19 and 7, respectively. Gro in puncture was performed in 27 patients (93%) within 6 h of onset. Good reperfusion (thrombolysis in cerebral infarction [TICI] 2b/3) was obtained in 24 patients (82%) with only one patient exhibiting hemorrhagic complication. A total of 12 patients (41%) had a modified Rankin Scale (mRS) score of 0–3 after 90 days or at the time of discharge. Univariate analysis identified a DWI-ASPECTS of 7 or higher as the only significant factor associated with a good neurological prognosis (P <0.05). Neurological prognosis was the most favorable at the furthest hospital where patients had a good DWI-ASPECTS.</p><p><b>Conclusion:</b> By employing a 1-hour arrival time window and proper patient selection, the “Drip and Go” inter-hospital cooperative system can be an alternative approach for covering areas where no neuro-endovascular specialists are available for AIS.</p>

DOI： 10.5797/jnet.oa.2020-0097

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CiNii Research

Authorship：Corresponding author   Language：Japanese   Publishing type：Research paper (scientific journal)  

DOI： 10.11477/mf.1436204319

PubMed

Language：English  

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.

DOI： 10.18999/nagjms.82.3.557

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OBJECTIVE: Cerebral revascularization surgery has been established as an effective treatment for moyamoya disease. On the other hand, harvesting grafts and tissues to nourish the scalp may increase the risk of postoperative wound-related complications. The purpose of this study was to clarify risk factors for wound-related complications after examining the relationship with the surgical design. METHODS: We retrospectively analyzed 115 patients who underwent 197 revascularization procedures between October 2004 and March 2019. The design of the revascularization was classified into 6 types, then further classified according to the number of grafts harvested, resulting in 11 subtypes. Incidences of minor and major wound-related complications for the 11 different surgical designs were assessed. The risk of complications from each design was statistically examined. In addition, the yearly transition rate of complications was also investigated. RESULTS: Wound-related complications occurred in 38 of the 195 operations (19.5%), including 10 major events (26.3%) and 28 minor events (73.7%). Significant differences in the incidence of complications were seen according to surgical design (P < 0.05), with complications significantly more frequent for L(a) double type and L(p) double type and less frequent for L(a) single type and L(p) single type. In addition, significant differences were found in the incidence and degree of complications according to the number of grafts (0-2) (P < 0.05). The incidence of wound-related complications has clearly decreased since 2015. CONCLUSIONS: Wound-related complications were more frequent and tended to become more severe with double-bypass procedures but were clearly improved under a plastic surgery approach.

DOI： 10.1016/j.wneu.2020.03.217

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DOI： 10.2176/nmc.oa.2019-0271

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Language：Japanese   Publisher：(一社)日本脳卒中学会  

血液凝固第XIII因子(F XIII)濃縮製剤使用後にGalen静脈血栓症が疑われた1例を報告する.76歳女性で,意識障害により救急搬送された.前交通動脈破裂脳動脈瘤によるくも膜下出血と診断し,basal interhemispheric approachによるクリッピング術を施行した.術後4日目に髄液鼻漏が生じ,F XIII活性の低下を認めたためF XIII濃縮製剤を使用した.その後髄液鼻漏は消失し,意識障害も徐々に改善傾向となるも,再度意識障害の悪化を認めた.脳血管撮影検査でGalen静脈に狭窄所見を認め,脳静脈血栓症による意識障害と診断し,低分子ヘパリンの持続点滴後,エドキサバンの内服を継続した.出血性合併症を認めず,Galen静脈狭窄の改善と意識障害の改善を認めた.脳静脈血栓症発症とF XIII濃縮製剤使用の関連性が疑われ,さらに低分子ヘパリンとエドキサバンが有用である可能性が示唆された.(著者抄録)

Other Link： https://search.jamas.or.jp/default/link?pub_year=2020&ichushi_jid=J01786&link_issn=&doc_id=20200608310011&doc_link_id=%2Fdh3strok%2F2020%2F004203%2F011%2F0196-0202%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fdh3strok%2F2020%2F004203%2F011%2F0196-0202%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：English   Publishing type：Research paper (scientific journal)  

OBJECTIVE: In pediatric patients with moyamoya disease, the pathophysiology of transient neurological deficits and the clinical features of perioperative cerebral blood flow (CBF) changes are unclear. The purpose of this study was to investigate the risk factors of postoperative transient neurological deficits and identify predictors of perioperative CBF changes. METHODS: This retrospective study included 42 surgical procedures in 28 pediatric patients who underwent surgical revascularization for moyamoya disease, including encephalo-myo-synangiosis (EMS) with or without superficial temporal artery-middle cerebral artery (MCA) anastomosis. Magnetic resonance images and single photon emission computed tomography results were obtained. Brain compression by EMS was also checked in fluid attenuated inversion recovery images. Using single photon emission computed tomography, CBF was measured at each anterior and posterior part of the MCA region. RESULTS: Postoperative transient neurological deficits were observed in 12 (28.6%) out of 42 surgical procedures. Brain compression by EMS was a significant risk for transient neurological deficits (P = 0.009). The postoperative CBF in the anterior region increased in 9 cases (21.4%) and decreased in 10 cases (23.8%); in the posterior region, it increased in 12 cases (28.6%) and decreased in 10 cases (23.8%). Preoperative CBF of the anterior region was significantly related to both perioperative CBF changes in the MCA regions (anterior part, P = 0.004; posterior part, P = 0.025). CONCLUSIONS: Brain compression by EMS is a risk factor for postoperative transient neurological deficits in pediatric patients with moyamoya disease, and preoperative CBF of the anterior MCA region could predict perioperative CBF change in the MCA regions.

DOI： 10.1016/j.wneu.2019.09.093

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Language：Japanese   Publisher：The Japan Stroke Society  

<p>We report our experience of great vein of Galen thrombosis after treatment consisted of Factor XIII (F XIII) concentrate. A 76-year-old woman presented with subarachnoid hemorrhage (SAH) caused by ruptured anterior communicating artery aneurysm and was successfully treated with direct surgery. Four days after operation, she was awake but presented with cerebrospinal fluid rhinorrhea and was found to be F XIII deficiency, therefore we performed intravenous injection of F XIII concentrate. Sixteen days after operation, she became drowsy without cerebrovascular spasms and hydrocephalus. CT angiography and digital subtraction angiography demonstrated the obstruction of great vein of Galen. She received the treatment with low-molecular-weight heparin (LMWH) and after that, direct oral anticoagulants (DOAC). The patient responded to the treatment, and followed an uneventful course without developing any hemorrhagic complication. To the best of our knowledge, this is the first case of cerebral venous thrombosis after the treatment of F XIII concentrate. The thrombosis can be attributed to the treatment of F XIII concentrate, and would be better served by treatment with LMWH and DOAC.</p>

DOI： 10.3995/jstroke.10720

CiNii Research

Language：English   Publisher：Nagoya Journal of Medical Science  

Hyperperfusion syndrome occurs after treatment of a large or giant cerebral aneurysm. Recently, flow-diverter stent placement has emerged as an effective treatment method for a large cerebral aneurysm, but postoperative ipsilateral delayed intraparenchymal hemorrhage occurs in a minority of cases. The mechanism underlying delayed intraparenchymal hemorrhage is not established, but one possibility is hyperperfusion syndrome. The incidence of delayed intraparenchymal hemorrhage appears to be higher for giant aneurysms; hence, we speculated that large/giant aneurysms may create flow resistance, and mitigation by flow-diverter stent deployment leads to hyperperfusion syndrome and delayed intraparenchymal hemorrhage. The purpose of this study was to identify aneurysm characteristics promoting flow resistance by the analysis of pressure loss in an internal carotid artery paraclinoid aneurysm model using computational fluid dynamics. A virtual U-shaped model of the internal carotid artery siphon portion was created with a spherical aneurysm of various angles, body diameters, and neck diameters. Visualization of streamlines, were calculated of pressure loss between proximal and distal sides of the aneurysm, and vorticity within the aneurysm were calculated. The pressure loss and vorticity demonstrated similar changes according to angle, peaking at 60°. In contrast, aneurysm diameter had little influence on pressure loss. Larger neck width, however, increases pressure loss. Our model predicts that aneurysm location and neck diameter can increase the flow resistance from a large internal carotid artery aneurysm. Patients with large aneurysm angles and neck diameters may be at increased risk of hyperperfusion syndrome and ensuing delayed intraparenchymal hemorrhage following flow-diverter stent treatment.

DOI： 10.18999/nagjms.81.4.629

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DOI： 10.1016/j.wneu.2018.12.136

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OBJECTIVETransient neurological events (TNEs) occur frequently in the acute phase after direct bypass surgery for moyamoya disease (MMD), but there is currently no way to predict them. FlowInsight is a specialized software for analyzing indocyanine green (ICG) videoangiography taken with a surgical microscope. The purpose of this study was to investigate whether intraoperative evaluation of local hemodynamic changes around anastomotic sites using FlowInsight could predict the incidence and duration of TNEs.METHODSFrom patients who were diagnosed with MMD in our hospital between August 2014 and March 2017 and who underwent superficial temporal artery-middle cerebral artery bypass surgery, we investigated 25 hemispheres (in 22 patients) in which intraoperative ICG analysis was performed using FlowInsight. To evaluate the local cerebral hemodynamics before and after anastomosis, regions of interest were set at 3 locations on the brain surface around the anastomotic site, and the mean cerebral blood flow (CBF), mean gradation (Grad), mean transit time (MTT), and mean time to peak (TTP) were calculated from the 3 regions of interest. Furthermore, the change rate in CBF (ΔCBF [%]) was calculated using the formula (postanastomosis mean CBF - preanastomosis mean CBF)/preanastomosis mean CBF. ΔGrad (%), ΔMTT (%), and ΔTTP (%) were similarly calculated.RESULTSPostoperative stroke without TNE occurred in 2 of the 25 hemispheres. These 2 hemispheres (in 2 patients) were excluded from the study, and data from the remaining 23 hemispheres (in 20 patients) were analyzed. For each parameter (ΔCBF, ΔGrad, ΔMTT, and ΔTTP) calculated by FlowInsight, the difference between the groups with and without TNEs was significant. The median values for ΔCBF and ΔGrad were significantly higher in the TNE group than in the no-TNE group (ΔCBF 30.13 vs 3.54, p = 0.0106; ΔGrad 62.05 vs 10.78, p = 0.00435), whereas the median values for ΔMTT and ΔTTP were significantly lower in the TNE group (ΔMTT -16.90 vs -7.393, p = 0.023; ΔTTP -29.07 vs -7.02, p = 0.00342). Comparison of the area under the curve (AUC) for each parameter showed that ΔTTP had the highest AUC and was the parameter with the highest diagnostic accuracy (AUC 0.857). The Youden index revealed that the optimal cutoff value of ΔTTP was -11.61 (sensitivity 77.8%, specificity 71.4%) as a predictor of TNEs. In addition, Spearman's rank correlation coefficients were calculated, and ΔCBF, ΔGrad, ΔMTT, and ΔTTP each showed a strong correlation with the duration of TNEs. The larger the change in each parameter, the longer the TNEs persisted.CONCLUSIONSIntraoperative ICG videoangiography findings were correlated with the occurrence and duration of TNEs after direct bypass surgery for MMD. Screening for cases at high risk of TNEs can be achieved by ICG analysis using FlowInsight.

DOI： 10.3171/2017.10.JNS171523

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DOI： 10.1177/1591019918779196

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Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.18999/nagims.80.2.207

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Nagoya University  

We investigated the association between CYP2C19 genotype and additional effect of cilostazol on clopidogrel resistance (CR) in neuroendovascular therapy. Between January 2012 and January 2016, 447 consecutive patients were administered with 75-mg cilostazol/day. The VerifyNow System was used for evaluating P2Y12 reaction units (PRU) &gt
230 and/or percentage inhibition of platelet function (% Inhibition) ≤ 20 as CR. Among 158 patients with CR, 31 were administered with additional 100- or 200-mg cilostazol/day and their platelet function was evaluated. According to CYP2C19 genotypes revealed using the Spartan RX and DNeasy Blood &amp
Tissue Kit, patients were classified into three phenotypic groups: extensive metabolizer (EM, three patients), intermediate metabolizer (IM, 12 patients), and poor metabolizer (PM, 16 patients). Administration of additional cilostazol decreased PRU (EM group: 160.7 ± 85.2 after vs 278.3 ± 40.1 before, P = 0.15
IM group: 205.6 ± 74.0 vs 254.3 ± 35.0, P = 0.02
and PM group: 227.8 ± 52.2 vs 282.1 ± 30.4, P = 0.003), and increased % Inhibition (EM group: 40.0 ± 27.9 vs 9.3 ± 3.8, P = 0.25
IM group: 31.4 ± 18.0 vs 11.8 ± 8.2, P = 0.001
and PM group: 24.6 ± 15.0 vs 10.4 ± 9.3, P = 0.001). However, the rate of normalized-clopidogrel response, thromboembolic lesions, and bleeding complications were not significantly different among the three groups. Thus, the addition of cilostazol was effective on CR in terms of PRU, % Inhibition, rate of change of normalized-clopidogrel response, thromboembolic events, and bleeding complications irrespective of phenotype.

DOI： 10.18999/nagjms.80.2.207

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PubMed

Language：English   Publishing type：Research paper (scientific journal)   Publisher：SAGE Publications Inc.  

Background: This study aimed to evaluate the detailed location and the number (single or multiple) of cavernous sinus dural arteriovenous fistula (CSDAVF) shunted pouches as well as the relationship between the characteristics of shunted pouch(es) and the treatment outcome of transvenous embolization for CSDAVF. Methods: A total of 23 consecutive patients with CSDAVFs who underwent angiogram and transvenous embolization were retrospectively analyzed. Shunted pouches were assessed using three-dimensional angiogram and multiplanar reformatted image obtained from the rotational angiogram data. Results: Of the 23 patients with CSDAVFs, 40 shunted pouches were identified. Twelve CSDAVFs had a single shunted pouch, and 11 had multiple shunted pouches. The mean CSDAVF with multiple shunted pouches was 2.5. The shunted pouches were more often found in the posterior compartment of the CS, which was connected with the intercavernous sinus (23/40
57.5%). In 12 CSDAVFs with a single shunted pouch, 10 were treated with selective embolization and complete occlusion was achieved during the follow-up. Two CSDAVFs with single shunted pouch were just observed without intervention, and DAVFs disappeared spontaneously during the follow-up period. In 11 CSDAVFs with multiple shunted pouches, eight were treated with selective embolization and three with sinus embolization. In six of eight (75%), complete occlusion was achieved following selective embolization, but two of eight (25%) recurred and required retreatment. Conclusions: Rotational angiography data suggested that the shunted pouches of CSDAVFs were mostly located in the posterior compartment of the CS connected with the intercavernous sinus. Selective embolization for CSDAVFs with a single shunted pouch is the first-line treatment alternative to sinus packing, and selective embolization with multiple shunted pouches will be a considerable treatment option.

DOI： 10.1177/1591019917743064

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：The Japanese Society on Surgery for Cerebral Stroke  

Transient neurological events (TNEs) are relatively common phenomena after superficial temporal artery-middle cerebral artery (STA-MCA) bypass for the surgical treatment of moyamoya disease. Cortical-sulcal hyperintensity (CSHI) signs in magnetic resonance imaging (MRI) fluid-attenuated inversion recovery (FLAIR) images during the acute stage after the surgery have also been reported. These symptoms and radiological findings are reportedly correlated; however, few studies have examined these characteristics after indirect vascularization surgery. Therefore, here we retrospectively investigated the incidence and correlation of this issue. The CSHI signs were observed in 10 of 16 hemispheres (62.5%), and TNEs after the surgery were recognized in nine (56.3%). This correlation was statistically significant (p = 0.01). Our findings indicate that CSHI signs are associated with direct and indirect bypass surgery and may be closely related to postoperative TNEs.

DOI： 10.2335/scs.46.439

CiNii Research

Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

INTRODUCTION: In endovascular embolization for intracranial aneurysms, it is important to properly control the coil insertion force. However, the force can only be subjectively detected by the subtle feedback experienced by neurointerventionists at their fingertips. The authors envisioned a system that would objectively sense and quantify that force. In this article, coil insertion force was measured in cases of intracranial aneurysm using this sensor, and its actual clinical application was investigated.
METHODS: The sensor consists of a hemostatic valve (Y-connector). A little flexure was intentionally added in the device, and it creates a bend in the delivery wire. The sensor measures the change in the position of the bent wire depending on the insertion force and translates it into a force value. Using this, embolization was performed for 10 unruptured intracranial aneurysms.
RESULTS: The sensor adequately recorded the force, and it reflected the operators' usual clinical experience. The presence of the sensor did not affect the procedures. The sensor enabled the operators to objectively note and evaluate the insertion force and better cooperative handling was possible. Additionally, other members of the intervention team shared the information. Force records demonstrated the characteristic patterns according to every stage of coiling (framing, filling, and finishing).
CONCLUSIONS: The force sensor system adequately measured coil insertion force in intracranial aneurysm coil embolization procedures. The safety of this sensor was demonstrated in clinical application for the limited number of patients. This system is useful adjunct for assisting during coil embolization for an intracranial aneurysm.

DOI： 10.1016/j.wneu.2017.06.092

Web of Science

Scopus

PubMed

Language：English   Publishing type：Research paper (scientific journal)   Publisher：ELSEVIER SCIENCE INC  

BACKGROUND: Combined direct and endovascular surgery has been performed to treat large to giant internal carotid artery (ICA) aneurysms. This report describes successful treatment of a large ICA aneurysm by coiling of the aneurysm via an extracranial-intracranial saphenous vein (SV) graft just after bypass and ICA proximal ligation.
CASE DESCRIPTION: A 66-year-old woman presented with a left ICA supraclinoid aneurysm with progressive visual field defect and impaired visual acuity in the left eye. While waiting for scheduled surgery, she experienced a subarachnoid hemorrhage. An extracranial-intracranial high-flow bypass using an SV graft and proximal ligation of the ICA were performed. Coiling of the aneurysm was immediately performed successfully via the SV bypass graft. The patient experienced no new neurologic deficit after this treatment. Follow-up radiologic evaluations using magnetic resonance imaging and magnetic resonance angiography revealed complete aneurysm occlusion.
CONCLUSIONS: Aneurysm coiling via an extracranial-intracranial SV bypass graft could offer an alternative when an antegrade access route to the ICA is not used because of prior parent artery ligation.

DOI： 10.1016/j.wneu.2016.11.066

Web of Science

Scopus

PubMed

Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective:</b> We encountered a patient with lateral medullary infarction during transarterial embolization of the posterior meningeal artery (PMA). We reviewed the anatomic characteristics/imaging findings of this disorder.</p><p><b>Case Presentation:</b> A 69-year-old male. Cerebral infarction involving the lateral medulla occurred during transarterial embolization of a dural arteriovenous fistula. It was considered to be a complication related to occlusion of a lateral medulla-penetrating vessel on microcatheter/guidewire operations in the PMA. When examining images in detail, the blood vessel could be confirmed using DSA and 3D angiography.</p><p><b>Conclusion:</b> When performing embolization, the presence of a brainstem-penetrating vessel originating from the PMA must be considered.</p>

DOI： 10.5797/jnet.cr.2017-0038

CiNii Research

Language：Japanese   Publisher：The Japan Stroke Society  

A 38 year-old woman with a sudden headache was transferred to the ER. Head CT and CT angiography (CTA) revealed subarachnoid hemorrhage without any aneurysm. Multimodality examinations were performed repeatedly during the acute period. On her 14th hospital day, digital subtraction angiography showed a slight protruded change of the right internal carotid artery (C3 portion), which was suspected as a blood blister-like aneurysm. As a result of comparing the MRI and CTA images, the false lumen was speculated to spread around the posterior wall of the ophthalmic artery bifurcation. Balloon occlusion test showed tolerance, however, no intraorbital blood flow was observed through any angiographies during ICA occlusion. We changed the strategy to the stent assisted coil embolization with preserved ophthalmic artery flow because trapping of dissecting lesion carried a very high risk of visual impairment. After this embolization, there was good course with no neurological deterioration, no blurred vision, and no recurrence of this aneurysm. As for the present patient, diagnostic multimodality imaging with MRI and angiography seemed to not only change the determination of therapeutic strategy but also avoid complication risk.

DOI： 10.3995/jstroke.10412

CiNii Research

Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective:</b> The purpose of this study was to compare the clinical outcome of transarterial embolization for isolated sinus type dural arteriovenous fistula (iDAVF) using n-butyl-cyanoacrylate (NBCA) and Onyx.</p><p><b>Methods:</b> Seventeen lesions of iDAVF in 17 patients who underwent transarterial embolization between March 2008 and February 2015 were retrospectively analyzed. They were treated by embolization using NBCA in 10 patients, Onyx in 5 patients, and combination of NBCA and Onyx in 2 patients. We compared the results between embolization with NBCA and Onyx as follows: complete occlusion rate, number of embolized vessels, procedure-related complications, treatment time, dose of radiation exposure, amount of contrast agent, and total cost of the devices.</p><p><b>Results:</b> The complete occlusion rate of iDAVF was significantly higher in the Onyx group: 4 of 10 (40%) in NBCA and 5 of 5 (100%) in Onyx (P = 0.04). The number of treated vessels (5.1 ± 1.2 in NBCA, 1 in Onyx [P <0.001]), the maximum skin entrance dose (NBCA: 5030 ± 1646 [mGy], Onyx: 1670 ± 564 [mGy] in Onyx [P <0.01]), and total cost of the devices (601,265 ± 15,749 [yen] in NBCA, 374,210 ± 122,142 [yen] in Onyx [P <0.01]) were significantly higher in the NBCA. No significant difference was observed in the treatment time and contrast agent dose.</p><p><b>Conclusion:</b> In transarterial embolization of iDAVF, a higher complete occlusion rate was obtained with Onyx, which was also advantageous for reducing the exposure dose and cost of the devices.</p>

DOI： 10.5797/jnet.oa.2016-0090

CiNii Research

Language：English   Publishing type：Research paper (scientific journal)   Publisher：NAGOYA UNIV, SCH MED  

The optional endovascular approach for acute ischemic stroke is unclear. The Trevo stent retriever can be used as first-line treatment for fast mechanical recanalization. The authors developed a treatment protocol for acute ischemic stroke based on the assessment of clot quality during clot removal with the Trevo. This prospective single-center study included all patients admitted for acute ischemic stroke between July 2014 and February 2015, who underwent emergency endovascular treatment. According to the protocol, the Trevo was used for first-line treatment. Immediately after the Trevo was deployed, the stent delivery wire was pushed to open the stent by force (ACAPT technique). Clot quality was assessed on the basis of the perfusion status after deployment of the Trevo; continued occlusion or immediate reopening either reoccluded or maintained after the stent retriever had been in place for 5 min. If there was no obvious clot removal after the first pass with the Trevo, according to the quality of the clot, either a second pass was performed or another endovascular device was selected. Twelve consecutive patients with acute major cerebral artery occlusion were analyzed. Thrombolysis in cerebral infarction score 2b and 3 was achieved in 11 patients (91.7%) and 9 (75%) had a good clinical outcome after 90 days based on a modified Rankin scale score &lt;= 2. Symptomatic intracranial hemorrhage occurred in 1 patient (8.3%). The overall mortality rate was 8.3%. Endovascular thrombectomy using the Trevo stent retriever for first-line treatment is feasible and effective.

Web of Science

Language：English   Publishing type：Research paper (scientific journal)   Publisher：NAGOYA UNIV, SCH MED  

Our aim was to assess the clinical safety and efficacy of overlap stenting for in-stent restenosis after carotid artery stenting. The study was conducted between July 2008 and February 2015. A database of consecutive carotid artery stenting procedures was retrospectively assessed to identify the cases of in-stent restenosis that were treated with overlap stenting under proximal or distal protection. The clinical and radiological records of the patients were then reviewed. Of the 155 CAS procedures in 149 patients from the database, 6 patients met the inclusion criteria. All the 6 patients were initially treated with moderate dilatation because of the presence of an unstable plaque. The technical success rate of the overlap stenting was 100%, with no 30-day mortality or morbidity. In addition, there was no further in-stent restenosis during a follow-up period of over 12 months. These results indicated that overlap stenting for in-stent restenosis after carotid artery stenting was both safe and effective in our cohort.

Web of Science

Language：English  

PubMed

Language：English   Publisher：Nagoya University Graduate School of Medicine, School of Medicine  

DOI： 10.18999/nagjms.78.2.143

Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective:</b> The purpose of this retrospective study was to compare the therapeutic results of middle-sized or small cerebral aneurysms coiling using 10 coil (thickness, 0.0095 inch–0.012 inch) and 14 coil (thickness, 0.0135 inch) as a complex framing coil.</p><p><b>Methods:</b> Fifty aneurysms (maximum size, 4 mm–10 mm) in 50 patients treated in our hospital between May 2012 and May 2015 were assigned in this study. We compared the volume embolization rate, recurrence rate, initial occlusion grade between 14 coil (25 aneurysms) and 10 coil (25 aneurysms).</p><p><b>Results:</b> The mean volume embolization ratio was significantly higher (14 coil 37.5 ± 8.8%, 10 coil 32.6 ± 8.4%; P <0.05) in aneurysms coiled with 14 inch coil than those coiled with 10 inch coil. Fourteen inch coil has a higher initial occlusion grade, and lower recurrence rate than 10 coil, but these differences were not significant.</p><p><b>Conclusion:</b> The use of 14 inch framing coil to embolize middle-sized or small cerebral aneurysms is more effective in terms of a higher packing ratio.</p>

DOI： 10.5797/jnet.oa.2016-0045

CiNii Books

Other Link： http://search.jamas.or.jp/link/ui/2017210157

Language：Japanese   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective</b>: With recent increase of endovascular treatment, direct surgery on vessels with previously placed stents may be encountered. Our question is whether we can shut off the stent-placed vessel safely and reliably with a titanium clip. The authors conducted an experiment in vitro.</p><p><b>Methods</b>: Three types of intracranial stents that have been used in Japan [Enterprise VRD (Codman), Neuroform (Stryker), Wingspan (Stryker)] were deployed to the 3.5-mm diameter silicon tube for vascular anastomosis training. The stent-placed region was blocked with a single temporary clip, one permanent clip, and two permanent clips, respectively. In order to apply pressure linearly, we used a pressurized fluid with 33% glycerol, which was similar to blood in viscosity. While increasing the pressure, the fluid leakage was confirmed. Finally, the stent strut damage around the clipped part was assessed by a cone-beam computed tomography (CT).</p><p><b>Results</b>: It is easier to shut off the flow through Enterprise VRD than Neuroform or Wingspan. Tube with Wingspan is the most difficult to block due to its larger radial force. When we used the two permanent clips, it was possible to block each vessel to a relatively higher pressure up to 180 mmHg. After release, the shape of every stent was promptly restored without stent strut damage.</p><p><b>Conclusion</b>: By using clips it was possible to shut off the blood flow with all three stents temporarily. If neurosurgeons attempt to block the stent-placed parent vessel permanently, they should use two permanent clips.</p>

DOI： 10.20626/nkc.oa.2015-0047

CiNii Research

Publisher：Nagoya Journal of Medical Science  

Our aim was to assess the clinical safety and efficacy of overlap stenting for in-stent restenosis after carotid artery stenting. The study was conducted between July 2008 and February 2015. A database of consecutive carotid artery stenting procedures was retrospectively assessed to identify the cases of in-stent restenosis that were treated with overlap stenting under proximal or distal protection. The clinical and radiological records of the patients were then reviewed. Of the 155 CAS procedures in 149 patients from the database, 6 patients met the inclusion criteria. All the 6 patients were initially treated with moderate dilatation because of the presence of an unstable plaque. The technical success rate of the overlap stenting was 100%, with no 30-day mortality or morbidity. In addition, there was no further in-stent restenosis during a follow-up period of over 12 months. These results indicated that overlap stenting for in-stent restenosis after carotid artery stenting was both safe and effective in our cohort.

Scopus

Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<b>Objective:</b> Permanent therapeutic occlusion of the carotid artery is one of the treatment options for patients with a large/giant internal carotid artery aneurysm or tumor involving the neck or skull base. Balloon test occlusion (BTO) is performed to predict the tolerance of parent artery occlusion (PAO). The authors combined various modalities to improve the sensitivity of BTO. The purpose of this study is to present the efficacy of the multimodal BTO.<b>Methods:</b> Between January 2008 and September 2014, a total of 50 patients (internal carotid aneurysms: 39, neck or skull base tumor: 8, others: 3; mean 58.4 years, range 7–81 years; 10 men and 40 women) underwent multimodal BTO. Tolerance of PAO was evaluated by the algorithm with various assessment modalities including neurological symptoms with/without induced hypotension, findings of angiogram (collateral flow, venous phase laterality), perfusion CT, and stump pressure. Clinical data of patients with BTO were analyzed retrospectively. Procedures were performed in the angio/CT combination suite. BTO was performed in the usual fashion and when the patient passed the immediate test occlusion, perfusion CT was performed. Subsequently, the angiogram under balloon inflation followed. If the patient did not show neurological symptoms for 20 min, hypotension was induced by intravenous injection of the vasodilator. Neurological symptoms were then checked for more than 30 min.<b>Results:</b> By multimodal assessment of BTO, 33 patients were considered tolerable, six were partially tolerable, and 11 were intolerable. Thirteen of 33 patients with predictive tolerance underwent PAO without bypass, and all but one showed no hemodynamic ischemia postoperatively. Three of six patients with predictive partial tolerance were treated by PAO with extracranial-intracranial bypass, and they experienced no hemodynamic ischemia. In contrast, one with predictive partial tolerance treated by PAO without bypass developed ischemic events as feared.<b>Conclusions:</b> The multimodal BTO is helpful to evaluate the tolerance of PAO and is a reliable predictor of postoperative ischemic events. It reduces risks and increases treatment safety for permanent therapeutic occlusion of the carotid artery.

DOI： 10.5797/jnet.oa.2015-0012

CiNii Research

Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

<p><b>Objective:</b> The purpose of this retrospective study was to compare the therapeutic results of middle-sized or small cerebral aneurysms coiling using 10 coil (thickness, 0.0095 inch–0.012 inch) and 14 coil (thickness, 0.0135 inch) as a complex framing coil.</p><p><b>Methods:</b> Fifty aneurysms (maximum size, 4 mm–10 mm) in 50 patients treated in our hospital between May 2012 and May 2015 were assigned in this study. We compared the volume embolization rate, recurrence rate, initial occlusion grade between 14 coil (25 aneurysms) and 10 coil (25 aneurysms).</p><p><b>Results:</b> The mean volume embolization ratio was significantly higher (14 coil 37.5 ± 8.8%, 10 coil 32.6 ± 8.4%; P <0.05) in aneurysms coiled with 14 inch coil than those coiled with 10 inch coil. Fourteen inch coil has a higher initial occlusion grade, and lower recurrence rate than 10 coil, but these differences were not significant.</p><p><b>Conclusion:</b> The use of 14 inch framing coil to embolize middle-sized or small cerebral aneurysms is more effective in terms of a higher packing ratio.</p>

DOI： 10.5797/jnet.oa.2016-0045

CiNii Research

Language：English   Publisher：The Japan Neurosurgical Society  

<p>Aneurysms of the large basilar artery (BA) occasionally cause cranial nerve palsy and motor disorder through mass effect. Since 1967, five cases of cerebral aneurysm leading to parkinsonism have been reported. Herein, we describe a rare case of progressive parkinsonism caused by the recurrence of a large aneurysm of the basilar tip after stent-assisted coil embolization. A 66-year-old man visited our hospital with an asymptomatic large aneurysm (maximum diameter, 21 mm) of the BA tip. Magnetic resonance imaging (MRI) revealed no perianeurysmal edema. Coil embolization with a Y-configuration stent with cross-placement was performed. Although thrombus formation occurred and the perforator infarction was complicated, complete occlusion was achieved. Three months later, the patient developed progressive and severe parkinsonism. MRI revealed mild enlargement of the aneurysm and perianeurysmal mesencephalic edema with minor neck recurrence. A trial administration of levodopa and additional stent-assisted coil embolization were performed. Levodopa dramatically improved parkinsonism; thus, the patient’s symptoms were controlled by a continuous levodopa regimen. In a large BA-tip aneurysm patient, moderate regrowth and minor neck recurrence occurred after initial treatment, and chronic compression of the midbrain caused secondary parkinsonism. In such cases, it is important to consider levodopa administration and therapeutic strategies to prevent recurrence or regrowth.</p>

DOI： 10.2176/nmccrj.cr.2020-0023

PubMed

CiNii Research

Language：English   Publisher：The Japan Neurosurgical Society  

<p>In cases of a dural arteriovenous fistula (AVF) with a pial arterial supply, postoperative hemorrhagic complications occur frequently. Six cases in which patients were diagnosed with a coexisting dural AVF and pial arteriovenous malformation (AVM) sharing a common drainer are presented. These cases were initially thought to be dural AVFs with pial arterial supplies, but careful examination of preoperative images showed that a pial AVM coexisted near the dural AVF, and that both shared a common drainer. The coexistence of a pial AVM is difficult to notice during surgery; for this reason, determining the presence of a pial AVM on preoperative imaging is essential to safely treat a dural AVF with a pial arterial supply. The details of each case, specifically, the diagnostic evidence for this condition (coexisting dural AVF and pial AVM sharing a common drainer), as well as imaging findings that should be noted, are presented.</p>

DOI： 10.2176/nmccrj.cr.2020-0349

PubMed

CiNii Research

Language：Japanese  

J-GLOBAL

Language：Japanese  

J-GLOBAL

Language：Japanese   Publisher：(株)にゅーろん社  

当院で非もやもや病小児閉塞性脳血管障害が疑われた5例(男児2例、女児3例、平均年齢11.4歳)を対象に臨床経過や画像所見、神経学的予後について検討した。その結果、5例とも生来健康で外傷歴や血管危険因子は認めなかった。画像所見では、全例で内頸動脈終末部の狭窄を認めたが、ウイリス動脈輪周囲や基底核にもやもや血管は伴っていなかった。だが、3例(60%)は基底核を中心とする脳梗塞で発症していた。また、脳動脈解離に特徴的な所見を呈する症例はなく、1年以内の水痘ウイルス感染、自己免疫疾患や膠原病、全身性血管病変なども否定的であった。RNF213遺伝子多型は1例のみ陽性であった。脳梗塞を認めた3例では発症後早期にMRA上の狭窄進行がみられたが、それ以外は発症後から改善傾向にあった。最終診察時におけるmodified Rankin Scaleは全例で1以下であった。

Language：English   Publisher：The Japanese Society for Neuroendovascular Therapy  

CiNii Books

Event date： 2020.8

Language：Japanese   Presentation type：Oral presentation (general)  

Venue：横浜   Country：Japan  

Event date： 2020.8

Language：Japanese   Presentation type：Poster presentation  

Venue：横浜   Country：Japan