A simplified pull-through angioplasty technique without a snare device. A technical note.

The pull-through angioplasty technique allows stable wire tension and stabilization of the device during the procedure. In this technique, a guide wire is passed from one sheath to another, usually with the aid of a snare device. We describe the treatment of occlusive subclavian artery disease and lesion at the origin of the vertebral artery employing a brachiofemoral pull-through technique without using a snare device. In this technique, the guide wire is advanced from the femoral artery to the brachial artery. The guide wire is directly inserted into the sheath placed at the brachial artery. The brachial artery is compressed proximal to the point of sheath insertion to prevent bleeding. The sheath is extracted temporally and the guide wire is caught outside of the body. The sheath is then introduced again through the guide wire. We used the pull-through technique without a snare device in seven cases, and we were able to build the pull-through system in six of these cases without a snare device. This pull-through technique without a snare device is not difficult to use, and may reduce the time and cost of angioplasty procedures.

Carotid artery stenting for calcified lesions.

BACKGROUND AND PURPOSE: Our aim was to assess the feasibility of carotid artery stent placement (CAS) for calcified lesions. MATERIALS AND METHODS: Using embolic protection devices (EPDs), we performed 51 CAS procedures in 43 patients with severe carotid artery stenosis accompanied by plaque calcification. Before intervention, all lesions were subjected to multidetector-row CT. The arc of the circumferential plaque calcification was measured on axial source images at the site of maximal luminal stenosis, and the total volume of the plaque calcification was determined. The angiographic outcome immediately after CAS, and intra- and postoperative complications were recorded. RESULTS: The mean arc of calcification was 201.1 +/- 72.3 degrees (range, 76-352 degrees ), and the mean of the total calcification volume was 154.9 +/- 35.4 mm(3) (range, 92-2680 mm(3)). Balloon rupture occurred in 1 procedure (2.0%) at predilation angioplasty; all 51 CAS procedures were successful without clinical adverse effects. Although there was a correlation between the arc of plaque calcification and residual stenosis (r = 0.6, P < .001), excellent dilation with residual stenosis < or =30% was achieved in all lesions. There was no correlation between the total volume of calcification and residual stenosis. None of the patients developed stroke or death within 30 days of the CAS procedure. CONCLUSION: CAS by using EPDs to treat lesions with plaque calcification is feasible even in patients with near-total circumferential plaque calcification.

Direct superficial temporal vein approach for dural carotid cavernous fistula.

SUMMARY: We present an alternative endovascular approach to treat dural carotid cavernous fistulae (dural CCF) that drain only into the superior ophthalmic vein. Four cases of cavernous dural AVFs that could not be treated via the inferior petrosal vein were accessed via the direct superficial temporal vein approach through the superior ophthalmic vein. Successful embolization was documented radiographically and clinically in all patients. The trans-superficial temporal vein approach is safe and useful for inaccessible dural CCFs through the inferior petrosal sinus.

Mechanisms of perianeurysmal edema following endovascular embolization of aneurysms.

SUMMARY: After coil embolization for an aneurysm, edema surrounding the aneurysm revealed by magnetic resonance imaging (MRI) is rarely seen and is usually associated with neurological symptoms. Perianeurysmal edema was found by postoperative MRI in three out of 182 patients with cerebral aneurysm, which was treated with Guglielmi Detachable Coil (GDC), and neurological symptoms developed simultaneously. In cases where neurological symptoms improved with conservative medical treatment, a temporary increase in the volume of an aneurysm, due to coil and thrombus formation, may result in edema. In cases where symptoms were not alleviated with conservative medical treatment, persistent water-hammer effect against the residual lumen of the aneurysm as well as an increase in the volume of aneurysm by hemorrhage in the aneurysmal wall may contribute to the development of perianeurysmal edema. Consideration of the mechanism of edema development by neurological symptoms, MRI findings, and angiographic findings is needed in order to select appropriate treatment.

Direct carotid puncture for the endovascular treatment of anterior circulation aneurysms.

We report the usefulness of Guglielmi detachable coil (GDC) embolization by direct carotid puncture for anterior circulation aneurysms. For all 27 patients, GDC embolization by direct carotid puncture was safely performed by using a 5F sheath introducer 5 cm long and a Tracker-38 catheter. Neurologic deficits and hemorrhage were not found in any patient during the follow-up period. If the transfemoral approach cannot be applied, GDC embolization should be considered as an alternative method.

The significance of incomplete stent apposition in patients undergoing stenting of internal carotid artery stenosis.

BACKGROUND AND PURPOSE: Incomplete stent apposition after carotid angioplasty and stent placement (CAS) is often seen but little is known about how the incomplete attachment goes after stent placement. For example, some may change into restenosis around the stent edge and some may remain unchanged. The purpose of this study is to clarify the morphologic prognosis of an incomplete stent apposition at the stent edge. METHODS: CAS was attempted on 135 consecutive stenotic lesions (124 patients). Angiograms were then evaluated immediately after the procedure. An incomplete stent apposition at stent edge was found in 15 patients, and all of them were followed up by angiography and MR imaging with antiplatelet therapy. RESULTS: No ischemic event caused by the lesions occurred during the mean follow-up period of 11 months (from 4 to 32 months). The angiography findings of 15 lesions at a mean of 8.8 months (from 2 to 28 months) after CAS showed that all remained unchanged. No patients required any additional intervention. No new ischemic lesions were detected in any of the 15 patients who underwent follow-up MR imaging at a mean of 10 months (from 2 to 32 months) after CAS. CONCLUSION: In this study, the existence of a segment of incomplete stent apposition had no adverse morphologic or clinical effect.

Spontaneous improvement of persistent ulceration after carotid artery stenting.

BACKGROUND AND PURPOSE: Because carotid plaque ulceration is associated with an increased risk of cerebral embolism, residual carotid plaque ulceration directly around a stent (persistent ulceration) after carotid angioplasty and stent placement (CAS) could still be a risk factor for a stroke. The purpose of this study is to understand the morphologic and clinical prognosis of persistent ulceration. PATIENTS AND TECHNIQUES: CAS was attempted on 91 consecutive stenotic lesions (80 patients). Of these, 54 lesions (48 patients) had ulceration before CAS. Angiograms were evaluated immediately after the procedure. Persistent ulceration was found in 34 lesions (30 patients). The mean depth and length of persistent ulcers were 2.1 mm (range, 1-4.7 mm) and 8.9 mm (range, 1.5-22 mm), respectively. All patients with persistent ulceration were followed with antiplatelet therapy. RESULTS: No ischemic event due to the lesions occurred during the mean follow-up period of 25.5 months (range, 3-48 months). Angiography on 25 lesions (21 patients) at a mean of 5.8 months (range, 1-21 months) after CAS showed that persistent ulceration disappeared in 12 lesions (48%), improved in 11 lesions (44%), and remained unchanged in 2 lesions (8%). Nine lesions (36%) showed restenosis, which were < or =30% and did not require any additional intervention. New ischemic lesions were not detected in any of the 14 patients (17 lesions) who underwent follow-up MR imaging at a mean of 9 months (range, 1-32 months) after CAS. CONCLUSION: We conclude that persistent ulceration after CAS improves spontaneously and is not a risk factor for cerebral embolism.

A nonadhesive liquid embolic agent of ethylene vinyl alcohol copolymer and ethanol mixture for cerebral arteriovenous malformations. Clinical experience.

SUMMARY: We report our experience using our new nonadhesive liquid embolic agent, an ethylene vinyl alcohol copolymer (EVAL)/Ethanol mixture, to treat human arteriovenous malformations (AVM). Between June 1995 and April 2001, 57 patients with confirmed AVM underwent embolization with the EVAL/Ethanol mixture. Using 87 procedures consisting of one to three stages, we embolized 185 feeding arteries to occlude as much of the AVM as possible. Repeated injections under fluoroscopic control could be performed smoothly without encountering cementing of the catheter in the vessel wall. Among 87 procedures undertaken in 57 patients, seven (8.0%) procedures in six patients produced new postembolization symptoms. Resolution of these symptoms occurred within hours or days following four of the seven procedures; permanent neurological deficits remained after three embolization procedures (3.4%). Of the 57 patients, three underwent postembolization radiosurgery, 54 were radically treated with microsurgical extirpation. Histopathological examinations of the 54 specimens disclosed mild inflammation within the embolized lumen without inflammatory reactions in the media or adventitia. Follow-up angiograms obtained three years after they underwent radiosurgery showed that in all three patients the nidus had completely disappeared. The EVAL/Ethanol mixture is handled easily and appears to be an effective and safe embolic agent for the preoperative embolization of AVM.

[A case of cerebral arteriovenous malformation complicated with intracerebral hemorrhage after endovascular embolization].

We reported a case of cerebral arteriovenous malformation (AVM), complicated with intracerebral hemorrhage (ICH), after endovascular embolization. A 51-year-old male suffered from intraventricular hemorrhage due to a rupture of an intranidal aneurysm on October 4, 1999. The first embolization procedure for the aneurysm and a part of the nidus was performed with 2-hydroxyethyl methacrylate-methyl methacrylate (HEMA-MMA) and Liquid coil on day 21 after admission. On day 28, a second embolization was carried out for the residual nidus. Although most of the nidus was obliterated, the patient became comatose 10 hours after the second embolization. Computed tomography revealed a massive ICH in the right parietal lobe, and he underwent emergency evacuation of the hematoma. During the surgery, HEMA-MMA was seen in a draining vein. This caused venous stasis. Although the patient gradually improved postoperatively, he became comatose again because of a recurrence of ICH on day 36. Evacuation of the hematoma and removal of the nidus were performed again. The operative specimen showed AVM embolized by HEMA-MMA with non-specific inflammation and partial inflammatory degeneration of the vascular wall. Hemodynamic change such as venous stasis or elevated pressure of the feeding artery seemed to be the cause of the hemorrhage. Multi-staged embolization with longer intervals and intraoperative flow control were regarded as crucial for avoiding delayed hemorrhage.

Clinicopathological Investigation of AVMs Embolized with HEMA-MMA. A New Non-Adhesive Liquid Material.

SUMMARY: We have recently developed a non-adhesive liquid embolic agent, hydroxyethylmethacrylate methylmethacrylate copolymer (HEMA-MMA), and used it for arteriovenous malformations (AVMs) in the central nervous system. To evaluate the toxicity and usefulness of this agent, we made a clinicopathological study of AVMs that were embolized with it and then excised surgically. This study includes ten cases: nine with pial AVM and one with scalp AVM. In a pathological study, special attention was paid to vascular and perivascular inflammation, angionecrosis, recanalization of the embolized vessels, and foreign body reactions. Inflammation was absent or very mild regardless of the interval between embolization and excision. There was no angionecrosis. Recanalization could be expected to occur in the partially occluded vessel. Foreign body reactions such as infiltration of monocytes or giant cells, and proliferation of fibroblasts or capillaries were also not seen in any case. It was concluded that HEMA-MMA is an excellent embolic material that is easy to handle, less vasotoxic than other agents, and highly histocompatible.

Transarterial embolization with HEMA-MMA of variant convexity-superior sagittal sinus dural arteriovenous fistula--case report.

A 62-year-old male presented with a variant dural arteriovenous fistula (DAVF) within the wall of the convexity-superior sagittal sinus, fed by branches of the bilateral external carotid arteries and only cortical venous drainage despite the presence of a patent sinus. Transarterial embolization with poly(2-hydroxyethyl methacrylate-co-methyl methacrylate) (HEMA-MMA) was performed, resulting in complete obliteration of the DAVF. Embolization with HEMA-MMA is an effective and safe procedure for the treatment of DAVF.

[Dural arteriovenous fistula of the transverse-sigmoid sinus with intraventricular hemorrhage: a case report].

We report a case of dural arteriovenous fistula of the transverse-sigmoid sinus (TS-DAVF) with intraventricular hemorrhage. An 83-year-old woman presented with headache and vomiting. Neurological examination showed no defects. CT scans demonstrated intraventricular hemorrhage. Left external carotid angiograms showed a dural arteriovenous fistula of the isolated transverse-sigmoid sinus fed by the occipital and middle meningeal arteries. The draining vein was the leptomeningeal vein. Left internal carotid angiograms demonstrated venous congestion in the left temporal and occipital lobes. This case was grade 4 according to Lalwani's classification. 123I-IMP SPECT revealed a low perfusion are in the left temporal and occipital regions. Dynamic CT scans revealed venous congestion in the left temporal and occipital regions. We considered that the venous congestion was the cause of intraventricular hemorrhage. Initially, we embolized the DAVF using a transarterial approach with liquid material. However, the embolization of the DAVF was not complete. Therefore, we treated the DAVF by sinus packing with coils using a small craniotomy. Angiographic cure was obtained and the postoperative course was uneventful. We discuss the clinical features, the hemodynamic findings and the management of this case.

How to embolize wide-necked aneurysms? Two embolization techniques for wide-necked aneurysms.

Novel endovascular approaches are needed for safer and more definitive treatment of wide-necked aneurysms, to overcome the limitations of the Guglielmi detachable coil (GDC) system and further, the application of this technique. The double GDC technique (DGT), for embolization of wide-necked aneurysms, and the combination of stent placement and coil deposition(CTSC) for management of fusiform aneurysms have been developed and their usefulness is reviewed. The DGT involves scaffolding of a GDC coil to form a stabilizing frame inside the aneurysmal neck and then positioning of a second coil to reinforce the first coil. After confirming the absence of coil herniation in the parent artery, both coils are released together. A patient with a wide-necked large aneurysm of the left internal carotid artery was treated using this technique, and followed up angiographically and clinically for a period of three months. The follow-up angiograms revealed complete embolization of the aneurysm. The patient had no neurological changes or adverse events during the procedure. The CTSC involves reconstructing the artery with a stent and packing the aneurysm lumen with GDCs through the stent interstices. A patient with a dissecting fusiform aneurysm of the vertebral artery associated with hypoplasia of the contralateral vertebral artery was treated using this technique to prevent rebleeding. His clinical course was uneventful over a six-month follow-up period. Angiography performed two months after the procedure confirmed excellent flow through the right vertebral artery and absence offilling of the daughter aneurysm.

[Dural arteriovenous fistula of the transverse sigmoid sinus after transvenous embolization of the carotid cavernous fistula].

We report a case of dural arteriovenous fistula of the transverse-sigmoid sinus after transvenous embolization of the carotid cavernous fistula. A 72-year-old woman presented with left exophthalmos, chemosis, bruit and left abducens nerve palsy in June 1996. Bilateral external and internal carotid angiograms revealed the dural arteriovenous fistula of the cavernous sinus. We embolized the dural arteriovenous fistula using a transvenous approach via the left inferior petrosal sinus. Angiograms demonstrated the complete disappearance of the dural arteriovenous fistula. Two years and six months later, she complained of tinnitus at the retroauricular region. Left external carotid angiograms showed a dural arteriovenous fistula of the transverse-sigmoid sinus fed by occipital, posterior auricular, middle meningeal and superficial temporal arteries. We embolized the dural arteriovenous fistula using a transarterial approach. Her symptoms disappeared but the dural arteriovenous fistula did not disappear completely. We discussed the clinical features and etiology of this case.

[Langerhans cell histiocytosis in the hypothalamus: a case report].

A case of Langerhans cell histiocytosis (LCH) in the hypothalamus is presented. A 52 year old man with eosinophilic granuloma of the lung was referred to our hospital. He complained of headache, easy fatigability, high fever, and voiding large quantities of urine, but was otherwise asymptomatic. T1-weighted images demonstrated a small mass in the hypothalamus. After about six months, the mass had grown to 2 cm in diameter. Surgery was performed by a pterional approach and a biopsy specimen was collected. Light microscopic examination of sections of the biopsy specimen showed polymorphous cellular infiltration by histiocytic cells, eosinophils, neutrophils, and lymphocytes. Electron microscopy showed Langerhans cells and Birbeck granules in the cytoplasm. The histological diagnosis was LCH, multifocal type. After low-dose radiation therapy, the mass gradually decreased in size. The clinicopathological features, neuroradiological findings, and treatment are briefly discussed.

Meningeal melanocytoma in the left frontal region.

We report a rare case of meningeal melanocytoma in the left frontal region. A 45-year-old man complained of a headache. Magnetic resonance (MR) scanning showed characteristic patterns: a slightly high signal intensity mass in the left frontal region on the T1-weighted image and a low signal intensity on the T2-weighted image. The patient underwent gross total removal of the tumor. The postoperative course was uneventful. After two years, there was a small local recurrence. The histological finding of the tumor showed meningeal melanocytoma. To our knowledge, this is the second published report of a meningeal melanocytoma in the supratentorial region.

Embolization of posterior circulation aneurysms with detachable coils.

SUMMARY: We evaluated the usefulness of endovascular treatment of posterior circulation aneurysms with GDCs and IDCs. Five cases were treated with IDCs, and 15 cases were treated with GDCs. In this study, 8 aneurysms were identified at the basilar bifurcation, 3 at the PI segment of the posterior cerebral artery, 1 at the origin of the superior cerebellar artery, 2 at the vertebrobasilar junction, 1 at the origin of the posterior inferior cerebellar artery, 1 at the distal anterior inferior cerebellar artery, and 4 dissecting aneurysms at the vertebral artery. Thirteen of the aneurysms were small (< 12 mm), 5 were large (13-24 mm), and 2 were giant (> 25 mm). Of the 20 patients, 14 patients returned to their previous occupation. Patients with permanent deficits included 2 patients with infarction caused by thromboembolic complications during the embolization procedure, and 2 with infarction caused by vasospasm. There were 2 deaths. The outcomes of the patients seemed favorable. However, long-term followup is necessary to determine the usefulness of detachable coils.

[Histological findings in aneurysm treated with IDC: scanning electron microscopical study].

We reported the scanning electron microscopic findings of an aneurysm embolized with interlocking detachable coils (IDC). A 78-year-old man was referred to our hospital because of left hemiparesis and dysphagia. CT scan showed multiple lacunar infarction in the bilateral corona radiata. Angiography demonstrated a small incidental aneurysm of the right internal carotid artery (IC-PC junction). The left hemiparesis gradually improved and 2 weeks after admission the aneurysm was treated with IDC. Three coils were placed in the aneurysm and post-operative angiography demonstrated complete embolization. Dysphagia caused by the pseudobulbar pulse did not improve and, 4 weeks after endovascular surgery, the patient died of aspiration pneumonia. An autopsy was performed and the scanning electron microscopical findings of the aneurysm showed development of endothelial cells on the coil surface. Many clinical reports supported the usefulness of Guglielmi detachable coils (GDC) and several experimental reports demonstrated the intimal proliferation in aneurysms embolized with coils. However, pathological changes of the aneurysms treated with coils have been reported in only four clinical cases. There was no evidence of endothelialization in any of these cases. To our knowledge, our case is the first report describing the endothelial proliferation over the coils. It is necessary to accumulate histopathological data and long-term follow-up in humans treated with coils.