RESUMO
OBJECTIVES: Carotid artery stenting is sometimes adapted for some at-risk cases; however, appropriate treatment timing with stroke onset is controversial. This study aims to identify factors that have an impact on complications and outcomes, especially in patients at high risk. MATERIALS AND METHODS: We examined the characteristics of 152 consecutive patients treated by carotid artery stenting between January 2018 and March 2022 and retrospectively analyzed the risk factors for complications and poor outcomes (modified-Rankin-Scale deterioration), such as patient background, carotid artery stenting risks (access route tortuosity, severe calcification, vulnerable plaque, estimated glomerular filtration rate <30 mL/min/1.73 m2, etc.), characteristics of the stenosis, details of treatment, and treatment timing. RESULTS: The average North American Symptomatic Carotid Endarterectomy Trial criteria score was 68.3% and the lesion length was 20.5±9.7mm. Among patients, 107 (70.4%) had a carotid artery stenting risk. In high-risk carotid artery stenting cases, symptomatic complications occurred in 32 (30.0%), and the 90-day modified Rankin scale score deteriorated in 15 cases (14.0%). Multivariate analysis showed that cases with triple antithrombotic therapy (p=0.003), stenting within 7 days (p=0.0032), and after 28+ days (p=0.0035) of stroke onset were independently associated factors for complications. CONCLUSIONS: This study showed that among risk factors, triple antithrombotic therapy in particular was a risk factor for perioperative complications. Carotid artery stenting for patients with stroke after 28 days of onset affects the prognosis. Therefore, although further study is warranted, waiting more than one month for treatment in patients requiring carotid artery stenting is a potential risk.
Assuntos
Estenose das Carótidas , Acidente Vascular Cerebral , Humanos , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Fibrinolíticos , Estudos Retrospectivos , Stents , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Artérias CarótidasRESUMO
OBJECTIVES: A foreign body granuloma after an endovascular intervention is a rare complication. Some cases of foreign body granulomas, especially after coil embolization, have been reported. However, only four cases of foreign body granulomas after mechanical thrombectomy (MT) have previously been reported. The current study reports two cases of post-MT foreign body granulomas, including a biopsy-proven case. MATERIAL AND METHODS: Case 1: A 73-year-old woman presented with complete occlusion of the right middle cerebral artery. Cerebral angiography and MT were successfully performed with improvement in clinical symptoms. Left hemiparesis and a disturbance in attention appeared after discharge and progressed slowly. She was re-admitted to our hospital 120 days after cerebral infarction owing to foreign body granulomas diagnosed on biopsy. Case 2: A 78-year-old man presented with occlusion of the left cervical internal carotid artery and the left middle cerebral artery. Cerebral angiography, percutaneous transluminal angioplasty, and MT were successfully performed. On the 34th day, he experienced progressive consciousness disorder because of foreign body granulomas. Both cases were successfully treated with steroid therapy. RESULTS: MRI after steroid treatment showed the disappearance of most nodular lesions and improvement of the encephalopathy. CONCLUSIONS: The cause of the granuloma may be an allergic reaction to the hydrophilic polymers that peel from endovascular devices. Steroid therapy is an effective treatment; therefore, neurologists should consider this complication when neurological symptoms or signs on image appears or worsens. A reliable diagnosis is important for prompt treatment.
Assuntos
Granuloma de Corpo Estranho , Masculino , Feminino , Humanos , Idoso , Granuloma de Corpo Estranho/diagnóstico por imagem , Granuloma de Corpo Estranho/etiologia , Granuloma de Corpo Estranho/terapia , Trombectomia/efeitos adversos , Trombectomia/métodos , Artéria Cerebral Média , Infarto Cerebral/etiologia , EsteroidesRESUMO
OBJECTIVES: Gastrointestinal endoscopy (GIE) is useful for the early detection and treatment of many diseases; however, GIE is considered a high-risk procedure in the coronavirus disease 2019 (COVID-19) pandemic era. This study aimed to explore the rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity in saliva and gastrointestinal fluids to which endoscopy medical staff are exposed. METHODS: The study was a single-center cross-sectional study. From June 1 to July 31, 2020, all patients who underwent GIE at Yokohama City University Hospital were registered. All patients provided 3 mL of saliva. For upper GIE, 10 mL of gastric fluid was collected through the endoscope. For lower GIE, 10 mL of intestinal fluid was collected through the endoscope. The primary outcome was the positive rate of SARS-CoV-2 in saliva and gastrointestinal fluids. We also analyzed serum-specific antibodies for SARS-CoV-2 and patients' background information. RESULTS: A total of 783 samples (560 upper GIE and 223 lower GIE samples) were analyzed. Polymerase chain reaction (PCR) on saliva samples did not show any positive results in either upper or lower GIE samples. However, 2.0% (16/783) of gastrointestinal fluid samples tested positive for SARS-CoV-2. No significant differences in age, sex, purpose of endoscopy, medication, or rate of antibody test positivity were found between PCR positive and PCR negative cases. CONCLUSIONS: Asymptomatic patients, even those with no detectable virus in their saliva, had SARS-CoV-2 in their gastrointestinal tract. Endoscopy medical staff should be aware of infection when performing procedures. The study was registered as UMIN000040587.
Assuntos
COVID-19 , SARS-CoV-2 , Estudos Transversais , Endoscopia Gastrointestinal , Humanos , Japão/epidemiologia , Prevalência , Estudos Prospectivos , SalivaRESUMO
PURPOSE: Through the progression of devices, the adaptation of carotid artery stenting (CAS) has been expanded according to the non-inferiority of CAS for carotid endarterectomy reported by several randomized control trials. To maintain favorable outcomes, identifying prognostic factors is essential for optimizing treatment indications and periprocedural management. This study focused on the prognostic factors of CAS using real-world data. METHODS: This retrospective multicenter cohort study aimed to identify the prognostic factors after CAS using real-world data from the stroke registry of Yokohama (STrOke Registry of Yokohama; STORY) from January 1, 2018 to May 31, 2021. Patient characteristics, procedural factors, complications, and prognoses were collected using medical records. RESULTS: Data from 107 patients were enrolled in this study after excluding those with insufficient data (2 cases). The mean participant age was 74.9±8.2 years, and 66 patients (61.7%) were symptomatic. Symptomatic lesions were a significant prognostic factor in the overall analysis (p=0.003). A multivariate analysis showed that the estimated glomerular filtration rate (eGFR) (odds ratio: 1.11, p=0.003) and staged CAS (odds ratio: 38.9, p=0.04) were independent prognostic factors. The odds ratio and relative risk of mRS deterioration when eGFR was under 49 mL/min/1.73 m2 compared with when eGFR was above 49 mL/min/1.73 m2 were 5.2 and 3.74, respectively. CONCLUSIONS: In this real-world multicenter study, we established independent prognostic factors for CAS using high totality data. For patients with symptomatic lesions and low eGFR (≤49 mL/min/1.73 m2), indication for treatment should be considered strictly.
Assuntos
Artérias Carótidas , Estenose das Carótidas , Nefropatias , Idoso , Idoso de 80 Anos ou mais , Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Humanos , Nefropatias/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , StentsRESUMO
Depressed skull fracture commonly results from trauma and usually occurs following high-speed impact with a small object. The outer and inner tables of the skull typically break concurrently. We present a case of depressed skull fracture involving only the inner table. The case resulted in a good outcome with only conservative treatment, although the mechanism remained unclear. Fracture models of cadavers have been the main tool for biomechanical investigation, but this classical method cannot accurately measure mechanical factors. We utilized a computer simulation model to assess the human head following skull fracture. This is the first report of an inner table fracture;the fracture mechanism was determined using a simulated computer model.
Assuntos
Fratura do Crânio com Afundamento/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
Cavernous sinus dural arteriovenous fistula can cause cerebral edema and hemorrhage due to cortical venous reflux and congestion. Understanding complex venous reflux and drainage routes is crucial for treatment planning. Here, we present a case of a cavernous sinus dural arteriovenous fistula with cortical venous reflux via two separate terminations of the telencephalic veins caused by an aplastic basal vein of Rosenthal. The patient presented with diplopia and eye redness and was diagnosed with a Cognard type IIa + b cavernous sinus dural arteriovenous fistula. The shunt was supplied by the dural branches of the internal and external carotid arteries. Multiple shunt points involving the intercavernous sinus and the medial aspect of the left cavernous sinus were identified, with drainage into the supraorbital and intracranial veins, including two separate terminations of the telencephalic veins, one leading to the laterocavernous sinus via the superficial middle cerebral vein and the other to the cavernous sinus via the uncal vein, resulting in basal ganglia venous congestion in the absence of the basal vein of Rosenthal. During transvenous embolization, the intracranial veins, cavernous sinus, and intercavernous sinus were obliterated using a double-catheter technique with a combination of coils and liquid embolics. Telencephalic venous variations can lead to cavernous sinus drainage into the basal ganglia and orbitofrontal brain. This unique drainage pattern underscores the importance of recognizing anatomical variations when managing cavernous sinus dural arteriovenous fistula.
RESUMO
Although rare, cerebral arterial fenestration may present challenges in diagnosis and treatment. Here we present a case of a supraclinoid internal carotid artery (ICA) fenestration adjacent to an ICA aneurysm, successfully treated with balloon-assisted coil embolization. A female in her 50's presented with an acute subarachnoid hemorrhage from a ruptured left ICA-ophthalmic artery (OA) aneurysm. Digital subtraction angiography revealed a focal ICA fenestration distal to the posterior communicating artery (Pcom). The patient underwent successful coil embolization of the aneurysm using the balloon-assisted technique. No immediate hemorrhagic, thromboembolic, or neurological complications were observed. The patient was discharged in good condition after 2 weeks of hospitalization. A comprehensive literature review of 33 cases was subsequently performed to understand the characteristics of this condition. Cases involving the cranial division of the ICA forming the fenestration exhibited caliber differences significantly more frequently (p = 0.02). Embryological insights revealed distinctions between the cranial divisions of the ICA, influencing fenestration morphology and associated aneurysm formation. Endovascular treatment poses the risk of vascular injury, necessitating the identification of this variation and procedural planning.
RESUMO
PURPOSE: Tandem occlusion, in which the intracranial artery is obstructed along with proximal carotid occlusive or stenotic lesions, occurs in 10-15% of patients with large vessel occlusion. Our study introduces a novel technique for tandem occlusion treatment that involves the simultaneous coaxial deployment of a percutaneous transluminal angioplasty balloon and aspiration catheters with the delivery wire of a stent retriever. After percutaneous transluminal angioplasty of the carotid lesion with a thin balloon catheter, the aspiration catheter was advanced over the balloon to eliminate the ledge between the catheter tip and delivery wire. After balloon removal, intracranial thrombectomy was performed using an aspiration catheter and stent retriever. This study aimed to evaluate the safety and efficacy of this approach. MATERIALS AND METHODS: Medical records of patients with acute stroke due to tandem occlusion treated using our technique were analyzed for its effectiveness and safety. The puncture-to-recanalization time, modified thrombolysis in cerebral infarction (mTICI) grade, functional prognosis and incidence of hyperperfusion were assessed. RESULTS: Seven patients were included in this study. In all patients, mTICI 2b-3 recanalization was achieved after smooth delivery of the aspiration catheter from the carotid lesion to the intracranial thrombus. The median puncture-to-recanalization time was 52 min. Ninety days post-stroke onset, six of seven patients had a modified Rankin Scale score of 0-2, and none of the patients had perioperative hyperperfusion syndrome. CONCLUSION: Our technique allows simultaneous treatment of carotid and intracranial lesions, leading to faster recanalization. Furthermore, percutaneous transluminal angioplasty with a thin balloon may reduce the risk of hyperperfusion.
RESUMO
Objectives: The superiority and usefulness of liquid material over particles for embolization have been a topic of debate due to differences in materials and techniques. This study aimed to identify the complications and outcomes associated with both embolization materials. Methods: This retrospective multicenter cohort study included 93 patients from an endovascular treatment registry, treated from January 1, 2018 to May 31, 2022. It included patients who underwent preoperative embolization for meningioma, solitary fibrous tumor/hemangiopericytoma, and hemangioblastoma. Data for patient characteristics, procedural factors, complications, and outcomes were collected from medical records. Results: A tortuous access route was the only factor independently associated with complications (p = 0.020). Although liquid material was more frequently used for embolization in relatively high-risk conditions, complication rates did not differ significantly between the groups (p = 0.999). In the liquid material group, the tip of the microcatheter could be guided closer to the tumor (p <0.001) using a distal access catheter and flow-guide microcatheters. The subgroup middle meningeal artery embolization had less operative bleeding in the liquid material group (p <0.001), whereas the particles group exhibited less intraoperative blood loss than the liquid material group (p = 0.006). Conclusion: The vascular tortuosity of the access route was only associated with complications in preoperative tumor embolization. Liquid material and particles showed no difference in complication rates. The use of particles in embolization may reduce intraoperative bleeding, but not in all cases can it be used safely. Therefore, a thorough understanding of the characteristics of both approaches and their relative advantages in clinical practice is essential to opt for the appropriate material according to the case.
RESUMO
Introduction Preoperative embolization can potentially facilitate surgical resection of challenging tumors in the intracranial and facial regions; however, its clinical efficacy remains controversial, mainly due to potential morbidity risks. We explored negative factors of the combined treatment of preoperative embolization and tumor resection that affect neurological prognosis. Method This retrospective study used clinical data from 132 consecutive tumors that underwent combined treatment at multiple facilities between January 2016 and May 2021. Basic patient information, tumor characteristics, and treatment details were assessed to identify predictors of deterioration as measured using the modified Rankin scale (mRS) score at three months post-treatment. Results Among the 126 eligible combined treatments, a deterioration in the postoperative mRS score was observed in 19/126 (15.1%). Complications related to embolization and tumor resection occurred in 8/126 (6.3%) and 19/125 (15.2%) of procedures, respectively. Multivariate analyses indicated significant associations between migration of embolic material (adjusted odds ratio 13.80; 95% confidence interval 1.25-152.52; p=0.03), elevated intraoperative blood loss (p=0.04), and deterioration of postoperative mRS score. Embolic material migration was identified as the primary prognostic factor for the deterioration of score. An analysis of 192 procedures, excluding those that exclusively used coils, identified embolization targeting the accessory meningeal artery (p=0.046) and the third segment of the internal maxillary artery (p=0.03) as a risk factor for embolic material migration. Conclusions Embolic material migration is the predominant factor associated with declining neurological outcome that persists into the chronic phase after combined treatment. Given that preoperative embolization is a supplementary treatment option, a thorough understanding of vascular anatomy and striving safe procedure are critical.
RESUMO
PURPOSE: The 2021 World Health Organization (WHO) classification of central nervous system (CNS) tumors uses an integrated approach involving histopathology and molecular profiling. Because majority of adult malignant brain tumors are gliomas and primary CNS lymphomas (PCNSL), rapid differentiation of these diseases is required for therapeutic decisions. In addition, diffuse gliomas require molecular information on single-nucleotide variants (SNV), such as IDH1/2. Here, we report an intraoperative integrated diagnostic (i-ID) system to classify CNS malignant tumors, which updates legacy frozen-section (FS) diagnosis through incorporation of a qPCR-based genotyping assay. EXPERIMENTAL DESIGN: FS evaluation, including GFAP and CD20 rapid IHC, was performed on adult malignant CNS tumors. PCNSL was diagnosed through positive CD20 and negative GFAP immunostaining. For suspected glioma, genotyping for IDH1/2, TERT SNV, and CDKN2A copy-number alteration was routinely performed, whereas H3F3A and BRAF SNV were assessed for selected cases. i-ID was determined on the basis of the 2021 WHO classification and compared with the permanent integrated diagnosis (p-ID) to assess its reliability. RESULTS: After retrospectively analyzing 153 cases, 101 cases were prospectively examined using the i-ID system. Assessment of IDH1/2, TERT, H3F3AK27M, BRAFV600E, and CDKN2A alterations with i-ID and permanent genomic analysis was concordant in 100%, 100%, 100%, 100%, and 96.4%, respectively. Combination with FS and intraoperative genotyping assay improved diagnostic accuracy in gliomas. Overall, i-ID matched with p-ID in 80/82 (97.6%) patients with glioma and 18/19 (94.7%) with PCNSL. CONCLUSIONS: The i-ID system provides reliable integrated diagnosis of adult malignant CNS tumors.
Assuntos
Neoplasias Encefálicas , Neoplasias do Sistema Nervoso Central , Glioma , Adulto , Humanos , Estudos Retrospectivos , Reprodutibilidade dos Testes , Neoplasias do Sistema Nervoso Central/diagnóstico , Neoplasias do Sistema Nervoso Central/genética , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/patologia , Glioma/diagnóstico , Glioma/genética , Glioma/cirurgiaRESUMO
BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for ischemic stroke prevention in patients with carotid artery stenosis. However, the beneficial effects of CEA/CAS for cerebral hypoperfusion due to carotid artery stenosis have yet to be fully established. As dizziness is a common symptom in patients with carotid artery stenosis, we aimed to evaluate the effects of CEA/CAS on cerebral function in patients with carotid artery stenosis, using equilibrium function tests. METHODS: This prospective observational cohort study included 50 patients who had carotid artery stenosis and were scheduled to undergo CEA or CAS. Before CEA/CAS, we quantitatively evaluated the vestibulo-ocular reflex (VOR) and vestibular evoked myogenic potential (VEMP), as indicators of brainstem/inner ear functions related to balance, and visual suppression of VOR, as an indicator of cerebral control over the brainstem reflex related to balance. These were then compared with supratentorial cerebral blood flow (CBF). Changes in VOR, VEMP, visual suppression of VOR, CBF, and dizziness after CEA/CAS were also evaluated. RESULTS: The visual suppression rates of VOR correlated with supratentorial CBFs before CEA/CAS (correlation coefficient = 0.47, p = 0.003). The visual suppression rates of VOR (p < 0.001) and supratentorial CBFs (p = 0.003) were improved by CEA/CAS, while VOR and VEMP did not change. Symptoms of dizziness improved after CEA/CAS. CONCLUSIONS: Our results suggest that visual suppression of the VOR may be a novel and practical marker for the beneficial effects of CEA/CAS on supratentorial cerebral function.
Assuntos
Estenose das Carótidas , Endarterectomia das Carótidas , Acidente Vascular Cerebral , Humanos , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Reflexo Vestíbulo-Ocular , Estudos Prospectivos , Tontura/etiologia , Resultado do Tratamento , Stents , Artérias Carótidas , Endarterectomia das Carótidas/efeitos adversos , Circulação Cerebrovascular , Acidente Vascular Cerebral/etiologia , Fatores de RiscoRESUMO
BACKGROUND: At craniotomy, the dura shrinks due to the drying effect of illumination and air exposure, rendering its primary closure difficult. When the opening is narrow, it can be patched with autologous grafts. However, tissue harvesting and meticulous suturing take time. As the cost-effectiveness of using dural substitutes is poor, we developed a new technique that involves dural scratching for the primary closure of dural openings. METHODS: We applied our technique because in 53 adults who underwent supratentorial craniotomy we encountered difficulties with the primary closure of a dural opening 5 mm or less in width. With a scalpel, we placed several fine scratches parallel to the edge of the opening on the surface of the dura, taking care not to perforate the deep layer. This relieved dural tension and the tissue was stretched enough to permit closing with sutures. RESULTS: Our technique achieved primary dural closure in 46 of 53 patients (87%) who primarily had undergone narrow supratentorial craniotomies. The other 7 additionally required small autologous grafts to patch narrow residual openings at the intersection of the durotomy. There were no procedure-related complications such as cerebrospinal fluid leakage and persistent headache due to tension of the closed dura. CONCLUSIONS: Dural scratching is simple, safe, requires no special instrumentation, facilitates primary closure of the shrunken dura by stretching, and reduces the need for patch grafting.
Assuntos
Craniotomia , Crânio , Adulto , Humanos , Crânio/cirurgia , Craniotomia/métodos , Vazamento de Líquido Cefalorraquidiano/cirurgia , Procedimentos Neurocirúrgicos , Cefaleia/cirurgia , Dura-Máter/cirurgia , Complicações Pós-Operatórias/cirurgiaRESUMO
Common carotid artery (CCA) occlusion (CCAO) is a rare cause of ischemic stroke and bypass surgery is the common treatment approach. However, safer alternatives should be developed to treat CCAO. A 68-year-old male was diagnosed with left-sided CCAO with decreased left visual acuity due to neck radiation therapy for laryngeal cancer. Recanalization therapy using a pull-through technique was initiated because cerebral blood flow progressively decreased during the follow-up period. First, after a short sheath was inserted into the CCA, the occluded CCA was retrogradely penetrated through the sheath. Second, a micro-guidewire was guided to the aorta from the femoral sheath where it was caught using a snare wire guided from the cervical sheath. Subsequently, the micro-guidewire was gently pulled out from the cervical sheath, penetrated the occluded lesion, and was secured to the femoral and cervical sheaths. Finally, the occluded lesion was dilated using a balloon, and the stent was placed. Five days postprocedure, the patient was discharged uneventfully and exhibited improved left visual acuity. In terms of reliable penetration of obstructive lesions and reduction of embolic and hemorrhagic complications, combined endovascular antegrade and direct retrograde carotid artery stenting is a versatile and minimally invasive treatment option for CCAO.
Assuntos
Doenças das Artérias Carótidas , Estenose das Carótidas , Procedimentos Endovasculares , Masculino , Humanos , Idoso , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Stents , Artérias Carótidas , Artéria Carótida Primitiva/cirurgia , Resultado do Tratamento , Procedimentos Endovasculares/métodosRESUMO
BACKGROUND: Meningiomas are often embolized preoperatively to reduce intraoperative blood loss and facilitate tumor resection. However, the procedure is controversial and its effects have not yet been reported. We evaluated preoperative embolization for meningiomas and its effect on postoperative outcome and recurrence. METHODS: We retrospectively reviewed the medical records of 186 patients with WHO grade I meningiomas who underwent surgical treatment at our hospital between January 2010 and December 2020. We used propensity score matching to generate embolization and no-embolization groups (42 patients each) to examine embolization effects. RESULTS: Preoperative embolization was performed in 71 patients (38.2%). In the propensity-matched analysis, the embolization group showed favorable recurrence-free survival (RFS) (mean 49.4 vs 24.1 months; Wilcoxon p=0.049). The embolization group had significantly less intraoperative blood loss (178±203 mL vs 221±165 mL; p=0.009) and shorter operation time (5.6±2.0 hours vs 6.8±2.8 hours; p=0.036). There were no significant differences in Simpson grade IV resection (33.3% vs 28.6%; p=0.637) or overall perioperative complications (21.4% vs 11.9%; p=0.241). Tumor embolization prolonged RFS in a subanalysis of cases who experienced recurrence (n=39) among the overall cases before variable control (mean RFS 33.2 vs 16.0 months; log-rank p=0.003). CONCLUSIONS: After controlling for variables, preoperative embolization for meningioma did not improve the Simpson grade or patient outcomes. However, it might have effects outside of surgical outcomes by prolonging RFS without increasing complications.
Assuntos
Embolização Terapêutica , Neoplasias Meníngeas , Meningioma , Humanos , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Estudos Retrospectivos , Perda Sanguínea Cirúrgica , Procedimentos Neurocirúrgicos , Embolização Terapêutica/métodos , Resultado do Tratamento , Cuidados Pré-Operatórios , Recidiva Local de Neoplasia/prevenção & controle , Recidiva Local de Neoplasia/cirurgiaRESUMO
BACKGROUND: Intraosseous clival arteriovenous fistulas (AVFs), in which the shunt drains extracranially from the posterior and anterior condylar veins rather than from the cavernous sinus (CS), are rare. Targeting embolization of an intraosseous clival AVF is challenging because of its complex venous and skull base anatomy; therefore, a therapeutic strategy based on detailed preoperative radiological findings is required to achieve a favorable outcome. Here, the authors report the successful targeted embolization of an intraosseous clival AVF using an ingenious access route. OBSERVATIONS: A 74-year-old woman presented with left-sided visual impairment, oculomotor nerve palsy, and right facial pain. A fusion image of three-dimensional rotational angiography and cone-beam computed tomography revealed a left CS dural AVF and a right intraosseous clival AVF. The shunt flow of the clival AVF drained extracranially from the posterior and anterior condylar veins via the intraosseous venous route. Transvenous embolization was performed by devising suboccipital, posterior condylar, and intraosseous access routes. The symptoms resolved after the bilateral AVFs were treated. LESSONS: Accurate diagnosis and proper transvenous access based on detailed intraosseous and craniocervical venous information obtained from advanced imaging modalities are key to resolving intraosseous clival AVF.
RESUMO
BACKGROUND: This study assessed the efficacy and safety of thrombectomy for acute ischaemic stroke in a population with pre-stroke modified Rankin scale (mRS) scores of 2-3 using real-world data. METHODS: Our sample set included 2313 consecutive patients enrolled in the Kanagawa Registry of Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry between January 2018 and June 2020 in 40 stroke centres in Kanagawa Prefecture, Japan. Patients treated with intravenous tissue plasminogen activator (t-PA), thrombectomy, or both were included. Patients with pre-stroke mRS scores of 4-5 and those treated only with intra-arterial thrombolysis were excluded. The primary outcome of this study was an mRS score of 0-3 at 90 days after onset to assess the efficacy of thrombectomy for pre-stroke disabled individuals. We performed multivariate logistic regression analyses to investigate independent factors for a 90-day mRS score of 0-3. We also performed nearest-neighbour within-calliper matching between thrombectomy and t-PA only. RESULTS: After excluding patients meeting the exclusion criteria, we analysed data of 2136 consecutive patients, of which 315 (14.7%) had pre-stroke disabilities (mRS score 2-3). A 90-day mRS score of 0-3 was achieved by 33.3% of patients with pre-stroke mRS scores of 2-3. According to multivariate analysis, the National Institutes of Health Stroke Scale (NIHSS) score was an independent factor. Furthermore, after propensity-score matching, thrombectomy showed considerable superiority for achieving a 90-day mRS score of 0-3. CONCLUSION: Intravenous t-PA and especially thrombectomy were safe and effective for the population with pre-stroke disabilities, particularly for patients with low NIHSS scores.
RESUMO
BACKGROUND: For patients who undergo endovascular treatment for acute ischemic stroke, the total time for treatment may increase during off-duty hours leading to worse outcomes. The present study compared endovascular treatment outcomes for on-duty and off-duty hours and examined factors that could be responsible for the prolonged treatment of patients in a multicenter registry. METHODS: The study group comprised 1571 patients listed in the multicenter stroke registry (K-NET) who had undergone endovascular treatment between January 2018 and June 2020. The modified Rankin Scale (mRS), evaluated at 90 days after stroke onset, was utilized as the primary outcome. Patients were divided into on-duty and off-duty patients based on admission time. Multivariate logistic regression analysis was used to identify the independent factors that increased the time from admission to puncture during the off-duty period. RESULTS: The mean mRS score at 90 days after stroke onset was 2.9, similar in both on-duty and off-duty patients, with no significant difference (p = 0.77); however, significant differences were observed in time from door-to-puncture (74.7 vs. 88.8, p < 0.01). Additionally, the mRS score at 90 days worsened significantly for door-to-puncture time >60 min in the off-duty period. Multivariate logistic regression analysis revealed that a low National Institute of Health Stroke Scale (NIHSS) score, high pre-mRS score, posterior circulation, and diabetes were independent indicators of door-to-puncture time >60 min during the off-duty period. CONCLUSION: Door-to-puncture time >60 min during off-duty hours was associated with poor outcomes related to low NIHSS, high pre-mRS, posterior circulation, and diabetes.
RESUMO
BACKGROUND: Preoperative identification of the carotid bifurcation (CB) location and plaque and stenosis distal end of the cervical internal carotid artery in relation to bony structures is essential for carotid endarterectomy (CEA). However, for patients with contrast contraindications, cervical 3-dimensional computed tomography angiography (3D-CTA) is unavailable. In this study, we created fusion images of magnetic resonance angiography (MRA), black-blood (BB) magnetic resonance imaging (MRI), and CT to determine if these noncontrast agent images are superior to 3D-CTA for preoperative CEA planning. METHODS: The fusion images showed vascular structures obtained by MRA, plaque observed by BB-MRI, and bone structures shown by CT. Spatial localization accuracy was verified by directly overlaying contrast-enhanced 3D-CTA images on the fusion images. We validated this technique in 50 patients with unilateral ICA stenosis, 28 of whom underwent CEA. The 2D-distance CB MRA-CTA (the 2D distance difference between CB MRA and CB CTA perpendicular to the long axis of the carotid artery) was measured. We also compared the findings of the fusion image regarding the CB location and plaque distal end with the operative findings. RESULTS: The median 2D distance CB MRA-CTA was 1 mm. CB MRA was located distal and proximal to CB CTA in 21and 29 patients, respectively. The CB location and fusion-image plaque were consistent with the intraoperative findings in all CEA patients. CONCLUSIONS: Fusion images created from MRA, BB-MRI, and noncontrast CT were feasible as an alternative to 3D-CTA for patients with contrast contraindications.
Assuntos
Estenose das Carótidas , Endarterectomia das Carótidas , Humanos , Endarterectomia das Carótidas/métodos , Angiografia por Ressonância Magnética/métodos , Meios de Contraste , Constrição Patológica , Estudos de Viabilidade , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Estenose das Carótidas/patologia , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: Despite holding soft tissue away from high-speed drills during surgery, tissue can unexpectedly wrap around the drill shaft. We performed experiments to examine what precipitates such mishaps. METHODS: In a windless environment, a Signature Drill System (Stryker) featuring a 4-mm diameter coarse diamond or cutting bit was placed parallel to a suspended strip of polypropylene. The distance between the end of the strip and the drill shaft or bits was 4 or 8 mm. In another experiment, we placed the drill horizontally 10 mm above the top of dry-ice fog. The maximum drill speed was 75,000 rpm, and the horizontal motion of the polypropylene strip and the vertical motion of the dry-ice fog were recorded by a video camera. RESULTS: In the experiments, the strip parallel to the vertical shaft and the dry-ice fog were pulled toward the shaft; the higher the revolving drill speed, the faster its motion. On the other hand, in experiments where the end of the strip was next to either bit, no such motion was observed. CONCLUSIONS: The pulling force generated by revolving high-speed drill shafts may result in tissue wraparound even when soft tissue is held away from the shaft.