Unexpected coil mass migration during transvenous embolization of a dural arteriovenous fistula resolved with guidewire-assisted snaring technique.

Endovascular embolization is a standard treatment for dural arteriovenous fistulas (dAVFs). Although it is considered relatively safe, intraoperative and postoperative complications can occur. Herein, a rare case of unexpected coil mass migration requiring a retrieval procedure during sinus occlusion for a transverse-sigmoid sinus dAVF (TSdAVF) is described. An 83-year-old man presented with worsening decline in cognitive function. Magnetic resonance angiography showed a TSdAVF. Since his symptoms seemed to be a result of the TSdAVF, transvenous embolization preserving the normal cranial venous circulation was planned. During sinus occlusion, including embolization of the shunted pouch of the TSdAVF, unexpected migration of the coil mass to the confluence of the superior sagittal sinus and the transverse sinus occurred. The migrated coil mass impeded venous circulation in the superior sagittal sinus. Since the presence of the coil mass at the confluence could have had catastrophic sequelae, the coil mass was retrieved using a guidewire-assisted snaring technique. Sinus occlusion was subsequently completed with repositioning of the coil mass at the target site. The TSdAVF resolved, with no recurrence confirmed for 1 year. Clinicians should be aware that coil mass migration can unexpectedly occur during sinus occlusion performed for treatment of a TSdAVF. The guidewire-assisted snaring technique might be effective in resolving this intraoperative complication.

An extremely rare complication during carotid artery stenting using a Wallstent: Migration of a stent holder of a Carotid Wallstent.

BACKGROUND: Carotid artery stenting (CAS) is an established treatment for internal carotid artery stenosis (ICS). The Carotid Wallstent is commonly used as a stent device in CAS procedures. Rare complications associated with the use of the Carotid Wallstent in CAS procedures include delayed shortening and incomplete stent expansion due to displacement of a marker ring. However, there have been no previous reports of a stent holder becoming unpredictably detached from a Carotid Wallstent during a procedure, requiring the additional deployment of another Carotid Wallstent. CASE PRESENTATION: The case of a 72-year-old man with progressive ICS is described. Since the ICS was resistant to medical treatment, CAS was planned to prevent ischemic events. During the procedure, a Mo.Ma Ultra and a carotid guardwire were used for proximal and distal protection, respectively. Following the introduction of those protective devices, a Carotid Wallstent was deployed at the stenotic lesion of the ICS. After the deployment of the Carotid Wallstent, a stent holder unpredictably detached was identified in the lumen of the Carotid Wallstent. Since it was impossible to mechanically retrieve the detached stent holder, another Carotid Wallstent was deployed to trap the substance. Postoperatively, the substance was identified as a stent holder of the first Carotid Wallstent. CONCLUSION: This is the first report of an extremely rare complication concerning a Carotid Wallstent in CAS.

Lumbar Subarachnoid-Peritoneal Shunting Deteriorates Superficial Siderosis Associated with a Dural Defect.

Superficial siderosis is a disease in which hemosiderin is deposited under the leptomeninges and subpial layers of hindbrain structures, e.g., the cerebellum, brainstem, and eighth cranial nerve. The main symptoms of superficial siderosis are cerebellar ataxia, hearing loss, cognitive decline, and myelopathy. The activities of daily living of patients with superficial siderosis are severely impaired due to the progressive symptoms. Here, we report a patient with superficial siderosis whose symptoms deteriorated after lumbar subarachnoid-peritoneal (L-P) shunt surgery. She received L-P shunt surgery based on the diagnosis of idiopathic normal pressure hydrocephalus at another hospital. The patient had a history of cervical surgery, and a dural defect was identified at the C4-5 level by a detailed magnetic resonance imaging study. We hypothesized that the L-P shunt reduced cerebrospinal pressure and increased bleeding from the fragile vessels in the dural defect, which might have increased hemosiderin deposition.

Favorable prognosis in posterior circulation ischemic stroke: Insights from a nationwide stroke databank.

INTRODUCTION: Clinical trials have historically underrepresented patients with posterior circulation ischemic stroke (PCIS). This study aimed to comprehensively assess the clinical characteristics and outcomes of PCIS patients compared to those with anterior circulation ischemic stroke (ACIS). METHODS: A retrospective analysis was conducted using data from the Japan Stroke Data Bank, encompassing 20 years across 130 stroke centers. The study focused on patients diagnosed with PCIS or ACIS. RESULTS: Among 37,069 patients reviewed, 7425 had PCIS, whereas 29,644 had ACIS. PCIS patients were younger and had a lower female representation than ACIS patients. Notably, PCIS patients had more favorable outcomes: 71% achieved a modified Rankin Scale of 0-2 or showed no deterioration at discharge (17 days at the median after admission), compared to 60% for ACIS patients (p < 0.001). Factors associated with an unfavorable outcome in the PCIS subgroup were older age, female sex (assigned at birth), history of hypertension, and higher National Institute of Health Stroke Scale (NIHSS) scores at admission. In both sexes, older age and higher NIHSS scores were negatively associated with favorable outcomes. CONCLUSIONS: PCIS patients demonstrated a more favorable prognosis than ACIS patients. Factors like older age, female sex, and higher NIHSS scores at admission were identified as independent predictors of unfavorable outcomes in PCIS patients. Older age and higher NIHSS scores at admission were common independent negative factors for a favorable outcome regardless of sex.

Serum perampanel levels in patients with seizures are not affected by hemodialysis.

Perampanel belongs to a novel class of antiseizure medications (ASMs). Studies examining the effect of hemodialysis on perampanel serum levels in clinical settings are lacking. We aimed to evaluate the changes in serum perampanel levels during hemodialysis. We studied patients with seizures who received oral perampanel between April 2020 and March 2023 and whose serum concentration of perampanel was measured before and after hemodialysis. We analyzed the serum concentrations of levetiracetam and lacosamide for comparison. Fourteen patients, with a mean age of 76.1 ± 7.88 years, were included. The dose of perampanel was 2.14 ± 1.27 mg. The hemodialysis clearance rate of perampanel, levetiracetam, and lacosamide was 0 ± 13%, 69 ± 11%, and 59.6 ± 8.2%, respectively. The post-dialysis CD ratio decreased significantly with levetiracetam but not with perampanel. Adverse but acceptable effects of perampanel were observed in two patients. The serum concentrations of several ASMs have been shown to be reduced during hemodialysis. Our study revealed that the serum perampanel concentration does not decrease during hemodialysis. Owing to the low rate of adverse effects and the stability of perampanel serum concentration during hemodialysis, perampanel could be a favorable choice as an ASM for patients with seizures undergoing hemodialysis. PLAIN LANGUAGE SUMMARY: Our study looked at how hemodialysis affects the serum levels of perampanel, a new type of medication for seizures. In 14 patients who started treatment between April 2020 and March 2023, perampanel serum levels did not decrease during hemodialysis, unlike other seizure medications. This shows that perampanel can be a good option for patients with seizures who need hemodialysis, with fewer side effects compared to other medications.