Custom shaping of distal access catheter for navigation of microcatheter into inferolateral and meningohypophyseal trunk feeders.

OBJECTIVE: Navigating a microcatheter to tiny feeding arteries such as the inferolateral trunk (ILT) and meningohypophyseal trunk (MHT) of the internal carotid artery (ICA) is technically challenging because of the anatomical features of steep angulation, small diameter, and significant caliber difference from the ICA. To guide the microcatheter to these ICA side branch feeders, the authors thought that a custom shaping of the intermediate catheter would be helpful to determine the direction of the microcatheter and strongly back it up. The aim of this study was to report the detailed methodology and clinical outcomes of patients who had undergone the embolization of ILT and MHT feeders using this method. METHODS: This was a retrospective study of consecutive patients with intracranial tumors and dural arteriovenous fistulas (DAVFs) who had undergone endovascular embolization. The details of the embolization procedures were examined, especially the technique of guiding a low-profile microcatheter supported by the thermoformed intermediate catheter. The authors assessed the patient background, procedural outcomes, and postoperative complications. RESULTS: Between October 2013 and June 2022, 43 patients with intracranial tumors and 45 with DAVFs underwent embolization at the authors' institutions. Among these cases, embolization of the ICA side branch feeder was attempted in 10 intracranial tumors and 2 DAVFs. Of these 12 patients, the microcatheter was guided deep enough for successful embolization in 11 cases (92%). Two asymptomatic arteriovenous fistulas were complicated during guidewire manipulation deep in the feeder. Yet, both disappeared completely after glue injection into the feeding artery. No spasm or dissection of the parent artery occurred during the procedure. Postoperative radiological evaluation showed no intracranial hematoma or symptomatic cerebral infarction. One patient (9%) developed permanent postoperative cranial neuropathy that gradually improved after embolization. CONCLUSIONS: This study revealed that custom shaping of distal access catheters is an effective technique that enabled the embolization of ILT and MHT feeders with a success rate of more than 90%.

Efficacy of a Novel Augmented Reality Navigation System Using 3D Computer Graphic Modeling in Endoscopic Transsphenoidal Surgery for Sellar and Parasellar Tumors.

In endoscopic transsphenoidal skull base surgery, knowledge of tumor location on imaging and the anatomic structures is required simultaneously. However, it is often difficult to accurately reconstruct the endoscopic vision of the surgical field from the pre-surgical radiographic images because the lesion remarkably displaces the geography of normal anatomic structures. We created a precise three-dimensional computer graphic model from preoperative radiographic data that was then superimposed on a visual image of the actual surgical field and displayed on a video monitor during endoscopic transsphenoidal surgery. We evaluated the efficacy of this augmented reality (AR) navigation system in 15 consecutive patients with sellar and parasellar tumors. The average score overall was 4.7 [95% confidence interval: 4.58-4.82], which indicates that the AR navigation system was as useful as or more useful than conventional navigation in certain patients. In two patients, AR navigation was assessed as less useful than conventional navigation because perception of the depth of the lesion was more difficult. The developed system was more useful than conventional navigation for facilitating an immediate three-dimensional understanding of the lesion and surrounding structures.

Anatomical Factors That Impede Using the Radial Artery Approach for Carotid Artery Revascularization.

OBJECTIVES: We investigated the anatomical characteristics that complicate utilizing the radial artery approach (RAA) for craniocervical intravascular intervention. METHODS: The data of 73 lesions in 65 consecutive patients who underwent transradial cervical carotid artery intervention was evaluated. We assessed the success rate of RAA in right-sided and left-sided lesions. The diameters and angles of the left and right common carotid arteries and the aortic, brachiocephalic, and right subclavian arteries, which constitute the paths of the guiding sheath, were assessed for each of the left- and right-sided lesions. RESULTS: It was difficult to apply RAA in 10 cases (13.7%), of which 2 (5.0%) involved right-sided and 8 (24.2%) left-sided lesions. The approach was significantly more difficult to perform in left-sided than in right-sided lesions (P = 0.02). Although the treatments were successfully completed, crossover to the femoral artery approach was required in 4 cases (5.5%, 2 cases for left-sided lesions). Placement of the guiding sheath in the common carotid artery was successful for all right-sided lesions; however, the guiding sheath slipped off to the aorta during stent advancement in 2 cases. When the angle between the brachiocephalic artery and aortic arch was small, the introduction of the guiding sheath to left-sided lesions was difficult in eight cases (P = 0.0001). CONCLUSIONS: RAA was difficult to perform in cases involving left-sided lesions and a small angle between the brachiocephalic artery and aortic arch. This study could help delineate the factors associated with difficulty of catheter introduction and instability of RAA.

Retrograde endovascular revascularization for chronic total occlusion of the internal carotid artery: a case report.

Endovascular revascularization of a chronically occluded internal carotid artery (ICA) is challenging because the occlusive segment can be long and tortuous. A case is presented of a successful recanalization of a chronically occluded ICA by retrograde passing of a guidewire from the intracranial ICA to the cervical ICA via the posterior communicating artery. This case suggests that a retrograde approach for reopening an occluded artery may be useful during neurovascular interventions, similar to percutaneous coronary interventions. In this patient, daily transient ischemic attacks disappeared after successful recanalization of the ICA.

A Case of Intravascular Treatment for Acute Ischemic Stroke with Internal Carotid Artery Stenosis That Developed While Driving.

Objective: We report a case of acute cerebral infarction that may have been associated with high-energy trauma due to onset while driving. Case Presentation: A 67-year-old man had a traffic accident. His neurological symptoms were left hemiplegia and contrast CT revealed right middle cerebral artery occlusion. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and intravascular treatment were performed. Right carotid artery angiography demonstrated internal carotid artery stenosis. Middle cerebral artery (MCA) revascularization was performed only by percutaneous transluminal angioplasty (PTA) of the internal carotid artery. Thoracic hemorrhage was observed a few hours after surgery, and hemostasis was performed by thoracotomy. Carotid artery stenting (CAS) was performed 8 days after onset. The patient was transferred to a convalescent rehabilitation hospital. Conclusion: Rt-PA and acute CAS were not recommended for cerebral infarction due to traffic accident.

Isolated Shoulder Palsy due to Intracerebral Hemorrhage.

A small cortical infarction confined to the medial location of the precentral knob on the precentral gyrus may cause isolated shoulder palsy. However, there are no reports indicating intracerebral hemorrhage as a cause of isolated shoulder palsy. We herein report the case of a 48-year-old man who presented with isolated shoulder palsy as an initial symptom of subcortical hemorrhage at the precentral gyrus. Such cases may be easily misdiagnosed as shoulder or cervical spine problems. The distribution of muscle weakness is the key to an accurate diagnosis.