Successful endovascular coiling of infectious cerebral aneurysm following Staphylococcus haemolyticus endocarditis.

Recent reports suggest that Staphylococcus haemolyticus can cause infective endocarditis (IE). However, no data are available regarding infectious intracranial aneurysm (IIA) following S. haemolyticus endocarditis. Endovascular coiling is a challenging approach for the treatment of IIA. We describe the case of a 63-year-old woman who suddenly developed aphasia and dysarthria following an acute cerebral infarction in her left insular and temporal cortex. After a total hysterectomy at the age of 39, the patient had suffered from recurrent bacterial pyomyositis in her legs. At admission, there was no evidence of cerebral aneurysm, as assessed by magnetic resonance angiography, and no vegetation, as assessed by transesophageal echocardiography (TEE), resulting in an incorrect diagnosis. However, subarachnoid hemorrhage and development of cerebral aneurysm in the left middle cerebral artery occurred within 1 week of hospitalization. Continuous positive blood culture results and a second TEE finally revealed that IE was caused by S. haemolyticus. Coil embolization of the IIA was successful on day 26 after symptom onset; after this procedure, the patient began to recover. This case demonstrates that S. haemolyticus-induced endocarditis can cause IIA. Endovascular coiling is a potentially effective approach to treat IIA.

Precision microcatheter shaping in vertebrobasilar aneurysm coiling.

BACKGROUND: Inventing an optimal curve on a microcatheter is required for successful intracranial aneurysm coiling. Shaping microcatheters for vertebrobasilar artery aneurysm coiling is difficult because of the vessel's long, tortuous and mobile anatomy. To overcome this problem, we devised a new method of shaping the microcatheter by using the patient's specific vessel anatomy and the highly shapable microcatheter. We report our preliminary results of treating posterior circulation aneurysms by this method. METHODS: An unshaped microcatheter (Excelsior XT-17; Stryker Neurovascular, Fremont, CA, USA) was pretreated by exposure to the patient's vessel for five minutes. The microcatheter was placed in the vicinity of the targeted aneurysm and was left in contact with the patient's vessel before extraction. This treatment precisely formed a curve on the microcatheter shaft identical to the patient's vessel anatomy. Following the pretreatment, the tip of the microcatheter was steam shaped according to the long axis of the target aneurysm. Five consecutive vertebrobasilar aneurysms were treated using this shaping method and evaluated for the clinical and anatomical outcomes and microcatheter accuracy and stability. RESULTS: All of the designed microcatheters matched the vessel and aneurysm anatomy except in one case that required a single modification. All aneurysms were successfully catheterized without the assistance of a microguidewire, and matched the long axis of the aneurysm. All microcatheters retained stability until the end of the procedure. CONCLUSIONS: A precise microcatheter shaping for a vertebrobasilar artery aneurysm may be achieved by using the patient's actual vessel anatomy and the highly shapable microcatheter.

Embolization for Refractory Subacute Subdural Hematoma in a Child with Severe Hemophilia Type A.

Hemophilia is an X-linked hemorrhagic disease due to coagulation factor VIII or IX deficiency with approximately 5-10% incidence of central nervous system bleeding. We present an intriguing case of a refractory subacute subdural hematoma (SDH) controlled with endovascular embolization in a hemophilic patient. A 5-year-old severe hemophilic A boy presented with a life threatening left parietal subcortical hemorrhage, for which he underwent craniotomy and evacuation of the hematoma. Recurrent hemorrhage necessitated a repeat craniotomy. This was followed by three episodes of SDH development at the craniotomy site that were treated surgically, and finally controlled with embolization in the subacute period. This case presents a novel option for treating a refractory SDH in patients with coagulation disorders.

A Case of Dural Arteriovenous Fistula in the Falx Cerebri: Case Report and Review of the Literature.

A 67-year-old man presented with consciousness disturbance and right hemiparesis. Computed tomography (CT) scan showed an intracerebral hematoma with two enhanced vascular lesions. Digital subtraction angiography revealed the dural arteriovenous fistula (dAVF) in the falx cerebri which was supplied by both bilateral middle meningeal arteries and left pericallosal artery and drained into both the superior sagittal sinus and the vein of Galen via the posterior callosal vein accompanied by two venous pouches. The dAVF was obliterated by a combination of the endovascular and the direct surgeries. A dAVF in a falx cerebri is very rare and only five cases were reported. Clinical characteristics of the dAVFs are uncertain. Before deciding the strategy of treatment, it is important to consider the pathological condition including embryology of the falx, the falcine sinus, and the falcine venous plexus.

Microcatheter Shaping for Intracranial Aneurysm Coiling Using the 3-Dimensional Printing Rapid Prototyping Technology: Preliminary Result in the First 10 Consecutive Cases.

OBJECTIVE: An optimal microcatheter is necessary for successful coiling of an intracranial aneurysm. The optimal shape may be predetermined before the endovascular surgery via the use of a 3-dimensional (3D) printing rapid prototyping technology. We report a preliminary series of intracranial aneurysms treated with a microcatheter shape determined by the patient's anatomy and configuration of the aneurysm, which was fabricated with a 3D printer aneurysm model. METHODS: A solid aneurysm model was fabricated with a 3D printer based on the data acquired from the 3D rotational angiogram. A hollow aneurysm model with an identical vessel and aneurysm lumen to the actual anatomy was constructed with use of the solid model as a mold. With use of the solid model, a microcatheter shaping mandrel was formed to identically line the 3D curvature of the parent vessel and the long axis of the aneurysm. With use of the mandrel, a test microcatheter was shaped and validated for the accuracy with the hollow model. All the planning processes were undertaken at least 1 day before treatment. The preshaped mandrel was then applied in the endovascular procedure. Ten consecutive intracranial aneurysms were coiled with the pre-planned shape of the microcatheter and evaluated for the clinical and anatomical outcomes and microcatheter accuracy and stability. RESULTS: All of pre-planned microcatheters matched the vessel and aneurysm anatomy. Seven required no microguidewire assistance in catheterizing the aneurysm whereas 3 required guiding of a microguidewire. All of the microcatheters accurately aligned the long axis of the aneurysm. The pre-planned microcatheter shapes demonstrated stability in all except in 1 large aneurysm case. CONCLUSION: When a 3D printing rapid type prototyping technology is used, a patient-specific and optimal microcatheter shape may be determined preoperatively.

Ocular thrombosis after stent-assisted coiling of a c7 (paraclinoid) internal carotid artery aneurysm. A report of two cases and literature review.

Stent-assisted coiling of paraclinoid aneurysms is widely performed in neurointerventional surgery. The most common adverse event related to this procedure is cerebral thromboembolism. However, reports on ocular thromboembolism are scarce. We report our experience with two patients who developed ocular thromboembolism following Enterprise stent-assisted coiling of paraclinoid aneurysms. We then review the available literature for the possible pathomechanism of ocular thrombosis. Ocular thromboembolism may be a risk of stent-assisted coiling when the stent traverses the orifice of the ophthalmic artery or the stent is placed in the C3 internal carotid artery. Further study is needed to clarify how to avoid this disabling complication.

Percutaneous medial saphenous artery approach for Swine central artery access.

A percutaneous medial saphenous artery catheterization technique for swine femoral access is described. The medial saphenous artery is accessed with a 22-gauge catheter-over-needle assembly, followed by 4-Fr 10-cm sheath insertion using the Seldinger technique. The 4-Fr sheath is subsequently exchanged over a 0.035-inch guidewire for a 5-Fr sheath to establish central artery access. The technique was applied to seven vessels in five swine, with successful catheterization in five vessels. The reason for failure was technical difficulty in one case and vasospasm in the other. Central artery access was still possible through direct exposure and puncture of the medial saphenous artery or the femoral artery. This technique may provide an alternative option for central artery access in swine. However, improvement in more reliable catheterization is warranted.