Transarterial Embolization With N-Butyl-2-Cyanoacrylate for Rapidly Enlarging Distal Anterior Choroidal Artery Aneurysm Associated With Moyamoya Disease: A Case Report.

Peripheral aneurysms associated with moyamoya disease, particularly those originating from the anterior choroidal artery, often have a poor prognosis and are typically managed with endovascular treatments. Comprehensive imaging diagnostics and anatomical expertise are critical in minimizing ischemic complications during treatment. We present a case of a 55-year-old woman with a rapidly enlarging distal anterior choroidal artery aneurysm identified during an intracerebral hemorrhage associated with moyamoya disease. The patient underwent super-selective embolization using N-butyl-2-cyanoacrylate (NBCA) during the chronic phase, resulting in a favorable outcome. Detailed intraoperative imaging was essential in guiding the treatment and mitigating risks.

[External Carotid Artery:Essential Knowledge of the External Carotid Artery Required for Neuroendovascular Surgery, with a Focus on the Middle Meningeal Artery and Occipital Artery].

The perfusion territory of the external carotid artery is often underestimated; however, this blood vessel forms abundant "dangerous anastomoses" with the internal carotid and vertebral arteries. An understanding of these vascular anastomoses is crucial to ensure safe cerebrovascular interventions. There are several important aspects of the middle meningeal artery that should be considered, including anastomoses with the anterior(frontal)branch and ophthalmic artery through the sphenoidal artery(recurrent meningeal artery)and meningolacrimal artery. Additionally, the blood supply to the facial nerve via branches of the petrosal branch, such as the superior tympanic artery, and the formation of the facial arcade by the superior tympanic and stylomastoid arteries, which often originate from the posterior auricular artery, is significant. The occipital artery demonstrates rich anastomoses with vessels, such as the ascending pharyngeal and vertebral arteries, forming what is known as the pharyngo-occipital system.

Association Between Cerebral Angiography and Asymmetrical Cortical and Deep/Medullary Vein Signs on T2 Star Magnetic Resonance Imaging in Patients with Hyperacute Horizontal Segment of the Middle Cerebral Artery Occlusion.

BACKGROUND: When treating acute ischemic stroke patients, evaluation of collateral flow to the ischemic area is essential. Blood-oxygen-level-dependent imaging, including T2 star (T2∗), can identify elevated deoxyhemoglobin levels, reflecting an increase in the oxygen extraction fraction. Prominent veins on T2∗ represent increased deoxyhemoglobin and cerebral blood volume. This study compared asymmetrical vein signs (AVSs) on T2∗ and digital subtraction angiography findings during mechanical thrombectomy (MT) in patients with hyperacute middle cerebral artery occlusion. METHODS: Clinical and imaging data of 41 patients with occlusion of the horizontal segment of the middle cerebral artery who underwent MT were collected. Patients were divided into 2 groups based on angiographic occlusion sites as: proximal and distal to the lenticulostriate artery (LSA). AVSs on T2∗ were divided into asymmetrical cortical vein sign (cortical AVS) and asymmetrical deep/medullary vein sign (deep/medullary AVS), and were compared with the findings of intraoperative digital subtraction angiography. RESULTS: Twenty-seven patients had AVSs. Cortical AVS was the only parameter with a significant association with poor angiographic collateral supply. In terms of occlusion site, deep/medullary AVS was the only parameter with a significant association with occlusion proximal to the LSA. CONCLUSIONS: In patients with occlusion of the horizontal segment of the middle cerebral artery, presence of the cortical AVS on T2∗ suggests a poor angiographic collateral supply, while presence of the deep/medullary AVS suggests impaired blood flow to the basal ganglia through LSAs. Both these signs contribute to poor outcomes in patients undergoing MT.

Intrapartum Subarachnoid Hemorrhage from Suspected Lateral Posterior Choroidal Artery Dissection.

Stroke associated with pregnancy or puerperium is rare, but represents an important problem for women of childbearing age. We herein report a case of subarachnoid hemorrhage (SAH) due to suspected lateral posterior choroidal artery (LPChA) dissection during delivery. A 34-year-old woman developed deterioration of consciousness during delivery at a maternity clinic. Her Glasgow Coma Scale score was E3V3M6. She was sent to our hospital after 12 hr, where CT revealed SAH with intraventricular hematoma. Radiographic examinations showed contrast pooling on the left LPChA. Repeated angiography showed enlargement of the contrast pooling, which indicated pseudoaneurysm. It also showed a relatively clear but stenosed LPChA communicated with the lesion which could not be recognized in the angiography on day 0. This stenosed LPChA indicated arterial dissection. Therefore, endovascular parent artery occlusion was performed on day 11. Determining the exact extent of dissection was difficult because the LPChA was extremely narrow. Occlusion of the posterior cerebral artery was needed to achieve complete hemostasis, which, however, resulted in infarction of the medial temporal and occipital lobes. At the time of final follow-up 3 years later, the patient was alert and completely independent, but showed persistent incomplete homonymous hemianopsia. We reported a rare case of SAH from suspected LPChA dissection during delivery. Repeated angiography provided information about the source of hemorrhage and definite diagnosis, which opened the way to treatment. It is also important to recognize the difficulty in identifying the exact extent of dissection when treating dissections of small arteries.

Delayed mesencephalic venous infarction after endovascular treatment of a giant aneurysm of the posterior cerebral artery: Case report and anatomical review.

A 54-year old male patient underwent stent reconstruction of the P1-2 segment of the left posterior cerebral artery (PCA) and concomitant coil embolization of a symptomatic giant partially thrombosed P1 segment aneurysm. After an uneventful postinterventional period, on the 7th day the patient developed severe disturbance of consciousness. The imaging workup demonstrated acute venous infarction in the midbrain, caused by the compressive occlusion of the median anterior pontomesncephalic vein by the aneurysm in the interpeduncular fossa.

Safety and efficacy of balloon angioplasty in symptomatic intracranial stenosis: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Endovascular treatment is offered for symptomatic intracranial stenosis (ICS) when medical therapy fails. The purpose of this meta-analysis is to evaluate the risks and effectiveness of balloon angioplasty (BA) alone. MATERIALS AND METHODS: Systematic review and meta-analysis of all available articles on BA for symptomatic ICS was conducted. Data was analyzed separately for > 70% (Group 1) and > 50% (Group 2) stenosis. The results of the Group 1 were compared with those of SAMMPRIS study to the extent possible. RESULTS: A total of 25 studies comprising 674 patients were included. The cumulative incidence of periprocedural (within 30 days) stroke and death were 16.3% (Group 1), 7.6% (Group 2) and 11.5% (all studies). Incidence rates of ischemic stroke in the qualifying artery territory during follow-up (per 100 patient-years) were 2.0, 2.4 and 2.3, any stroke and death during follow-up were 4.4, 7.4 and 6.9, restenosis rates were 4.9, 11.5 and 8.9 respectively. While comparison of cumulative incidences of periprocedural ischemic stroke between Group 1 (13.0%) and the medical arm from SAMMPRIS study(4.4%) showed a significant difference (P = 0.008), there was no significant difference between the Group 1 and the stenting arm from SAMMPRIS study(10.7%) in the same variable. CONCLUSION: Balloon angioplasty for stenosis of more than 70% is likely to have similar outcome comparable to the stenting arm in the SAMMPRIS study, however it presents lower rates of late ischemic events and restenosis. These data may help deciding on the endovascular method of choice in case of medical therapy failure.

Efficacy of Cone Beam Computed Tomography in Treating Cavernous Sinus Dural Arteriovenous Fistula.

BACKGROUND: Exact identification of feeding arteries, shunt points, and draining veins is essential in treating cavernous sinus dural arteriovenous fistula (CS dAVF). In addition to digital subtraction angiography (DSA) and 3-dimensional rotational angiography (3DRA), high-resolution cone beam computed tomography (CBCT; especially 80-kv high-resolution cone beam computed tomography) have been performed in recent years. We evaluated the efficacy of CBCT in treating CS dAVF. METHODS: Eight CS dAVFs were treated with endovascular embolization between January 2013 and December 2016. We retrospectively examined these cases regarding information from DSA, 3DRA, and CBCT with contrast medium. RESULTS: Although all procedures can evaluate feeding arteries, shunt points, and draining veins, CBCT can provide the best definition of feeders and their course through the bony structures and the compartment of CS. Therefore, CBCT with placed microcatheter in the CS can reveal whether the microcatheter is set at the appropriate compartment to be embolized. CONCLUSIONS: The efficacy of CBCT in treating dAVF is illustrating the relationships among the bony structures and feeders, compartment of CS, and the position of the microcatheter. Detailed information obtained with CBCT can lead to fewer complications and more effective treatment.

Efficacy of high-resolution cone-beam CT in the evaluation of perforators in vertebral artery dissection.

Introduction A major complication of internal coil trapping for vertebral artery dissection (VAD) is medullary infarction associated with perforator occlusion. Currently, higher spatial resolution imaging can be obtained with high-resolution cone-beam computed tomography (VASO CT), and the efficacy of perforator visualization adjacent to VAD was examined. Methods Eight patients who underwent internal coil trapping or stent-supported coil embolization underwent VASO CT to evaluate perforators around VAD. Visualization of perforators was compared with conventional digital subtraction angiography (DSA) and three-dimensional rotational angiography (3D-RA). Postoperative MRI was performed in all patients to investigate ischemic complications. The relationship between the perforators and the infarction was analyzed. Results Perforator visualization was much clearer on VASO CT than on 2D DSA or 3D-RA. It was sharp enough to identify each perforating artery. Medullary infarctions were detected in two cases. In these two cases, each ischemic lesion corresponded to the territory of a perforator that was well visualized on VASO CT. The axial view with adjoining tissue structures on VASO CT was useful to detect the territories of perforators. Conclusions VASO CT is an efficient modality for the detection and identification of perforators in the vicinity of VAD. It provides accurate anatomical information about the vertebrobasilar system that is useful for the treatment of unruptured VAD.

Delayed Normalization of Electrocardiograms in Patients with Takotsubo Cardiomyopathy due to Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Takotsubo cardiomyopathy (TCM) is caused by excessive physical and mental stress, and sometimes causes potentially fatal arrhythmias such as torsades de pointes. This study characterized the features of TCM due to aneurysmal subarachnoid hemorrhage, particularly the delayed normalization of electrocardiograms compared with that of transthoracic echocardiograms. METHODS: Ten patients with TCM were selected from the 450 patients with subarachnoid hemorrhage treated in our hospital between January 2007 and November 2015. We retrospectively examined these 10 patients with regard to various factors, including durations of abnormal electrocardiographic and echocardiographic findings. RESULTS: All 10 patients were women. Mean age at diagnosis was 69.3 years (range, 40-90 years). Electrocardiographic findings were as follows: inverted or flattened T waves (100%); QTc prolongation >0.45 seconds (90.0%); ST segment elevation (60.0%); and ST segment depression (20.0%). Echocardiograms showed typical findings of TCM in 9 cases and inverted TCM in 1 case. In 1 case, ventral fibrillation was observed. Normalization of electrocardiograms was consistently delayed compared with that of echocardiograms, by more than 3 weeks in at least 5 cases (50%). If follow-up of electrocardiographic parameters is discontinued at the point of normalization of wall motion and the end of the vasospasm period, fatal arrhythmia may occur in the aftermath. CONCLUSIONS: This study showed a notable delay in recovery of abnormal electrocardiographic findings compared with the recovery of echocardiographic findings. Sufficient attention to persistent abnormalities on electrocardiography is warranted, even after improvements in cardiac wall motion and the vasospasm period.

Subarachnoid hemorrhage from dissecting aneurysm of the posterior communicating artery.

A 36-year-old woman on chronic hemodialysis presented with sudden onset of headache and deterioration of consciousness. She was sent to our hospital on day 1, with subarachnoid hemorrhage. Cerebral angiography showed pearl and string sign on the left posterior communicating artery, which was consistent with a diagnosis of hemorrhage from a dissecting aneurysm of the left posterior communicating artery. She underwent parent artery occlusion via endovascular treatment on day 2. Although cone beam computed tomography before embolization showed a perforator from the lesion, there were no ischemic lesions on diffusion-weighted imaging after the procedure. She was discharged without any neurological deficits. It is important to recognize that dissecting aneurysm of the posterior communicating artery is one cause of subarachnoid hemorrhage. We also discuss the utility of cone beam computed tomography in formulating the treatment plan for such patients.

Efficacy of high-resolution cone-beam CT in the evaluation of carotid atheromatous plaque.

INTRODUCTION: A major disadvantage of carotid artery stenting (CAS) is the high incidence of perioperative cerebral embolism. Cerebral embolism after CAS is associated with soft plaque. Currently, higher spatial resolution imaging can be obtained with cone-beam CT (CB-CT). The correlation between the degree of contrast enhancement of the vasa vasorum (VV) on CB-CT and the vulnerability of plaque in terms of risk factors for CAS was evaluated. METHODS: 18 patients who underwent CAS had high-resolution CB-CT to evaluate enhancement of the VV covering carotid plaque performed intraoperatively. The appearance of the surface of the carotid plaque was classified as either enhancing (VV-positive) or non-enhancing (VV-negative). Carotid plaque vulnerability on black-blood MRI (BB-MRI) and postoperative ipsilateral ischemic lesions on diffusion-weighted imaging (DWI) were analyzed in the two groups. RESULTS: Of the 18 patients, 9 were VV-positive and 9 were VV-negative. The proportion of ipsilateral new ischemic lesions on DWI was significantly higher in the VV-positive group than in the VV-negative group (8/9 patients (88.9%) vs 3/9 patients (33.3%), p=0.026). BB-MRI was performed preoperatively in 15 of 18 patients. The proportion of unstable plaque on BB-MRI was significantly higher in the VV-positive group than in the VV-negative group (9/9 patients (100%) vs 1/6 patients (16.7%), p=0.002). CONCLUSIONS: Enhancement of the VV covering carotid plaque on high-resolution CB-CT was significantly associated with unstable plaque on BB-MRI and postoperative ipsilateral new ischemic lesions.

Ophthalmic systems completely supplied from dural arteries indicate the utility of endovascular treatment of cerebral aneurysms.

We report a 67-year-old man who harboured an unruptured left basilar-superior cerebellar artery aneurysm. Cerebral angiography and cone beam computed tomography with diluted contrast medium showed that the bilateral ophthalmic arteries were not supplied from internal carotid arteries but, rather, were supplied from the middle meningeal and accessory meningeal arteries. This meant that the ophthalmic system was predominantly supplied from the dural arteries and, therefore, pterional craniotomy might cause a compromise in blood supply to the retinal artery. To avoid this complication, coil embolization was selected instead of neck clipping, and this endovascular therapy succeeded without neurological deficit. This case report shows the importance of cerebral angiography (including cone beam computed tomography) and consideration of the patterns of ophthalmic artery perfusion when selecting operative procedures for management of aneurysms that require manipulation around the sphenoid ridge.