Usefulness and problems of Y-Stent and T-Stent assisted coiling for unruptured cerebral aneurysms.

INTRODUCTION: We are going to discuss about usefulness and problems of Y-stent and T-stent assisted coiling for unruptured cerebral aneurysms. METHODS: A retrospective review was performed to identify patients who were treated using Y-stent or T-stent assisted coiling (Y-SAC, T-SAC) for 25 unruptured cerebral aneurysms from April 2017 to September 2021. Fifteen cases were treated using Y-SAC, 10 were done using T-SAC. Only a case was treated with Low-profile Visualized Intraluminal Support (LVIS; MicroVention TRUMO, Aliso Viejo, California, USA) and Neuroform ATLAS (Striker, Kalamazoo, Michigan, USA), Others were done with two Neuroform ATLAS stents. RESULTS: Y-SAC and T-SAC were succeeded in all cases. In two cases that were treated using Y-SAC, ischemic complications were observed. A patient received additional embolization because subarachnoid hemorrhage (SAH) was appeared after discharge. On follow-up imaging, complete occlusion (CO) was confirmed in all cases. CONCLUSION: The position of deployment of stents was the most important issue. In particular, the second stent should be deployed as to contact the first stent, as possible. The case that the position of the second stent was shifted, and neck was not covered was observed. In the cases that are treated by using T-SAC, microcatheter must be navigated to distal position as possible. In that point, Y-SAC is more applicable. The familiarization of Y-SAC or T-SAC will expand the indication of endovascular treatment for unruptured cerebral aneurysms.

Iatrogenic Middle Meningeal Arteriovenous Fistula During Embolization: Two Case Reports and Literature Review.

Objective Dural arteriovenous fistulae of the middle meningeal artery are rare. There are few reports of complications associated with endovascular therapy. This report describes two cases of iatrogenic middle meningeal arteriovenous fistula due to vascular injury sustained during endovascular treatment. Case description Case 1 was that of a 46-year-old woman. She was treated for an incidentally discovered dural arteriovenous fistula of the cerebellar tentorium by transarterial embolization. During the procedure, a middle meningeal arteriovenous fistula occurred because of vessel laceration by the forced advancement of the distal access catheter (DAC). After the intervention, she developed tinnitus. Follow-up angiography revealed a middle meningeal arteriovenous fistula. The fistula was treated by coil embolization of the affected middle meningeal artery. The second case was that of a 56-year-old woman who developed a middle meningeal arteriovenous fistula from the perforation caused by the microguidewire during tumor embolization. The fistula was treated by occluding the proximal segment of the affected artery with coils. Both patients were discharged without neurological complications after the endovascular procedures. Conclusion Endovascular surgeons should be aware of the possibility of middle meningeal arteriovenous fistula as a potential complication of endovascular procedures.

[A Case of Successful Drug Management with Dabigatran and Idarucizumab to Address Embolic and Hemorrhagic Complications for Asymptomatic and Traumatic Subdural Hematoma with Non-valvular Atrial Fibrillation].

A 93-year-old woman incurred a head bruise 5 days prior to presentation, and head CT revealed right subacute subdural hematoma. As she was on direct oral anti-coagulant(DOAC)treatment for non-valvular atrial fibrillation(NVAF), the DOAC administration was stopped temporarily to prevent an increase in the size of the hematoma. Dabigatran treatment was initiated after the confirmation of no change in hematoma size and the follow-up CT revealed a reduction in the hematoma. However, left upper limb paresis occurred on day 12 of dabigatran treatment and head CT revealed the onset of right chronic subdural hematoma. Emergency burr hole surgery was performed after intravenous administration of idarucizumab to neutralize the dabigatran. Her neurologic symptoms improved after the operation and no recurrence of subdural hematoma was observed even after dabigatran treatment was resumed. Dabigatran could be administered relatively safely, even for subacute intracranial hemorrhage complicated with NVAF, suggesting the possibility of the prevention of ischemic stroke. Moreover, even when intracranial hemorrhage recurred, the prompt neutralizing effect of idarucizumab, a dabigatran-specific neutralizing agent, was useful in the surgical intervention and perioperative management.

[The Efficacy of Percutaneous Transluminal Angioplasty and Stenting for Traumatic Vertebral Artery Dissection due to Cervical Vertebral Fracture].

A 73-year-old man was admitted at another hospital after a traffic accident. The diagnosis was cervical vertebral fracture. Despite conservative treatment, 5 days later he manifested dysarthria due to cerebellar infarction and was transferred to our hospital. Imaging studies revealed right vertebral arterial dissection at the level of the axial fracture. We performed percutaneous transluminal angioplasty with stenting to address his subacute vertebral artery dissection prior to treating the cervical vertebral fracture using external fixation. His clinical course was good;ischemia did not recur after stenting and his dysarthria disappeared upon rehabilitation. Cerebral angiograms obtained 6 months later revealed no significant in-stent restenosis. While medical management tends to be the first-line treatment of traumatic vertebral artery dissection, percutaneous transluminal angioplasty with stenting is necessary before treating other traumatic lesions to prevent neurologic events.

Nε-(carboxymethyl)lysine Concentration in Debris from Carotid Artery Stenting Correlates Independently with Signal Intensity on T1-Weighted Black-Blood Magnetic Resonance Images.

BACKGROUND AND PURPOSE: Because magnetic resonance imaging (MRI) focuses on the morphological characteristics of carotid artery plaques, its diagnostic value with respect to plaque vulnerability is limited. We examined the correlation between Nε-(carboxymethyl)lysine (CML), a main chemical structure of advanced glycation end-products, and the vulnerability of plaques visualized on MRI scans. MATERIALS AND METHODS: We enrolled 43 patients who had undergone carotid artery stenting (CAS) for carotid artery stenosis; all underwent MRI studies, including black-blood MRI and diffusion-weighted imaging (DWI). The signal intensity ratio (SIR) of plaques to adjacent sternocleidomastoid muscle (P/M) on T1- and T2-weighted images (T1WI, T2WI) was calculated. Protein samples were extracted from debris trapped by a filter device. The concentrations of CML and myeloperoxidase (MPO) were measured by solid-phase enzyme-linked immunosorbent assay. RESULTS: The patients were classified into 2 groups based on their SIR-P/M on T1WI and T2WI scans. We observed a higher incidence of post-CAS DWI lesions in patients with a higher than a lower SIR-P/M on T1WI; the CML and MPO concentrations in their CAS debris were also higher. No such differences were seen in patients with a higher or lower SIR-P/M on T2WI scans. The concentration of CML in CAS debris correlated independently with the SIR-P/M on T1WI of the carotid plaques, and was related to the concentration of MPO in CAS debris. CONCLUSIONS: Our findings suggest CML as a candidate molecular imaging probe for the identification of vulnerable plaques.

[Transoral Penetrating Cranial Injury by a Chopstick:A Case Report].

Intracranial injury resultant from a chopstick penetrating the oral cavity is often fatal in children, and only 5 clinical cases have been reported. If the depth of penetration is indeterminable, due to the chopstick being removed or the remaining piece not being located, then injury management is challenging; here, we report such a case. A 26-month-old girl fell over with a plastic chopstick in her mouth. The chopstick was removed immediately and without breakage by her father. He noted that around 3 cm of the pointed end had pierced the palate. CT revealed air bubbles in the retropharyngeal space but no abnormality in the cranium. Subsequent complications included bacterial meningitis and right hemiparesis but neither MRI nor any alternative imaging modality could aid in locating the intracranial lesion that induced the weakness. Neurological findings suggested injury of the right lateral corticospinal tract at the lower end of the medulla oblongata. An axial T2-weighted MRI showed a 30-mm high signal path of penetration from the posterior nasopharyngeal wall to the dura at the craniocervical junction. When the route is extended 36 mm intracranially from the wound orifice, the path makes superficial contact with the right lateral portion of the medulla oblongata, which corresponds with the lateral corticospinal tract. We therefore hypothesize that this was the lesion location but that it was too small to be detected using MRI.

Treatment strategy for giant thrombosed aneurysm of the basilar artery with associated obstructive hydrocephalus.

Background: There is no established adequate treatment for thrombosed aneurysm of the basilar artery with obstructive hydrocephalus. We conducted coil embolization and peritoneal shunting followed by placement of a stent expected to exert flow diversion (FD) effects to treat 2 patients with giant thrombosed aneurysms of the basilar artery with associated obstructive hydrocephalus, with good results. Methods: From April 2019 to March 2021, consecutive two cases of symptomatic hydrocephalus due to giant thrombosed aneurysms in the posterior cranial fossa at our hospital were treated. At first, coil embolization was performed to prevent aneurysm rupture. After coil embolization, ventriculoperitoneal shunting was performed. Finally, stent-assisted coil embolization was performed with flow re-direction endoluminal device (FRED) or low-profile visualized intraluminal support device (LVIS) stent. Results: Both patients were discharged after recovering well, with no postoperative hemorrhagic or ischemic complications. Conclusion: Staged surgery using a FRED for flow diverter or an LVIS stent expected to have FD effects may offer an effective treatment option.

Usefulness of the Three-step Simple Binostril Approach in Endoscopic Endonasal Transsphenoidal Surgery.

We describe a three-step, simple binostril approach to endoscopic endonasal transsphenoidal surgery in cases of sellar/parasellar lesions. In the first step, the mucosa of the lower third of the ethmoid bulla on the outside was coagulated with monopolar microdissection needle and opened to create space on the outside of the middle turbinate. The middle turbinate was moved outward using this space, and the natural ostium of the sphenoid sinus could be confirmed easily. In the second step, a less than 10 mm incision was made from the right natural ostium of the sphenoid sinus to the right nasal septal mucosa. The anterior wall of the sphenoid sinus was removed to free the sphenoid sinus. In the third step, the instrument was inserted through the left nostril using a hole connected to the natural ostium of the sphenoid sinus to reach the sellar floor via both nostrils. It took longer for the trainee than for the instructor to reach the sellar floor in the first four cases. However, there was no significant difference in the approach time after the fifth case. Approach-related postoperative complications were observed in 52 cases of sellar/parasellar lesions performed. This approach was considered to provide sufficient space and was simple and less burdensome to the patient.

Successful use of an LVIS device to treat unruptured distal aneurysm of the superior cerebellar artery at a vascular bifurcation.

Background: Aneurysms of the distal superior cerebellar artery (SCA) account for only a small proportion of all cerebral aneurysms. Reports of the use of flow diverters (FDs) started to appear in 2013. We obtained good results from placement of a low-profile visualized intraluminal support device (LVIS) to treat unruptured distal aneurysm of the SCA at a vascular bifurcation. Case Description: A 65-year-old man presented at our hospital with sudden peripheral facial nerve palsy and suspected subarachnoid hemorrhage. Investigational cerebral angiography revealed an aneurysm at the bifurcation of the caudal and rostral trunks of the SCA. An LVIS was placed with the aim of obtaining flow diversion, and cerebral angiography 6 months after this procedure showed disappearance of aneurysm with preservation of the distal SCA. Conclusion: Twelve cases of the use of FDs to treat aneurysms of the SCA have been reported previously. However, none of those reports described FD use to treat an aneurysm at a vascular bifurcation, as in the present case. Our results suggested that LVIS placement with the aim of obtaining flow diversion may be useful for the treatment of aneurysms at such sites.

Usefulness of endoscope-assisted surgery under exoscopic view in skull base surgery: A technical note.

BACKGROUND: The use of the exoscope has been increasing in the field of neurosurgery, as it can set the visual axis freely, enabling the surgeon to operate in a comfortable posture. Although endoscope-assisted surgery for compensation of insufficient surgical field is useful under the microscope, we report that using an endoscope in exoscopic surgery is safer and more useful. METHODS: The exoscope used was ORBEYE. All surgical procedures were performed exoscopically from the beginning of the surgery. When endoscopic observation was required during the operation, the endoscope was inserted under observation by an exoscope. The exoscopic screen was 4K-3D and endoscopic screen was 4K-2D, the operation was performed while observing both screens at the same time. The endoscope was held manually or by a mechanical holder. RESULTS: Twenty-two cases, including 14 requiring microvascular decompression (MVD) and eight requiring tumor removal, were performed by endoscopic-assisted exoscopic surgery. The endoscope could be inserted safely because its relationship with the surrounding structure could be observed under the exoscope, and the operator could observe both screens without moving the head. Fourteen of 22 patients required additional endoscopic treatment. Satisfactory two-handed operation was performed in 13 cases. Symptomatology disappeared in all cases of MVD, and sufficient tumor resection was achieved. CONCLUSION: Exoscopic surgery provides excellent surgical view that is not inferior to conventional microsurgery. As a large space can be secured between the scope and the surgical field, it is safer and easier to manipulate the endoscope under the exoscope.

Case of Cyclic Cushing's Disease with Improvement of Psoriatic Skin Lesions During a Period of Hypercortisolemia.

Cushing's syndrome (CS) is known to involve periodic cortisol secretion in some patients. It has also been demonstrated that resolution of cortisol hypersecretion in CS may cause autoimmune-related disease to become apparent. At least 3 cases of psoriasis that became apparent after resolution of hypercortisolism in CS have been reported. We describe a 45-year-old man with cyclic Cushing's disease in whom psoriasis vulgaris, an autoimmune-related disease, was ameliorated during a period of hypercortisolemia. He had complained of intermittent sensations of "whole-body swelling" and improvement of his psoriatic skin lesions, which lasted 2 to 3 weeks at 2- to 3-month intervals over several years. During a 2-week hospitalization for endocrine investigations, an episode of hypercortisolemia appeared unexpectedly. During this time period, the peak serum cortisol level reached 75.7 µg/mL (adrenocorticotropic hormone level, 585 pg/mL) and 24-hour urinary free cortisol reached 10 500 µg/day. A diagnosis of Cushing's disease was made based on a markedly elevated urinary free cortisol level, an adequate increase in adrenocorticotropic hormone level in response to corticotropin-releasing hormone stimulation, and the presence of a giant pituitary tumor with a maximum diameter of approximately 4 cm. Interestingly, during this time period, there was a marked improvement in the psoriatic skin lesions and whole-body swelling sensations.

Distal Embolic Protection by Manual Compression of the Vertebral Artery in Subclavian Artery Stenting.

Objective: There is no established method for preventing vertebral artery embolization in percutaneous transluminal angioplasty (PTA) for subclavian artery stenosis. We manually compressed the supraclavicular fossa outside the sternocleidomastoid muscle to disrupt vertebral artery blood flow and prevent embolism. We report the usefulness of this procedure. Case Presentations: Between April 2017 and July 2018, three patients with severe stenosis of the subclavian artery of 80% or higher were examined. For these patients, subclavian artery stenting was performed. The approach was via the left brachial artery in one patient and right femoral artery in two patients. After crossing the lesion, the vertebral artery was manually compressed and angiography confirmed that blood flow was blocked. In all patients, stent placement was successfully performed and good dilatation was confirmed by angiography. There were no neurological complications and no findings suggestive of acute cerebral infarction were found on magnetic resonance imaging (MRI). Conclusion: Prevention of distal embolism by manual compression is simple, does not require multiple catheters, and is useful for subclavian artery stenting.

Usefulness of Consciousness Sedation with Dexmedetomidine and Pentazocine during Endovascular Treatment for Acute Stroke.

We investigated the safety and efficacy of consciousness sedation with dexmedetomidine (DEX) during the endovascular treatment of patients with acute cerebral infarction. Between April 2014 and November 2016, 38 stroke patients underwent endovascular thrombectomy (EVT) under local anesthesia and DEX consciousness sedation. The continuous intravenous administration of low-dose DEX (0.3-0.4 µg/kg/h) was started before entering the operating room. Patients not completely immobilized received an iv bolus of pentazocine (PTZ) and/or DEX (0.5-0.6 µg/kg/h). EVT was performed using a stent retriever and/or direct thrombo-aspiration. DEX sedation was stopped as soon as the operation was finished. A stent retriever was used in 8 (21.1%), direct thrombo-aspiration in 10 (26.3%), a stent retriever plus thrombo-aspiration in 14 (36.8%), and other devices in 6 patients (15.8%). Reperfusion exceeding 50% (thrombolysis in cerebral infarction >2b) was obtained in 30 patients (78.9%). DEX sedation alone immobilized 24 patients (63.2%), 14 (36.8%) required the additional injection of DEX or PTZ when EVT devices were navigated to the lesion. The administration of DEX and PTZ elicited no significant respiratory depression or cardiac dysfunction interfering with the procedures. Consciousness sedation by DEX was effective during the endovascular treatment of acute stroke patients. Under DEX sedation and the injection of PTZ, EVT was possible without significantly changing the patients' vital signs.