Foramen magnum dural arteriovenous fistula (DAVF) is a rare disease, with some reported cases of successful treatment. We achieved complete obliteration of the foramen magnum DAVF through ...microsurgery after complications of endovascular embolization. We reviewed the treatment modalities and outcomes, focusing on pathologic and anatomic features from the literature.
A 65-year-old man was admitted to our hospital with sudden diplopia. Magnetic resonance imaging revealed a subarachnoid hemorrhage around the right side of the prepontine cistern, and a foramen magnum DAVF was diagnosed by angiography. Subsequent angiography revealed that the fistula was supplied by the right neuromeningeal trunk of the ascending pharyngeal artery and the right posterior meningeal artery of the vertebral artery (VA), and the veins of the pouch via the fistula were retrogradely draining into the intracranial veins. We aimed to treat complete occlusion endovascularly with balloon-augmented transarterial Onyx injection via the posterior meningeal artery, but Onyx was refluxed to the VA through the anastomosis between the VA and posterior meningeal artery. Onyx subsequently migrated to the top of the basilar artery, causing occlusion, so we urgently removed the Onyx with a stent retriever (Trevo). Several weeks later, we performed complete obliteration of the foramen magnum DAVF via a lateral suboccipital approach with a C1 laminectomy.
Most foramen magnum DAVFs were obliterated completely with only endovascular treatment. Microsurgery is an effective and reliable treatment for incomplete occlusion and complications.
To assess the benefit and radiation dose of four-dimensional (4D) digital subtraction angiography (DSA) - a time resolved three-dimensional (3D) DSA application - to evaluate the flow and ...architecture of aneurysms and vascular malformations.
All patients with cerebrovascular disease were considered who underwent 4D-DSA at our institution between January 2015 and February 2016. For the aneurysm patients, we evaluated the image quality in terms of the visualization of contrast flow in the aneurysm on a 3-point scale (excellent, fair and poor). Interrater agreement between two raters was estimated using Cohen's Kappa statistics. For the shunt disease patients, the additional information obtained from the 4D-DSA was described for each disease. The median radiation dose and volume of contrast medium required for the acquisitions were estimated.
A total of 173 patients underwent 4D-DSA; 126 intracranial aneurysms, 10 arteriovenous malformations (AVM), 15 dural arteriovenous fistula (dAVF) and 22 other diseases. For aneurysm patients, excellent and fair visualization of the intra-aneurysmal flow was observed in 27.7%, 72.3%, and excellent (κ = 0.9) agreement between the raters was found. For AVM and dAVF patients, 4D-DSA clarified the complex vasculature by viewing the discrete time phase of contrast filling. Median radiation dose for intracranial lesions was 79.6 mGy for 6s 4D-DSA, and 175 mGy for 12s 4D-DSA. The median amount of contrast medium used was 18.0 ml for 6s 4D-DSA and 21.0 ml for 12s 4D-DSA.
4D-DSA provided additional information regarding intra-aneurysmal flow and contributed to detect different component of nidus or shunt points.
Moyamoya disease is often diagnosed after intracranial hemorrhage in adult patients. Here, we report a case of unilateral moyamoya disease treated with indirect revascularization combined with ...cranioplasty after treatment for acute subdural hematoma and subcortical hemorrhage. A middle-aged woman with disturbed consciousness was transferred to our hospital. Computed tomography (CT) revealed an acute subdural hematoma with left temporoparietal subcortical hemorrhage. Three-dimensional CT angiography indicated a scarcely enhanced left middle cerebral artery (MCA) that was suspected to be delayed or nonfilling due to increased intracranial pressure. Subsequently, hematoma evacuation and external decompression were performed. Postoperative digital subtraction angiography (DSA) revealed stenosis of the left MCA and moyamoya vessels, indicating unilateral moyamoya disease. Forty-five days after the initial procedure, we performed encephalo-arterio-synangiosis (EAS) using the superficial temporal artery simultaneously with cranioplasty for the skull defect. The modified Rankin Scale score of the patient one year after discharge was 1, and the repeat DSA showed good patency of the EAS. Revascularization using EAS in the second step can be an option for revascularization for hemorrhagic moyamoya disease if the patient required cranioplasty for postoperative skull defect after decompressive craniotomy.
Introduction Although thin‐walled regions (TWRs) in an intracranial aneurysm have a risk of rupture due to contact with surgical instruments, imaging modalities cannot accurately evaluate the ...thickness of aneurysm walls. The surgical operation will be able to perform safely by identifying the location of TWRs before the treatment. In previous studies, computational fluid dynamics (CFD) has been used to investigate the relationship between hemodynamics and TWRs. However, a quantitative method has not been employed to evaluate the location of TWRs. This study aims to clarify the relationship between hemodynamics and TWRs by comparing the results of CFD analysis with quantitatively defined TWRs. Methods We identified 70 aneurysms (MCA: 48, ACA: 20, ICA: 2) treated with craniotomy and clipping. CFD analysis was conducted to evaluate the pressure difference (PD), wall shear stress (WSS), and wall shear stress divergence (WSSD) on the aneurysm wall. High regions were defined as the regions with values above the 90th percentile for each parameter, and Low regions were defined as the regions with values below the 10th percentile for each parameter. In this study, 4 regions (HighPD, HighWSS, LowWSS, and HighWSSD) and 6 regions obtained by combining two of these regions were defined as regions of interest (RoI). Because TWRs generally indicate intense red, the comprehensive red value (cR value) was defined by using the RGB color model to evaluate the intensity of redness. The cR value was calculated for each pixel of the intraoperative images, and TWRs were defined using the cR value. Comparing the results of CFD analysis and identified TWRs, the percentage of the area of TWRs in RoI was calculated as the occupancy ratio. Results Table 1 shows the mean occupancy ratio for each defined RoI. The mean occupancy ratio in RoI by a single parameter is higher in the order of HighPD, HighWSSD, HighWSS, and LowWSS regions. In HighPD regions, which show the highest occupancy ratio, the impingement flow to the aneurysm wall is considered to make the aneurysm wall thinner. In HighWSSD regions, the aneurysm wall seems to have thinned due to the tensile force along the wall surface caused by blood flow. The mean occupancy ratio of RoI obtained by the combination of two regions is lower than that of HighPD regions. However, in some cases, TWRs that could not be identified by HighPD regions can be detected by HighPD or HighWSSD regions. Conclusions The mean occupancy ratio for RoI was higher in the order of HighPD, HighWSSD, HighWSS, and LowWSS regions. Therefore, it was suggested that these hemodynamic parameters are related to TWRs. Furthermore, in some cases, TWRs that the RoI of a single parameter could not identify can be detected using RoI obtained by the combination of two parameters.
Measurement of plasma levels of protein-conjugated acrolein (PC-Acro) together with IL-6 and CRP can be used to identify silent brain infarction (SBI) with high sensitivity and specificity. The aim ...of this study was to determine how these biomarkers vary during stroke.
Levels of PC-Acro, IL-6 and CRP in plasma were measured on day 0, 2, 7 and 14 after the onset of ischemic or hemorrhagic stroke.
After the onset of stroke, the level of PC-Acro in plasma was elevated corresponding to the size of stroke. It returned to near control levels by day 2, and remained similar through day 14. The degree of the decrease in PC-Acro on day 2 was greater when the size of brain infarction or hemorrhage was larger. An increase in IL-6 and CRP occurred after the increase in PC-Acro, and it was well correlated with the size of the injury following infarction or hemorrhage. The results suggest that acrolein becomes a trigger for the production of IL-6 and CRP, as previously observed in a mouse model of stroke and in cell culture systems. The increase in IL-6 and CRP was also correlated with poor outcome judging from mRS.
The results indicate that the degree of the decrease in PC-Acro and the increase in IL-6 and CRP from day 0 to day 2 was correlated with the size of brain infarction, and the increase in IL-6 and CRP with poor outcome at discharge.
We report the clinical outcomes of stent-assisted coiling for wide-necked intracranial aneurysms using 3 low-profile laser-cut stents and compare the results according to stent type.
All patients ...treated with stent-assisted coiling for their intracranial aneurysms at our hospital between July 2010 and September 2019 were reviewed. We selected patients with Enterprise, Neuroform EZ, or Neuroform Atlas stents who underwent imaging follow-up and investigated aneurysm and stent features, stent-related complications, recanalization, and retreatment rates. We compared the retreatment risk among the patients treated with the 3 stent types using Kaplan-Meier survival analysis and Cox regression analysis.
We evaluated 364 consecutive cases (103 Enterprise, 105 Neuroform EZ, and 156 Neuroform Atlas stents). Neuroform Atlas was more frequently used in distal vessels: 8 (7.8%) Enterprise, 2 (1.9%) Neuroform EZ, and 41 (26.3%) Neuroform Atlas cases, respectively. The median follow-up durations were 6.49, 4.91, and 1.24 years for the Enterprise, Neuroform EZ, and Neuroform Atlas cases, respectively, and retreatment was performed in 11 (10.1%), 9 (8.6%), and 6 (3.8%) cases. In the first 2 years of follow-up, the estimated retreatment risk ratios for Neuroform EZ and Neuroform Atlas with Enterprise as reference were 0.63 (95% confidence interval, 0.24–1.65; P = 0.35) and 0.54 (95% confidence interval, 0.18–1.59; P = 0.26), respectively.
Neuroform Atlas stents were more frequently deployed in small-caliber vessels compared with the other 2 types of stents. The complication rate and retreatment risk until at least 1 year after the aneurysm treatment appeared to be similar for the 3 stent types.
To investigate flow diverter (FD) apposition on fused images acquired by high-resolution cone-beam computed tomography (CBCT) and 3-dimensional (3D) digital subtraction angiography.
Patients with ...large or giant internal carotid artery aneurysms treated with Pipeline FDs who underwent CBCT imaging at our institution between October 2016 and May 2019 were included. Two neurosurgeons measured the maximum malapposition between FDs and vessel walls on 3D fusion images of high-resolution CBCT images displaying the FD and 3D digital subtraction angiography images displaying the vessels. Associations between the relative malapposition, FD diameter, vessel diameter, proximal and distal vessel diameter discrepancy, and siphon angle were evaluated by linear regression analysis. Inter-rater and intermethod (3D and 2D image) agreements of the malapposition measurements were assessed by Bland-Altman analysis and by interclass correlation coefficients.
Images of 2 patients were excluded because of image artifacts or fusion errors, and 3D fusion images were acquired in the remaining 26 patients. Our results did not suggest that relative malapposition was associated with vessel diameter (P = 0.12), vessel diameter discrepancy (P = 0.60), or syphon angle (P = 0.34), but relative malapposition increased by an estimated 13% (95% confidence interval: 4%–23%, P = 0.006) for each 1 mm increase in FD diameter. Inter-rater and intermethod agreements for apposition measurements were excellent and good, respectively.
Three-dimensional fusion images provided clear visualization of structures of both the stent and parent artery with excellent diagnostic reliability. Careful deployment may be needed for FDs with larger diameters, as they tended to have larger relative malapposition.
This is the first report of a carotid aneurysm that developed from a cavernous carotid artery contiguous with a prolactinoma during medical treatment of the prolactinoma, which gradually grew larger ...while the tumor regressed. A 78-year-old woman presented with headache and neurological symptoms indicating the involvement of cranial nerves in the cavernous sinus. Gadolinium-enhanced T1-weighted magnetic resonance imaging on admission revealed an abnormal right cavernous sinus, with an approximately 17 mm mass extending into the right cavernous portion of the internal carotid artery, and was contiguous with the intracavernous carotid artery. She was diagnosed with pituitary apoplexy due to a prolactinoma and started cabergoline treatment. After medical treatment, a carotid aneurysm emerged. The aneurysm continued to grow and reached a maximum diameter of 10.4 mm at 81 months after the initiation of treatment. The patient underwent endovascular coil embolization, following which the aneurysm regressed. Association between a prolactinoma and the development of a contiguous aneurysm remains undetermined. However, this is an odd phenomenon, and to the best of our knowledge, this is the first reported case of the development of an aneurysm that was associated with a pituitary tumor.
Background:
We reviewed the clinical outcomes of a procedure that combines endovascular embolization and a direct surgical approach in a hybrid operating room (OR) for the treatment of refractory ...dural arteriovenous fistulas (dAVFs).
Methods:
All patients with intracranial dAVFs who underwent a procedure combining endovascular embolization and direct surgical approach with biplane angiography or a robotic C-arm system in a hybrid OR between February 2004 and June 2020 were considered. Borden grading, occlusion rate, pre-and post-operative modified Rankin Scale (mRS) scores, and complications were retrospectively investigated. The pre-and postoperative mRS scores were compared using the Wilcoxon signed-ranks test.
Results:
We evaluated 14 arteriovenous fistulas (AVFs) in consecutive 13 patients. Of these, ten AVFs were previously treated with endovascular embolization, ten were located in the transverse-sigmoid sinus, and four in the cortical vein. The Borden grade was II in two AVFs and III in 12 AVFs. Immediate occlusion of the AVF was achieved in 13 AVFs, and gradual occlusion was observed in one case. The median preoperative mRS was 1 (0–3), whereas the median postoperative mRS was 0 (0–1) which indicated marked improvement (
P
= 0.006). Complications including postoperative transient visual disturbance and intraprocedural extravasation were observed in only two cases.
Conclusion:
The combination of endovascular embolization and direct surgical approach in a hybrid OR could achieve sufficient occlusion of refractory AVFs with acceptable complication rates and improved symptoms.
A spinal epidural arteriovenous fistula (AVF) is classified as a spinal arteriovenous malformation (AVM), and is much rarer than other types of AVMs. Spinal epidural AVF often presents with ...compressive myelopathy or radiculopathy due to the compression of the spinal cord outside the dura mater or root sleeves by an enlarged venous plexus. It is also accompanied by venous congestive myelopathy due to intradural venous reflux. The treatment of a spinal epidural AVF is occlusion of the shunt points or exclusion of an enlarged venous plexus if it compresses the spinal cord or root nerve. We report a rare case of spinal epidural hematoma caused by a spinal epidural AVF. A 62-year-old man developed sudden neck pain, followed by quadriplegia and urinary disturbance over several hours ; the patient was transported to the hospital on that day. Cervical computed tomography showed that the ventral epidural hematoma extending between the C1 and C6 levels resulted in compression of the spinal sac. The patient did not have a traffic accident, or abnormalities in coagulation. Magnetic resonance T2-weighted images showed a T2-flow void along the C2 root sleeve ; therefore, we diagnosed the patient as a spinal epidural AVF with some dilated venous plexus by angiography. The main cause of the neurological deterioration was the compression of the spinal sac by the epidural hematoma, and there were no findings that the venous plexus compressed the root nerve. We performed endovascular embolization of the right vertebral artery and ascending pharyngeal artery using coils to reduce the flow of the spinal epidural AVF, and thereafter, C2-C6 decompressive laminectomy was performed. The patient's symptoms improved after the treatment. Spinal epidural hematoma caused by a spinal epidural AVF is rare, with only two cases reported to date of spinal epidural AVFs with a dilated venous plexus without intradural venous reflux. We report a case of a spinal epidural AVF with spinal epidural hematoma that was treated with neuro-intervention and microsurgery, with a good clinical course.
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