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•We examine in-vitro factors related to microcatheter passage using the trans-cell approach with an LVIS.•A large cell width of the LVIS deployed in the aneurysm neck facilitates good ...passability.•An obtuse angle between the trans-cell surface and microcatheter direction facilitates good passability.•Microcatheter with a small ledge and small tip has a relatively high passability rate.
The trans-cell approach using a low-profile visualized intraluminal support (LVIS) device is sometimes used for aneurysm coil embolization. However, factors related to microcatheter passage remain uninvestigated. We aimed to examine in-vitro factors related to microcatheter passage using the trans-cell approach with an LVIS.
Silicone vessel models (inner diameter, 4 mm) were created with different bend segments and a 4-mm hole assuming an aneurysm neck on the side of the greater curvature. The LVIS Blue (4.5 × 32 mm) was deployed at the bend segment, and passability on the trans-cell surface was evaluated by passing the microcatheter along the micro guidewire. A total of 800 passage experiments were performed using two types of microcatheter, ten types of silicone vessel, four cell widths, five cells with the same LVIS device, and two micro guidewire directions in the aneurysm.
The Headway Duo microcatheter (35.5%, 142/400) tended to have better passability compared with the Headway 17 microcatheter (29.3%, 117/400) (p = 0.070). As the cell width and angle between the trans-cell surface and microcatheter direction increased, passability significantly increased (p = 0.027 and p < 0.001, respectively). There was no significant difference in passability when the micro guidewire was directed to the proximal side versus the distal side (p = 0.45).
A large cell width and an obtuse angle between the trans-cell surface and microcatheter direction facilitated good passability. Although statistically marginal, microcatheters with small ledges and small tips had relatively good passability.
An 80-year-old woman presented with impaired consciousness after malignant melanoma resection. Magnetic resonance angiography showed basilar artery occlusion, which was subjected to mechanical ...thrombectomy for recanalization. A pathological analysis of the retrieved embolus revealed that it was derived from a metastasis of malignant melanoma. Contrast-enhanced chest computed tomography showed multiple pulmonary metastases, one of which was in the right upper lobe and invaded the pulmonary vein. To our knowledge, this is the first case of white embolus-induced cerebral embolism due to pulmonary vein invasion of a metastasis of a pathologically diagnosed malignant melanoma.
Background
The first choice to treat acute subdural hematoma (SDH) is a large craniotomy under general anesthesia. However, increasing age or comorbid burden of the patients may render invasive ...treatment strategy inappropriate. These medically frail patients with SDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive and even available under local anesthesia. Although hematoma evacuation with a rigid endoscope for acute or subacute SDHs has been reported in the literature, use of a flexible endoscope may have distinct advantages. In this article, we attempted to clarify the utility of small craniotomy evacuation with a flexible endoscope for acute and subacute SDH in the elderly patients.
Method
Between November 2013 and September 2016, a total of 17 patients with acute SDH (15 patients), subacute SDH (1 patient), or acute aggravation of chronic SDH (1 patient) underwent hematoma evacuation with a flexible endoscope at our hospital and were enrolled in this retrospective study. Either under local or general anesthesia, the SDH was removed with a flexible suction tube with the aid of the flexible endoscope through the small craniotomy (3 × 4 cm). Hematoma evacuation rate, improvement of clinical symptoms, and procedure-related complications were evaluated.
Results
Hematoma evacuation rate was satisfactory, and statistically significant clinical improvement was observed in postoperative Glasgow Coma Scale in all cases compared to the preoperative assessment. No procedure-related hemorrhagic complications were observed.
Conclusions
The results reported here suggest that small craniotomy evacuation with a flexible endoscope is a safe, effective, and minimally invasive treatment for acute and subacute SDH in selected cases.
Objective: Injury to the inferior epigastric artery (IEA) caused by femoral puncture may lead to retroperitoneal hematoma. We report on two cases of IEA injury due to femoral venipuncture for ...neuroendovascular intervention that resulted in hemorrhagic shock and required transcatheter arterial embolization.Case Presentations: A 67-year-old woman and a 71-year-old man receiving dual antiplatelet therapy sustained injury to a branch of the IEA in the process of right femoral venipuncture for neuroendovascular intervention. In both cases, stent placement in the intracranial artery was accomplished as intended with systemic heparinization throughout the procedure; however, the patients became hypotensive during the procedure, and contrast-enhanced CT scans taken after the stenting revealed extravasation of contrast from the IEA and retroperitoneal hematoma. Transcatheter arterial embolization of the bleeding branch of the IEA was performed with the left femoral approach, and subsequent angiography confirmed the disappearance of the extravasation of contrast.Conclusion: Femoral venipuncture for neuroendovascular intervention in patients receiving antithrombotic agents may cause IEA injury requiring transcatheter arterial embolization. The risk of IEA injury may be reduced by using the femoral head as a reference, performing ultrasound-guided puncture, and confirming the course of the IEA by femoral angiography before venipuncture.
Highlights Using simple neck extension alone, we successfully improved the guiding catheter accessibility. We manually extended the neck and stretched the severe posterior curvature of a tortuous ...cervical internal carotid artery. It enabled us to guide a 6Fr guiding catheter superiorly and performed coil embolization with the aid of an occlusion balloon catheter in one case and with the balloon-assisted neck remodeling technique in the other patient. Our technique might be useful because it may increase the adjunctive techniques available and reduce procedure-related complications in selected patients.
We report a case of intraprocedural aneurysm rupture during coil embolization caused by a coil delivery wire. A 68-year-old woman underwent stent-assisted coil embolization for an unruptured aneurysm ...in the internal carotid artery (ICA). A low profile visible intraluminal support device was deployed at the aneurysm neck. Coil embolization was performed with a jailing technique. After deflection of the jailed microcatheter was released, a coil was placed in the aneurysm against resistance to coil insertion. The movement of the microcatheter tip was restricted with the stent. A coil delivery wire that was advanced after coil detachment perforated the aneurysm. Hemostasis was achieved, and coil embolization was finished with a slight neck remnant. Complete occlusion of the aneurysm was confirmed on angiography six months later. Advancement of a coil alignment marker after coil detachment may cause aneurysm perforation due to coil delivery wire advancement. In stent-assisted coil embolization, when the movement of the microcatheter tip in the aneurysm is restricted by the stent and there is resistance to coil insertion, the risk of perforation due to the coil delivery wire after coil detachment should be noted.
Metronidazole induced encephalopathy (MIE), an encephalopathy brought by an antibiotic, is characterized with cerebellar dysfunction, altered mental status and extrapyramidal symptoms. MIE can result ...in an acute manifestation, but MIE has not been reported as a stroke mimic. An 86-year-old patient undergoing metronidazole therapy for Clostridium difficile enteritis presented to our hospital with sudden disoriented status and motor weakness of the left extremities. Computed tomography (CT) was unrevealing of intracranial hemorrhagic change, and CT angiography did not show any apparent major occlusion or stenosis of the intracranial vessels. However, CT perfusion (CTP) revealed a decrease in peripheral blood flow in the right cerebral hemisphere, and tissue plasminogen activator was administrated for a possible acute ischemic stroke. The findings of follow-up magnetic resonance imaging (MRI) were typical for MIE, revealing areas of hyperintensity on fluid attenuated inversion recovery (FLAIR) signal intensity in the dentate nuclei, the splenium of the corpus callosum, and in the dorsal midbrain. The degree of hyperintensity was stronger in the left dentate nucleus than in the right left dentate on FLAIR and the apparent diffusion coefficient map. The asymmetric findings of the left dentate nucleus on MRI were considered to be responsible for the clinical symptoms and the findings of CTP. We report a rare case of MIE mimicking an acute ischemic stroke, and hypothesize the relationship between the findings of CTP and that of MRI based on the anatomical connection of the dentate nucleus and the cerebral hemisphere.
Objectives
Thrombi in cerebral large vessel occlusion associated with active cancer are often fibrin and platelet-rich white thrombi. However, evaluating the thrombus composition in a short time ...before thrombectomy is often ineffective. We sought to determine factors related to white thrombi in acute ischemic stroke due to large vessel occlusion in cancer patients.
Methods
Consecutive cancer patients undergoing thrombectomy for acute ischemic stroke due to large vessel occlusion between January 2018 and May 2022 were retrospectively reviewed. The patients were classified into white thrombus and red thrombus groups on the basis of the pathological findings of retrieved thrombi. Patient characteristics and laboratory findings were compared between the two groups.
Results
There were 12 patients in the white thrombus group and 11 patients in the red thrombus group. Active cancer was significantly more in the white thrombus group than in the red thrombus group (91.7% vs. 36.3%, p = 0.0094). Internal carotid artery occlusion was significantly less in the white thrombus group than in the red thrombus group (0% vs. 36.4%, p = 0.037). Among laboratory findings, D-dimer levels were an independent factor associated with white thrombi (odds ratio 8.97 95% confidence interval 1.71–368.99, p < 0.0001). The cutoff value of D-dimer levels for predicting white thrombi was 3.5 μg/mL (83.3% sensitivity and 100% specificity).
Conclusions
In acute ischemic stroke in cancer patients, active cancer, no internal carotid artery occlusion, and higher D-dimer levels (≥3.5 μg/mL) may be associated with occlusion with fibrin and platelet-rich white thrombi.
A 78-year-old woman was diagnosed with cerebral infarction due to left hemiplegia by her family physician and was transferred to our hospital. On arrival, she had the NIHSS score of 15, right M1 ...occlusion on head MRA taken by her family physician, and a DWI-Alberta stroke program early CT score (DWI-ASPECTS) of 8. A white thrombus was retrieved by thrombectomy, and recanalization of thrombolysis in cerebral infarction (TICI) grade 3 was obtained, but the left hemiplegia did not resolve. On day 2, there was progression of impaired consciousness, the NIHSS score was 19, right M1 occlusion was observed again on head MRA, and the DWI-ASPECTS was 5. A white thrombus was retrieved again by the second thrombectomy, leading to TICI grade 2b recanalization. Postoperative contrast-enhanced CT of the trunk showed advanced pancreatic cancer. Based on elevated D-dimer levels and characteristics of the thrombi, we determined that the mechanism of the first M1 occlusions was cancer-associated embolism. The patient died of the primary disease on day 39. Cancer-associated occlusion of the major cerebral artery requires careful follow-up because of the possibility of reocclusion of recanalized sites with vascular endothelial damage due to hypercoagulable conditions in a short time period after mechanical thrombectomy.
We report a case of possible contrast extravasation from a preexisting infected aneurysm distal to the occlusion after mechanical thrombectomy. In a 77-year-old woman with a history of infective ...endocarditis presenting with a cerebral infarction, a high-density area around a peripheral aneurysm distal to the occlusion was detected on head CT after mechanical thrombectomy. The patient underwent coil embolization for suspected hemorrhage from the aneurysm, which was eventually determined to be a contrast extravasation from a preexisting aneurysm associated with infective endocarditis into the surrounding tissues adhering to the aneurysm due to a past septic embolism. Contrast extravasation around the peripheral aneurysm after mechanical thrombectomy may be related to injection of contrast media through a microcatheter distal to the occlusion, cerebral ischemia, stagnation of contrast media in cerebral vessels, and aneurysm wall permeability to contrast media. Because the area around the peripheral aneurysm may appear as a high-density area on head CT due to the effect of using contrast media, the necessity of aneurysm embolization should be determined carefully on the basis of the clinical course, past images, and dual-energy CT findings.
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