1.Iatrogenic Carotid-Cavernous Fistula after Stent Assisted Coil Embolization of Posterior Communicating Artery Aneurysm.
Hye Ran PARK ; Seok Mann YOON ; Jai Joon SHIM ; Hack Gun BAE ; Il Gyu YUN
Journal of Cerebrovascular and Endovascular Neurosurgery 2015;17(1):43-48
Stent assisted coiling (SAC) is a useful technique for the treatment of wide necked complex aneurysm. As the frequency of SAC increases, stent-related complications such as thromboembolism, aneurysm rupture, and vessel rupture have been reported. However, to the best of our knowledge, carotid-cavernous fistula (CCF) after SAC has never been reported. The authors experienced a case of direct CCF after a SAC procedure for treatment of a complex posterior communicating artery (PCoA) aneurysm regrowth, which was treated by clip ligation 12 years before. The patient was managed conservatively and angiograms performed three months after the procedure showed the complete obliteration of the left PcoA aneurysm and the spontaneous disappearance of CCF. Navigation of Solitaire stent lumen with microcatheter can cause unexpected arterial injury, especially when the proximal tip is placed in the curved portion. It seems to be desirable to place the proximal tip of Solitaire stent in the straight portion whenever possible to reduce the risk of inadvertent arterial injury which might be caused by future navigation of stent lumen.
Aneurysm
;
Arteries
;
Embolization, Therapeutic*
;
Fistula*
;
Humans
;
Iatrogenic Disease
;
Intracranial Aneurysm*
;
Ligation
;
Neck
;
Rupture
;
Stents*
;
Thromboembolism
2.Delayed Perilesional Ischemic Stroke after Gamma-knife Radiosurgery for Unruptured Deep Arteriovenous Malformation: Two Case Reports of Radiation-induced Small Artery Injury as Possible Cause.
Dong Han KIM ; Dong Hun KANG ; Jaechan PARK ; Jeong Hyun HWANG ; Seong Hyun PARK ; Won Soo SON
Journal of Cerebrovascular and Endovascular Neurosurgery 2015;17(1):36-42
Radiation-induced vasculopathy is a rare occurrence, however, it is one of the most serious complications that can occur after gamma-knife radiosurgery (GKRS). The authors present two cases of incidentally found deep cerebral arteriovenous malformation (AVM), which were treated by GKRS, where subsequently there occurred delayed-onset cerebral infarction (11 and 17 months after GKRS) at an area adjacent to the AVM. In both cases, perforators of the M1 segment of the middle cerebral artery were included in the radiation field and delayed injury to these is suggested to be the mechanism of the ischemic event.
Arteries*
;
Arteriovenous Malformations*
;
Cerebral Infarction
;
Intracranial Arteriovenous Malformations
;
Middle Cerebral Artery
;
Radiosurgery*
;
Stroke*
3.Two Cases of Cavernous Malformation Presenting with Unusual and Large Intracerebral Hemorrhages.
Yeon Ju CHOI ; Ki Su PARK ; Seong Hyun PARK ; Jeong Hyun HWANG
Journal of Cerebrovascular and Endovascular Neurosurgery 2015;17(1):32-35
Cavernous malformations (CMs), characterized by the presence of a hemosiderin rim and intralesional hemorrhage, are relatively common intracranial vascular malformations. Extralesional hemorrhages arising from CMs are seen in a minority of cases, but most of them show typical CM findings on magnetic resonance imaging. Here, the authors report two cases of pathologically confirmed CM presenting with unusual and large intracerebral hemorrhages, which were not surrounded by the typical hemosiderin rim. CMs presenting with large intracerebral hemorrhage should be considered in the differential diagnosis of massive intracerebral hemorrhages.
Cerebral Hemorrhage*
;
Diagnosis, Differential
;
Hemorrhage
;
Hemosiderin
;
Magnetic Resonance Imaging
;
Vascular Malformations
4.Endovascular Stenting under Cardiac and Cerebral Protection for Subclavian Steal after Coronary Artery Bypass Grafting Due to Right Subclavian Artery Origin Stenosis.
Shigeyuki SAKAMOTO ; Yoshihiro KIURA ; Takahito OKAZAKI ; Nobuhiko ICHINOSE ; Kaoru KURISU
Journal of Cerebrovascular and Endovascular Neurosurgery 2015;17(1):27-31
Coronary-subclavian steal (CSS) can occur after coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA). Subclavian artery (SA) stenosis proximal to the ITA graft causes CSS. We describe a technique for cardiac and cerebral protection during endovascular stenting for CSS due to right SA origin stenosis after CABG. A 64-year-old man with a history of CABG using the right ITA presented with exertional right arm claudication. Angiogram showed a CSS and retrograde blood flow in the right vertebral artery (VA) due to severe stenosis of the right SA origin. Endovascular treatment of the right SA stenosis was planned. For cardiac and cerebral protection, distal balloon protection by inflating a 5.2-F occlusion balloon catheter in the SA proximal to the origin of the right VA and ITA through the right brachial artery approach and distal filter protection of the right internal carotid artery (ICA) through the left femoral artery (FA) approach were performed. Endovascular stenting for SA stenosis from the right FA approach was performed under cardiac and cerebral protection by filter-protection of the ICA and balloon-protection of the VA and ITA. Successful treatment of SA severe stenosis was achieved with no complications.
Arm
;
Brachial Artery
;
Carotid Artery, Internal
;
Catheters
;
Constriction, Pathologic*
;
Coronary Artery Bypass*
;
Endovascular Procedures
;
Femoral Artery
;
Humans
;
Mammary Arteries
;
Middle Aged
;
Stents*
;
Subclavian Artery*
;
Subclavian Steal Syndrome*
;
Transplants
;
Vertebral Artery
5.Contrast Extravasation on Computed Tomography Angiography Imitating a Basilar Artery Trunk Aneurysm in Subsequent Conventional Angiogram-Negative Subarachnoid Hemorrhage: Report of Two Cases with Different Clinical Courses.
Won Ho CHO ; Hyuk Jin CHOI ; Kyoung Hyup NAM ; Jae Il LEE
Journal of Cerebrovascular and Endovascular Neurosurgery 2015;17(1):20-26
Contrast extravasation on computed tomography angiography (CTA) is rare but becoming more common, with increasing use of CTA for various cerebral vascular diseases. We report on two cases of spontaneous subarachnoid hemorrhage (SAH) in which the CTA showed a saccular lesion of the upper basilar trunk suggesting a ruptured aneurysm. However, no vascular lesion was observed on immediate subsequent digital subtraction angiography (DSA). In one case, repeated follow up DSA was also negative. The patient was treated conservatively and discharged with no neurologic deficit. In the other case, the patient showed sudden mental deterioration on the third hospital day and her brain CT showed rebleeding. The immediate follow up DSA showed contrast stagnation in the vicinity of the upper basilar artery, suggestive of pseudoaneurysm. Double stent deployment at the disease segment was performed. Due to the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.
Aneurysm*
;
Aneurysm, False
;
Aneurysm, Ruptured
;
Angiography*
;
Angiography, Digital Subtraction
;
Basilar Artery*
;
Brain
;
Extravasation of Diagnostic and Therapeutic Materials
;
Follow-Up Studies
;
Humans
;
Neurologic Manifestations
;
Stents
;
Subarachnoid Hemorrhage*
;
Vascular Diseases
6.A Suction Thrombectomy Technique: A Rapid and Effective Method for Intra-Arterial Thrombolysis.
Journal of Cerebrovascular and Endovascular Neurosurgery 2015;17(1):13-19
OBJECTIVE: During mechanical thrombolysis, to reduce procedure-related complications and time, the authors have performed a simple suction thrombectomy technique. In this article, the authors describe the technical details and clinical outcomes of this technique. MATERIALS AND METHODS: From January 2013 to December 2013, 14 consecutive acute ischemic stroke (AIS) patients with large cerebral arterial occlusions in the middle cerebral artery (MCA; n = 7), internal cerebral artery (ICA; n = 5), basilar artery (BA; n = 1), and a tandem lesion (ICA and MCA; n = 1) were treated using this technique. The proximal part of the occluding clot was aspirated or captured and retrieved as one piece using a large bored microcatheter by applying negative suction pressure using a 50 mL syringe. RESULTS: Overall recanalization rate was 85.7% (12 patients). In the 8 patients in whom this technique was used alone, the recanalization rate was 87.5% (7 patients). The median procedural duration was 30 minutes (range 17-112) in these 7 patients. Distal embolism did not occur. Two patients developed post-procedural intracerebral hemorrhages and one was symptomatic. His modified Rankin Scale (mRS) score at 90 days was 4. CONCLUSION: This technique is a feasible, fast, and safe method for treatment of AIS.
Basilar Artery
;
Cerebral Arteries
;
Cerebral Hemorrhage
;
Embolism
;
Humans
;
Mechanical Thrombolysis
;
Middle Cerebral Artery
;
Stroke
;
Suction*
;
Syringes
;
Thrombectomy*
7.CT Fluoroscopy-guided Aspiration of Intracerebral Hematomas: Technique and Outcomes.
Kihwan HWANG ; Gyojun HWANG ; O Ki KWON ; Jae Seung BANG ; Chang Wan OH
Journal of Cerebrovascular and Endovascular Neurosurgery 2015;17(1):7-12
OBJECTIVE: The authors evaluated the feasibility and targeting accuracy of CT fluoroscopy (CTF)-guided catheter placement and aspiration of intracerebral hematoma (ICH)s. MATERIALS AND METHODS: Nine patients (mean age, 63.3 +/- 15.3 years) were treated by CTF-guided hematoma aspiration under local anesthesia. The targeting errors in the lesion center, volume of the aspirated hematoma, accuracy of the final catheter position, procedure time, and clinical outcomes were evaluated. RESULTS: All catheters were successfully placed in the center of the hematoma. The mean volume of the aspirated hematoma was 20.6 +/- 8.8 mL (pre-treatment, 44.7 +/- 20.1 mL; post-treatment, 24.1 +/- 13.8 mL). The average procedure time was 25.1 minutes (range, 18-32 minutes). In one case with a scanty residual hematoma, the catheter was removed at the end of the procedure. In the remaining eight cases, the catheter was left in the residual hematoma for drainage and all catheter tips were accurately located in the final position. There were no procedure-related complications, including rebleeding and infection. CONCLUSION: CTF-guided ICH aspiration is a feasible, quick, and accurate procedure which could substitute for stereotactic methods. The accurate catheter position provided by real-time observation enables an effective aspiration and drainage of hematomas.
Anesthesia, Local
;
Catheters
;
Cerebral Hemorrhage
;
Drainage
;
Fluoroscopy
;
Hematoma*
;
Humans
8.Emergent Double-barrel Bypass Shortly after Intravenous Administration of Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke.
Journal of Cerebrovascular and Endovascular Neurosurgery 2016;18(3):258-263
Although intravenous recombinant tissue plasminogen activator (IV rt-PA) is effective in many cases of acute ischemic stroke, the neurologic symptoms can worsen after IV rt-PA because of sustained vessel occlusion. For such cases, several reperfusion modalities are available, including intra-arterial thrombolysis (IAT), carotid endarterectomy, and superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Invasive procedures, such as major surgery, should be generally avoided within 24 hours after the administration of IV rt-PA. A 66-year-old man with no previous medical history developed left hemiparesis. A computed tomography scan revealed no acute lesion and he received IV rt-PA within 1.5 hours after symptom onset. Emergent magnetic resonance imaging showed significant diffusion-perfusion mismatch. He received IAT 2 hours after IV rt-PA administration, but IAT failed because of total occlusion of the cervical internal carotid artery. We initially planned to perform STA-MCA bypass the next morning because he had received IV rt-PA, but, 8 hours after IV rt-PA administration, his hemiparesis worsened from motor grade 3/4 to motor grade 1/2. Because of the large perfusion defect in both MCA divisions, double-barrel STA-MCA bypass was performed 10 hours after IV rt-PA administration. His symptoms rapidly improved after surgery and his modified Rankin Scale score 3 months later was grade 0. We suggest that emergent double-barrel bypass can be a viable option in patients who have perfusion defects of both MCA divisions in acute ischemic stroke after IV rt-PA administration.
Administration, Intravenous*
;
Aged
;
Carotid Artery, Internal
;
Cerebral Arteries
;
Cerebral Infarction
;
Cerebral Revascularization
;
Endarterectomy, Carotid
;
Humans
;
Magnetic Resonance Imaging
;
Neurologic Manifestations
;
Paresis
;
Perfusion
;
Reperfusion
;
Stroke*
;
Tissue Plasminogen Activator*
9.Delayed Rebleeding of Cerebral Aneurysm Misdiagnosed as Traumatic Subarachnoid Hemorrhage.
Seung Yoon SONG ; Dae Won KIM ; Jong Tae PARK ; Sung Don KANG
Journal of Cerebrovascular and Endovascular Neurosurgery 2016;18(3):253-257
An intracranial saccular aneurysm is uncommonly diagnosed in a patient with closed head trauma. We herein present a patient with delayed rebleeding of a cerebral aneurysm misdiagnosed as traumatic subarachnoid hemorrhage (SAH). A 26-year-old female visited our emergency department because of headache after a motorcycle accident. Brain computed tomography (CT) showed a right-side dominant SAH in Sylvian fissure. Although traumatic SAH was strongly suggested because of the history of head trauma, we performed a CT angiogram to exclude any vascular abnormalities. The CT angiogram showed no vascular abnormality. She was discharged after conservative treatment. One day after discharge, she returned to the emergency department because of mental deterioration. Brain CT showed diffuse SAH, which was dominant in the right Sylvian fissure. The CT angiogram revealed a right middle cerebral artery bifurcation aneurysm. During operation, a non-traumatic true saccular aneurysm was found. The patient recovered fully after successful clipping of the aneurysm and was discharged without neurologic deficit. Normal findings on a CT angiogram do not always exclude aneurysmal SAH. Follow-up vascular study should be considered in trauma patients who are highly suspicious of aneurysmal rupture.
Adult
;
Aneurysm
;
Brain
;
Craniocerebral Trauma
;
Emergency Service, Hospital
;
Female
;
Follow-Up Studies
;
Head Injuries, Closed
;
Headache
;
Humans
;
Intracranial Aneurysm*
;
Middle Cerebral Artery
;
Motorcycles
;
Neurologic Manifestations
;
Rupture
;
Subarachnoid Hemorrhage
;
Subarachnoid Hemorrhage, Traumatic*
10.Clinical Utility of Angiographic CT with a Flat-detector Angiographic System during Endovascular Procedure.
Seon Woong CHOI ; Kwang Wook JO ; Young Woo KIM ; Seong Rim KIM ; Ik Seong PARK ; Hoon KIM
Journal of Cerebrovascular and Endovascular Neurosurgery 2016;18(3):247-252
OBJECTIVE: We evaluated the feasibility of angiographic computed tomography (ACT) for visualizing stent material in patients who underwent intracranial or extracranial stent placement to treat atherosclerotic lesions or stent assisted coil embolization. MATERIALS AND METHODS: We performed intrarterial and intravenous ACT on biplane angiography system equipped with flat panel detectors (Axiom Arits dBA; Siemens Medical Solutions, Forchheim, Germany). Vistipaque 320 was injected for contrast medium, total 150 mL at flow rate of 5 mL/s through artery and 77 mL at flow rate of 3.5 mL/s through vein. RESULTS: ACT is a new imaging modality that provides a clear visualization of stent strut. CONCLUSION: Therefore this new application has potential to become the noninvasive option for follow-up after endovascular surgery using stents.
Angiography
;
Arteries
;
Atherosclerosis
;
Embolization, Therapeutic
;
Endovascular Procedures*
;
Follow-Up Studies
;
Humans
;
Stents
;
Veins