A 2-year-old boy with hypoplastic left heart syndrome that required multiple cardiovascular surgeries and a heterozygous prothrombin G20210A mutation with resulting thrombophilia maintained on warfarin presented with acute right middle cerebral artery (MCA) infarction manifesting as a left hemiplegia. An MRI revealed a complete occlusion of the right M1 segment with an area of restricted diffusion in the right basal ganglia representing only a small area of acute infarction. Patchy areas of subacute infarction were also present in the right MCA territory. He underwent endovascular mechanical thrombectomy with a stent retriever. This is an account of a successful mechanical thrombectomy performed in the youngest patient reported in the English literature to date.
Basal Ganglia ; Catheters* ; Child, Preschool* ; Diffusion ; Hemiplegia ; Humans ; Hypoplastic Left Heart Syndrome ; Infarction ; Magnetic Resonance Imaging ; Male ; Middle Cerebral Artery ; Prothrombin ; Stents ; Thrombectomy* ; Thrombophilia ; Warfarin

Symptomatic cerebral air embolism during cerebral angiography is extremely rare. We report on the case of a 69-year-old woman undergoing elective stent-assisted coiling of an unruptured right middle cerebral artery (MCA) bifurcation aneurysm, who was found to have severe attenuation of somatosensory evoked potential (SSEP) and electroencephalography (EEG) during the procedure. Intra-operative DynaCT showed hypodense cortical vessels consistent with cerebral air embolism. Diagnostic and management strategies for this rare complication are reviewed.
Aged ; Aneurysm ; Cerebral Angiography ; Diagnosis* ; Electroencephalography ; Embolism, Air* ; Evoked Potentials, Somatosensory ; Female ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery

OBJECTIVE: Symptomatic thoracic disc herniation often requires prompt surgical treatment to prevent neurological deterioration and permanent deficits. Anterior approaches offer direct visualization and access to the herniated disc and anterior dura but require access surgeons and are often associated with considerable postoperative pain and pulmonary complications. A disadvantage with using posterior approaches in the setting of central calcified thoracic disc herniation however, has been the limited visualization of anterior dura and difficulty to accurately assess the extent of decompression. METHODS: We report our experience with intraoperative ultrasound (US) guidance during a modified posterior transpedicular approach for removal of a central calcified thoracic disc herniation with a review of pertinent literature. RESULTS: The herniated thoracic disc was successfully removed with posterior approach with the aid of intraoperative US. The patient had significant neurological improvement at three months follow-up. CONCLUSION: Intraoperative ultrasound is a simple yet valuable tool for real-time imaging during transpedicular thoracic discectomy. Visualization provided by intraoperative US increases the safety profile of posterior approaches and may make thoracotomy unnecessary in a selected group of patients, especially when a patient has existing pulmonary disease or is otherwise not medically fit for the transthoracic approach.
Decompression ; Diskectomy ; Follow-Up Studies ; Humans ; Intervertebral Disc Displacement ; Lung Diseases ; Pain, Postoperative ; Thoracotomy ; Ultrasonography

Treatment options of ruptured vertebrobasilar fusiform aneurysms (VFA) are limited and often carry significant mortality and morbidity. We report the use of Pipeline Embolization Device (PED) to successfully treat a patient with a ruptured vertebrobasilar fusiform aneurysm (VFA) who presented with subarachnoid hemorrhage (SAH). A 73 year-old man with a history of cardiac stent placement seven days earlier presented with Hunt-Hess II SAH. He was taking aspirin and clopidogrel. Computed tomography angiogram revealed a large vertebrobasilar fusiform aneurysm. Microsurgical treatment options are technically challenging and carry high risk. He underwent endovascular treatment of the ruptured VFA using overlapping PEDs. Five PEDs were placed in a telescoping fashion to reconstruct the affected portions of the left vertebral and basilar arteries. An additional 2-mm blister aneurysm in the right vertebral artery was also discovered during the conventional cerebral angiography and was treated with one additional PED. The patient remained neurologically intact after the procedure. He was continued on aspirin and clopidogrel. Follow-up magnetic resonance imaging at three months demonstrated patency of the stents without any evidence of ischemic change. Follow-up conventional cerebral angiogram at six months demonstrated thrombosis of the VFA and reconstruction of the vertebrobasilar system. The patient remained clinically well. An endovascular approach using PEDs can be a safe and effective treatment option for ruptured VFA in selected cases.
Aneurysm ; Aneurysm, Ruptured ; Aspirin ; Basilar Artery ; Blister ; Cerebral Angiography ; Embolization, Therapeutic ; Follow-Up Studies ; Humans ; Magnetic Resonance Imaging ; Stents ; Subarachnoid Hemorrhage ; Thrombosis ; Ticlopidine ; Vertebral Artery ; Vertebrobasilar Insufficiency

The current assortment of microcatheters widely used for aneurysm coil embolization may not be well suited for several anatomic variants, including excessive vascular tortuosity and small aneurysms less than 3 mm. Longer microcatheters designed with a smaller caliber that can accommodate and deliver coils may be of use in these situations. This case series and literature review illustrates the advantages and limitations of the Marathon microcatheter (Covidien, Irvine, CA, USA) when used for coil embolization of cerebral aneurysms. Despite some technical compromises including the distal marker, length, and the risk of buckling, the Marathon microcatheter was able to adequately deliver coils to achieve satisfactory occlusion of cerebral aneurysms. We found unique advantages with regards to length and smaller distal outer diameter (OD). These results may serve as a guide for the further development of a microcatheter used for coil embolization that has the features of a smaller distal OD and longer length.
Aneurysm* ; Embolization, Therapeutic* ; Endovascular Procedures ; Intracranial Aneurysm

Coil herniation, premature deployment, and fracture are procedure associated complications of endovascular aneurysm embolization that optimally necessitate coil retrieval when feasible. Several published techniques describe different strategies for managing coil complications including various snare retrieval devices, alligator retrieval devices, stent fixation, and open surgical resection of coils when distal blood flow is compromised. We report a novel technique employed to retrieve a prematurely detached coil during an aneurysm embolization using a syringe fixed to the microcatheter to carefully aspirate a loose coil with direct fluoroscopic visualization. This technique can only be utilized in the circumstance where the proximal end of the coil remains in the microcatheter. Conventional techniques of coil retrieval and stenting are discussed and compared to the rational for using the manual aspiration technique.
Alligators and Crocodiles ; Aneurysm ; Embolization, Therapeutic ; Intracranial Aneurysm* ; SNARE Proteins ; Stents ; Syringes

The complex morphology of vertebrobasilar fusiform aneurysms makes them one of the most challenging lesions treated by neurointerventionists. Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents. Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety. However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH). We report a rare case of persistent aneurysmal growth after coiling and placement of the Pipeline Embolization Device (PED; ev3, Irvine, California, USA) for SAH from a fusiform vertebral artery aneurysm. As consequences of aneurysm rupture can be devastating especially in patients with a prior SAH, the clinical relevance of recognizing and understanding such patterns of failure cannot be overemphasized as highlighted in the present case.
Aneurysm* ; California ; Humans ; Parents ; Recurrence ; Rupture ; Stents ; Subarachnoid Hemorrhage ; Vertebral Artery*

With rapidly increasing numbers of neuroendovascular procedures performed annually in recent years, use of arterial closure devices after femoral artery access has been exceedingly common secondary to reduced time to hemostasis, decreased patient discomfort, earlier mobilization, and shortened hospital stay. Although uncommon, use of these devices can lead to a different spectrum of complications, as compared to manual compression. Ischemic symptoms following the use of these devices can have unexpected clinical sequelae and can occur in a delayed fashion. Awareness and recognition of such complications is important with the dramatically increased use of these devices in recent years. We report on a case of delayed vascular complication manifesting as vascular claudication following use of the AngioSeal closure device.
Cerebral Angiography* ; Femoral Artery ; Hemostasis ; Humans ; Length of Stay

Cerebral spinal fluid (CSF) diversion is frequently required in patients with aneurysmal subarachnoid hemorrhage who develop subsequent hydrocephalus. Procedures such as external ventricular drain (EVD) and ventriculoperitoneal shunt (VPS) usually carry a very low rate of complications. However, as flow diverting stents such as Pipeline Embolization Device (PED) become more widely available, flow diverters are being used in treatment of some ruptured complex aneurysms. EVD and VPS placement in the setting of dual antiplatelet therapy (DAT) in these patients are associated with a significant risk of intracranial hemorrhage. We describe a management strategy and surgical technique that can minimize hemorrhagic complications associated with VPS in patients on DAT after treatment with flow diverting stents.
Aneurysm* ; Blister* ; Humans ; Hydrocephalus ; Intracranial Aneurysm ; Intracranial Hemorrhages ; Stents ; Subarachnoid Hemorrhage ; Ventriculoperitoneal Shunt*

PURPOSE: Stent-assisted coiling allows embolization and parent vessel reconstruction of wide-necked intracranial aneurysms. The Neuroform EZ (Boston Scientific, Fremont, CA, U.S.A.) stent delivery system offers deployment of a Neuroform stent with fewer steps and improved operator control. Initial experience, technical considerations, and treatment outcomes using the Neuroform EZ stent delivery system in combination with coil embolization are reported. MATERIALS AND METHODS: Seventeen consecutive patients harboring 21 wide-necked saccular cerebral aneurysms were treated with stent reconstruction. Twenty aneurysms were unruptured; one was treated within 24 hours of diagnosis of rupture. Twenty aneurysms were located in the anterior circulation; one was in the posterior circulation. Immediate and six-month post-treatment angiography and clinical assessment were performed. RESULTS: In all cases, the stents were delivered and positioned without difficulty in deployment. Technical complications occurred in 4 patients, but none were directly related to the stent delivery system. On immediate post-treatment angiography, 5 of 21 aneurysms showed complete occlusion, 5 of 21 showed residual neck, and 11 of 21 showed residual contrast filling of the aneurysm sac. At six month follow-up, all 17 patients were clinically stable. Angiography of 18 of the aneurysms showed total occlusion in 12, residual neck in 3, and residual aneurysm filling in 3. Retreatment was performed in the three with residual aneurysm. CONCLUSION: The Neuroform EZ stent system offers improved anchoring and support in stent delivery, which is particularly useful when multiple stents are overlapped to further protect the parent vessel and increase flow diversion away from the aneurysm sac. The only significant problem encountered was coil prolapse, which could be treated with a second stent when necessary. The ease of deployment improves upon the already clinically successful Neuroform design.
Aneurysm ; Angiography ; Follow-Up Studies ; Glycosaminoglycans ; Humans ; Intracranial Aneurysm ; Neck ; Parents ; Prolapse ; Retreatment ; Rupture ; Stents