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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. doi:10.7461/jcen.2015.17.1.43

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

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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. doi:10.7461/jcen.2015.17.1.36

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*

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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. doi:10.7461/jcen.2015.17.1.32

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

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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. doi:10.7461/jcen.2015.17.1.27

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

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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. doi:10.7461/jcen.2015.17.1.20

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

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A Suction Thrombectomy Technique: A Rapid and Effective Method for Intra-Arterial Thrombolysis.

Hyun PARK

Journal of Cerebrovascular and Endovascular Neurosurgery.2015;17(1):13-19. doi:10.7461/jcen.2015.17.1.13

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*

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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. doi:10.7461/jcen.2015.17.1.7

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

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Retrieval of Distally Migrated Coils with Detachable Intracranial Stent during Coil Embolization of Cerebral Aneurysm.

Devendra Pal SINGH ; Soon Chan KWON ; Lijin HUANG ; Won Joo LEE

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(1):48-54. doi:10.7461/jcen.2016.18.1.48

Migration of coils during endovascular procedures is a rare, but well-known complication. We are reporting two cases of successfully retrieving migrated coil using detachable intracranial stent. In both of our cases there was distal migration of coil during the intracranial aneurysm coiling procedure. The Solitaire® AB stent (Covidien, Irvine, CA, USA) was used to retrieve those coils. The stent was passed distal to the migrated coil using standard technique. It was then partially deployed and gradually withdrawn along with the entangled coil. Coil retrieval using the fully retrievable intracranial stent is a very simple, safe and easily available alternative for retrieval of distally migrated coil.
Embolization, Therapeutic* ; Endovascular Procedures ; Intracranial Aneurysm* ; Stents*

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Posterior Spinal Artery Aneurysm Presenting with Leukocytoclastic Vasculitis.

Travis C HILL ; Omar TANWEER ; Cheddhi THOMAS ; John ENGLER ; Maksim SHAPIRO ; Tibor BECSKE ; Paul P HUANG

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(1):42-47. doi:10.7461/jcen.2016.18.1.42

Rupture of isolated posterior spinal artery (PSA) aneurysms is a rare cause of subarachnoid hemorrhage (SAH) that presents unique diagnostic challenges owing to a nuanced clinical presentation. Here, we report on the diagnosis and management of the first known case of an isolated PSA aneurysm in the context of leukocytoclastic vasculitis. A 53-year-old male presented to an outside institution with acute bilateral lower extremity paralysis 9 days after admission for recurrent cellulitis. Early magnetic resonance imaging was read as negative and repeat imaging 15 days after presentation revealed SAH and a compressive spinal subdural hematoma. Angiography identified a PSA aneurysm at T9, as well as other areas suspicious for inflammatory or post-hemorrhagic reactive changes. The patient underwent a multilevel laminectomy for clot evacuation and aneurysm resection to prevent future hemorrhage and to establish a diagnosis. The postoperative course was complicated by medical issues and led to the diagnosis of leukocytoclastic vasculitis that may have predisposed the patient to aneurysm development. Literature review reveals greater mortality for cervical lesions than thoracolumbar lesions and that the presence of meningitic symptoms portents better functional outcome than symptoms of cord compression. The outcome obtained in this case is consistent with outcomes reported in the literature.
Aneurysm* ; Angiography ; Arteries* ; Cellulitis ; Diagnosis ; Hematoma, Subdural, Spinal ; Hemorrhage ; Humans ; Laminectomy ; Lower Extremity ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Mortality ; Paralysis ; Rupture ; Spinal Cord Vascular Diseases ; Subarachnoid Hemorrhage ; Vasculitis* ; Vasculitis, Leukocytoclastic, Cutaneous

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Open-cell Stent Deployment across the Wide Neck of a Large Middle Cerebral Aneurysm Using the Stent Anchor Technique.

Shigeyuki SAKAMOTO ; Masaaki SHIBUKAWA ; Itaru TANI ; Shuichi OKI ; Kaoru KURISU

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(1):38-41. doi:10.7461/jcen.2016.18.1.38

We describe a case of successful open-cell stent deployment across the wide neck of a large middle cerebral artery aneurysm using the stent anchor technique. A microcatheter was looped through the aneurysm and navigated into a distal vessel across the aneurysm neck. Although the loop of the microcatheter in the aneurysm straightened as it was gently withdrawn, the microcatheter again protruded into the aneurysm by open-cell stent navigation. The stent was partially deployed in a vessel distal to the aneurysm neck, withdrawn slowly to straighten the loop of the microcatheter in the aneurysm, and completely deployed across the aneurysm neck. After successful stent deployment, stent-assisted coil embolization was performed without complications. The stent anchor technique was successfully used to deploy an open-cell stent across the aneurysm neck in this case of microcatheter protrusion into the aneurysm during stent navigation.
Aneurysm ; Embolization, Therapeutic ; Endovascular Procedures ; Intracranial Aneurysm* ; Neck* ; Stents* ; Subarachnoid Hemorrhage

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