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Open access

Removal of malformation in cerebral proliferative angiopathy: illustrative case

Gwang Yoon Choi, Hyuk Jai Choi, Jin Pyeong Jeon, Jin Seo Yang, Suk-Hyung Kang, and Yong-Jun Cho

BACKGROUND

Cerebral proliferative angiopathy (CPA) is a rare vascular disorder distinct from arteriovenous malformation. Because of the disorder’s rarity, there is still a controversy on the most promising treatment method for CPA. However, several meta-analysis articles suggest indirect vascularization such as encephalo-duro-arterio-synangiosis as an effective way of treating symptoms that are medically uncontrolled.

OBSERVATIONS

The authors describe a case of an 11-year-old boy with this disease, who had epilepsy that was intractable despite conservative management. The patient recovered from his symptoms after the vascular malformation was surgically removed. This is the first reported case of surgical removal in CPA.

LESSONS

Although further investigation on the best treatment for CPA is needed, the authors believe surgical intervention may also be an effective treatment modality when a patient presents with persisting symptoms.

Open access

Digital intravascular pressure wave recording during endovascular treatment reveals abnormal shunting flow in vertebral venous fistula of the vertebral artery: illustrative case

Yoshiteru Shimoda, Shinya Sonobe, Kuniyasu Niizuma, Toshiki Endo, Hidenori Endo, Mayuko Otomo, and Teiji Tominaga

BACKGROUND

An arteriovenous fistula is an abnormal arteriovenous shunt between an artery and a vein, which often leads to venous congestion in the central nervous system. The blood flow near the fistula is different from normal artery flow. A novel method to detect the abnormal shunting flow or pressure near the fistula is needed.

OBSERVATIONS

A 76-year-old woman presented to the authors’ institute with progressive right upper limb weakness. Right vertebral angiography showed a fistula between the right extracranial vertebral artery (VA) and the right vertebral venous plexus at the C7 level. The patient underwent endovascular treatment for shunt flow reduction. Before the procedure, blood pressures were measured at the proximal VA, distal VA near the fistula, and just at the fistula and drainer using a microcatheter. The blood pressure waveforms were characteristically different in terms of resistance index, half-decay time, and appearance of dicrotic notch. The fistula was embolized with coils and N-butyl cyanoacrylate solution.

LESSONS

During endovascular treatment, the authors were able to digitally record the vascular pressure waveform from the tip of the microcatheter and succeeded in calculating several parameters that characterize the shunting flow. Furthermore, these parameters could help recognize the abnormal blood flow, allowing a safer endovascular surgery.

Open access

Human herpesvirus DNA occurrence in intracranial aneurysmal wall: illustrative case

Nícollas Nunes Rabelo, Antonio Carlos Samaia da Silva Coelho, João Paulo Mota Telles, Giselle Coelho, Caio Santos de Souza, Tania Regina Tozetto-Mendoza, Natan Ponzoni Galvani de Oliveira, Paulo Henrique Braz-Silva, Manoel Jacobsen Teixeira, and Eberval Gadelha Figueiredo

BACKGROUND

Subarachnoid hemorrhages secondary to intracranial aneurysms (IAs) are events of high mortality. These neurological vascular diseases arise from local and systemic inflammation that culminates in vessel wall changes. They may also have a possible relationship with chronic viral infections, such as human herpesvirus (HHV), and especially Epstein–Barr virus (EBV), which causes several medical conditions. This is the first description of the presence of HHV deoxyribonucleic acid (DNA) in a patient with IA.

OBSERVATIONS

A 61-year-old woman with a downgraded level of consciousness underwent radiological examinations that identified a 10-mm ruptured aneurysm in the anterior communicating artery. A microsurgery clip was performed to definitively treat the aneurysm and occurred without surgical complications. Molecular analysis of the material obtained revealed the presence of EBV DNA in the aneurysm wall. The patient died 21 days after admission due to clinical complications and brain swelling.

LESSONS

This is the first description of the presence of herpesvirus DNA in a patient with IA, presented in 2.8% of our data. These findings highlight that viral infection may contribute to the pathophysiology and is an additional risk factor for IA formation, progression, and rupture by modulating vessel wall inflammation and structural changes in chronic infections.

Open access

Takotsubo cardiomyopathy following mechanical thrombectomy for acute ischemic stroke: illustrative case

Tomohiro Yamasaki, Kentaro Hayashi, Yohei Shibata, Tatsuya Furuta, Kazuhiro Yamamoto, Masahiro Uchimura, Yuta Fujiwara, Fumio Nakagawa, Mizuki Kambara, Tsutomu Yoshikane, Hidemasa Nagai, Yasuhiko Akiyama, Kazuaki Tanabe, and Junya Tanabe

BACKGROUND

Excess neurological stress by hemorrhagic stoke induces cardiomyopathy, namely takotsubo cardiomyopathy. Here, the authors report a case of takotsubo myopathy following mechanical thrombectomy for acute large vessel occlusion.

OBSERVATIONS

A 73-year-old man was emergently brought to the authors’ hospital because of left hemiparesis and consciousness disturbance. An ischemic lesion of the right cerebral hemisphere and the right internal carotid artery occlusion was revealed. Emergently, endovascular treatment was performed, and occlusion of the artery was reanalyzed. However, he suffered from hypotension with electrocardiogram abnormality. Subsequently, coronary angiography was performed, but the arteries were patent. The authors made a diagnosis of takotsubo cardiomyopathy.

LESSONS

Endovascular recanalization for large cerebral artery occlusion is so effective that it is becoming widely used. Even in the successful recanalization, we need to care for the takotsubo cardiomyopathy.

Open access

Failed endovascular therapy for acute internal carotid artery occlusion from pituitary apoplexy: illustrative case

Marwah A. Elsehety, Hussein A. Zeineddine, Andrew D. Barreto, and Spiros L. Blackburn

BACKGROUND

Large pituitary adenomas can rarely cause compression of the cavernous internal carotid artery (ICA) due to chronic tumor compression or invasion. Here, the authors present a case of pituitary apoplexy causing acute bilateral ICA occlusion with resultant stroke. Our middle-aged patient presented with sudden vision loss and experienced rapid deterioration requiring intubation. Computed tomography (CT) angiography revealed a large pituitary mass causing severe stenosis of the bilateral ICAs. CT perfusion revealed a significant perfusion delay in the anterior circulation. The patient was taken for cerebral angiography, and balloon angioplasty was attempted with no improvement in arterial flow. Resection of the tumor was then performed, with successful restoration of blood flow. Despite restoration of luminal patency, the patient experienced bilateral ICA infarcts.

OBSERVATIONS

Pituitary apoplexy can present as an acute stroke due to flow-limiting carotid compression. Balloon angioplasty is ineffective for the treatment of this type of compression. Surgical removal of the tumor restores the flow and luminal caliber of the ICA.

LESSONS

Pituitary apoplexy can be a rare presentation of acute stroke and should be managed with immediate surgical decompression rather than attempted angioplasty in order to restore blood flow and prevent the development of cerebral ischemia.

Open access

An algorithm to improve lateralization accuracy of inferior petrosal sinus sampling: procedural nuances for complex patterns of venous drainage. Patient series

Abhijith V. Matur, Alaina M. Body, Mark D. Johnson, Matthew S. Smith, Ruchi Bhabhra, Emily J. Lester, Trisha L. Stahl, Aaron W. Grossman, Peyman Shirani, Jonathan A. Forbes, and Charles J. Prestigiacomo

BACKGROUND

Inferior petrosal sinus sampling (IPSS) is a useful technique in the diagnosis of Cushing’s disease (CD) when the imaging finding is negative or equivocal. Different authors have reported considerable variability in the ability to determine tumor laterality with IPSS. Here the authors present a retrospective case series of 7 patients who underwent IPSS using a systematic algorithm to improve lateralization accuracy by identifying optimal sampling sites on the basis of individual cavernous sinus drainage patterns in each patient.

OBSERVATIONS

Of the 7 patients identified, 6 were determined to have CD and subsequently underwent surgery. IPSS was accurate in all patients from whom laterality was predicted. Arterial and venous angiography were used to define cavernous sinus drainage patterns and determine optimal sampling sites. All patients who underwent surgery achieved hormonal cure.

LESSONS

All IPSS predictions of lateralization were correct when available, and all patients who underwent surgery achieved hormonal cure. Advances in angiographic techniques for identification of the site of primary drainage from the cavernous sinus and subsequent optimization of microcatheter placement may improve the ability to predict tumor laterality.

Open access

Efficacy of intraarterial indocyanine green videoangiography in surgery for arteriovenous fistula at the craniocervical junction in a hybrid operating room: illustrative cases

Kenji Shimada, Izumi Yamaguchi, Takeshi Miyamoto, Shu Sogabe, Kazuhisa Miyake, Yasuhisa Kanematsu, and Yasushi Takagi

BACKGROUND

Sufficient understanding of the angioarchitecture of an arteriovenous fistula (AVF) at the craniocervical junction (CCJ) is crucial to surgical treatment but is often difficult because of the complex vascular anatomy. Intraarterial indocyanine green (ICG) videoangiography has emerged as a more useful option for understanding the vascular anatomy than intravenous ICG videoangiography. This report describes two cases of CCJ AVFs successfully treated by surgery using intraarterial ICG videoangiography and describes the efficacy of this technique.

OBSERVATIONS

Case 1 involved a 71-year-old man presenting with tetraparesis after sudden onset of severe headache due to subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) demonstrated CCJ epidural AVF. Intraarterial ICG videoangiography revealed the drainer, which had been difficult to identify. The AVF disappeared after disconnection of the drainer. Case 2 involved a 68-year-old man presenting with severe headache due to SAH. DSA showed multiple AVFs at the CCJ and cerebellar tentorium. Intraarterial ICG videoangiography demonstrated concomitant perimedullary AVF and dural AVF at the CCJ. All AVFs disappeared postoperatively.

LESSONS

Intraarterial ICG videoangiography was useful for definitive diagnosis of CCJ AVF, facilitating identification of feeders and drainers with bright and high phase contrast and allowing repeated testing to confirm flow direction.

Open access

Endovascular treatment of an aneurysm arising from the minor limb of an upper basilar artery fenestration: illustrative case

Ayaka Matsuo, Takeshi Hiu, Hiroaki Otsuka, Atsushi Miyazaki, Wataru Haraguchi, Ichiro Kawahara, Tomonori Ono, Tsuyoshi Izumo, Takayuki Matsuo, and Keisuke Tsutsumi

BACKGROUND

An aneurysm arising in an upper basilar artery (BA) fenestration is extremely rare. The authors reported a case involving successful endovascular treatment of an aneurysm arising from the minor limb of an upper BA fenestration.

OBSERVATIONS

A 65-year-old woman presented with an incidentally detected upper BA aneurysm arising from the minor limb of an upper BA fenestration. The irregularly shaped aneurysm was 6.0 × 2.7 mm in diameter, and the minor limb had several perforators. The aneurysm was nearly completely occluded with a catheter-assisted technique. The authors preserved both limbs of the BA fenestration. The postoperative course was uneventful, and the patient had an excellent clinical course with no neurological deficits or aneurysmal recanalization.

LESSONS

The case is the first report of an unruptured aneurysm arising at the minor limb of an upper BA fenestration. In this case, the authors preserved the minor limb with endovascular treatment. The authors believe catheter-assisted coil embolization to be a feasible endovascular technique in such cases.

Open access

Recurring cervical internal carotid artery vasospasm elicited by head rotation: illustrative case

Mika Kaneko, Toru Tateoka, Kazuya Kanemaru, Hideyuki Yoshioka, Takuma Wakai, Koji Hashimoto, and Hiroyuki Kinouchi

BACKGROUND

Idiopathic extracranial internal carotid artery vasospasm (IEICAV) is a rare cerebrovascular disorder causing transient or permanent cerebral ischemia. The pathophysiology underlying this disorder is not well understood. Although various medical treatments have been tried, complete remission of vasospasm is difficult to achieve. The first case of bilateral IEICAV induced by head rotation, which was successfully treated by carotid artery stenting (CAS), was presented.

OBSERVATIONS

A 40-year-old woman with bilateral IEICAV had been conservatively treated for 13 years. However, transient ischemic attacks (TIAs) were not suppressed. She eventually presented with a large brain infarction in the left hemisphere and was referred to our department. Digital subtraction angiography clearly demonstrated the triggering of internal carotid artery (ICA) vasospasm by head rotation. After CAS treatment, the TIAs disappeared completely.

LESSONS

Clinicians should recognize that ordinary mechanical stimulation to the ICA by head rotation can induce vasospasm, and CAS should be performed for refractory IEICAV at the appropriate time to avoid cerebral infarction causing severe neurological deficits.

Open access

Interactive spinal computed tomography angiography–guided spinal digital subtraction angiography and embolization for thoracolumbar epidural arteriovenous fistulas: illustrative case

Hirokuni Hashikata, Yoshinori Maki, Ryota Ishibashi, and Hiroki Toda

BACKGROUND

Spinal digital subtraction angiography (sDSA) is the gold standard for examining spinal arteriovenous fistulas; however, thorough sDSA evaluations of spinal arteriovenous fistulas require a long procedure, which may increase the radiation exposure time.

OBSERVATIONS

A 72-year-old man presented with progressive myelopathy due to a spinal epidural arteriovenous fistula. Spinal computed tomography angiography (sCTA) showed an epidural arteriovenous fistula fed by the left L3 segmental artery. To prepare for sDSA, the sCTA images were modified to mark the segmental artery bifurcations from T5 to L5 with multicolored markers. These modified sCTA images were loaded onto the multiwindow DSA display. The sCTA images were interactively modulated during sDSA. This sCTA-guided sDSA identified 18 segmental arteries within 47 minutes. The total radiation exposure was 1,292 mGy. Subsequently, transarterial embolization resolved the epidural arteriovenous fistula with clinical improvement.

LESSONS

Three-dimensional sCTA can provide detailed anatomical information before sDSA. Modified sCTA images with segmental artery bifurcation marking can provide interactive guidance on multipanel DSA displays. sCTA-guided sDSA is useful for accurate catheterization and reduction of procedure time.