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Open access

Evaluation of the shrinkage process of a neck remnant after stent-coil treatment of a cerebral aneurysm using silent magnetic resonance angiography and computational fluid dynamics analysis: illustrative case

Toru Satoh, Kenji Sugiu, Masafumi Hiramatsu, Jun Haruma, and Isao Date

BACKGROUND

Silent magnetic resonance angiography (MRA) mitigates metal artifacts, facilitating clear visualization of neck remnants after stent and coil embolization of cerebral aneurysms. This study aims to scrutinize hemodynamics at the neck remnant by employing silent MRA and computational fluid dynamics.

OBSERVATIONS

The authors longitudinally tracked images of a partially thrombosed anterior communicating artery aneurysm’s neck remnant, which had been treated with stent-assisted coil embolization, using silent MRA over a decade. Computational fluid dynamics delineated the neck remnant’s reduction process, evaluating hemodynamic parameters such as flow rate, wall shear stress magnitude and vector, and streamlines. The neck remnant exhibited diminishing surface area, volume, neck size, dome depth, and aspect ratio. Its reduction correlated with a decline in the flow rate ratio of the remnant dome to the inflow parent artery. Analysis delineated regions within the contracting neck remnant characterized by consistently low average wall shear stress magnitude and variation, accompanied by notable variations in wall shear stress vector directionality.

LESSONS

Evaluation of neck remnants after stent-coil embolization is possible through silent MRA and computational fluid dynamics. Predicting the neck remnant reduction may be achievable through hemodynamic parameter analysis.

Open access

Novel use of a closed-tip stent retriever to prevent distal embolism in the posterior circulation: illustrative case

Rikuo Nishii, Masanori Goto, Yuki Takano, Kota Nakajima, Takateru Takamatsu, Masanori Tokuda, Hikari Tomita, Mai Yoshimoto, Satohiro Kawade, Yasuhiro Yamamoto, Yuji Naramoto, Kunimasa Teranishi, Nobuyuki Fukui, Tadashi Sunohara, Ryu Fukumitsu, Junichi Takeda, Masaomi Koyanagi, Chiaki Sakai, Nobuyuki Sakai, and Tsuyoshi Ohta

BACKGROUND

In mechanical thrombectomy for tandem occlusions in vertebrobasilar stroke, distal emboli from the vertebral artery lesion should be prevented. However, no suitable embolic protection devices are currently available in the posterior circulation. Here, the authors describe the case of a vertebral artery lesion effectively treated with a closed-tip stent retriever as an embolic protection device in the posterior circulation.

OBSERVATIONS

A 65-year-old male underwent mechanical thrombectomy for basilar artery occlusion, with tandem occlusion of the proximal vertebral artery. After basilar artery recanalization via the nonoccluded vertebral artery, a subsequent mechanical thrombectomy was performed for the occluded proximal vertebral artery. To prevent distal embolization of the basilar artery, an EmboTrap III stent retriever was deployed as an embolic protection device within the basilar artery to successfully capture the thrombus.

LESSONS

A stent retriever with a closed-tip structure can effectively capture thrombi, making it a suitable distal embolic protection device in the posterior circulation.

Open access

Aortogenic calcified cerebral embolism diagnosed with an embolus retrieved by thrombectomy: illustrative case

Yasunori Yokochi, Hiroyuki Ikeda, Mai Tanimura, Takuya Osuki, Minami Uezato, Masanori Kinosada, Yoshitaka Kurosaki, and Masaki Chin

BACKGROUND

Calcified cerebral embolism has been reported as a cause of acute cerebral infarction, but an aortogenic origin has rarely been identified as the embolic source. The authors describe a case of aortogenic calcified cerebral embolism in a patient with other embolic sources.

OBSERVATIONS

In a patient with cerebral infarction and atrial fibrillation, a white hard embolus was retrieved by mechanical thrombectomy. Pathological analysis of the embolus revealed that it was mostly calcified, with some foam cells and giant cells. The macroscopic and pathological findings allowed the authors to finally diagnose an aortogenic calcified cerebral embolism.

LESSONS

Even in patients with cardiogenic embolic sources, it is possible to identify a complex aortic atheroma with calcification as the embolic source, based on the macroscopic and pathological findings of the embolus retrieved by mechanical thrombectomy.

Open access

First use of intraventricular nicardipine in a pediatric patient with vasospasm secondary to meningitis: illustrative case

V. Jane Horak, Nirali Patel, Sunny Abdelmageed, Jonathan Scoville, Melissa A LoPresti, and Sandi Lam

BACKGROUND

Cerebral vasospasm is commonly associated with adult aneurysmal subarachnoid hemorrhage but can develop in children. The standard vasospasm treatment includes induced hypertension, avoidance of hypovolemia, systemic use of the calcium channel blocker (CCB) nimodipine, and cerebral angiography for intraarterial therapy. Emerging treatments in adults, such as intraventricular CCB administration, have not been investigated in children. This study demonstrates the successful use of an intraventricular CCB in a pediatric patient with refractory vasospasm secondary to meningitis.

OBSERVATIONS

A 12-year-old female presented with Streptococcus pneumoniae meningitis and ventriculitis with refractory symptomatic cerebral vasospasm. She received a 5-day course of intrathecal nicardipine through an existing external ventricular drain. Her clinical status, transcranial Doppler studies, and radiography improved. Treatment was well tolerated.

LESSONS

Pediatric vasospasm is uncommon and potentially devastating. The management of vasospasm in adults occurs frequently. Principles of this management are adapted to pediatric care given the rarity of vasospasm in children. The use of intraventricular nicardipine has been reported in the care of adults with level 3 evidence. It has not been adequately reported in children with refractory vasospasm. Here, the first use of intraventricular nicardipine in treating pediatric cerebral vasospasm in the setting of meningitis is described and highlighted.

Open access

Acute large-vessel occlusion due to an infected thrombus formation induced by invasive sphenoid sinus aspergillosis: illustrative case

Yoshiyasu Matsumoto, Yosuke Akamatsu, Koji Yoshida, Yasushi Ogasawara, Toshinari Misaki, Shunichi Sasou, Hiromu Konno, and Kuniaki Ogasawara

BACKGROUND

The authors describe a rare case of acute large-vessel occlusion due to an infected thrombus formation that was induced by invasive sphenoid sinus aspergillosis.

OBSERVATIONS

An 82-year-old man with a history of immunoglobulin G4–related disease and long-term use of steroids and immunosuppressants was admitted to the authors’ hospital with severe right hemiparesis. Cerebral angiography revealed occlusion of the left internal carotid artery (ICA). He underwent thrombectomy, resulting in successful recanalization. However, severe stenosis was evident in the left ICA cavernous segment. Pathological analysis of the retrieved thrombus identified Aspergillus. Postoperative magnetic resonance imaging revealed sinusitis in the left sphenoid sinus as a possible source of the infection. The patient’s general condition deteriorated during the course of hospitalization due to refractory aspiration pneumonia, and he died 46 days after thrombectomy. Pathological autopsy and histopathological investigation of the left ICA and the left sphenoid sinus showed that Aspergillus had invaded the wall of the left ICA from the adjacent sphenoid sinus. These findings indicate a diagnosis of acute large-vessel occlusion due to infected thrombus formation induced by invasive sphenoid sinus aspergillosis.

LESSONS

Pathological analysis of a retrieved thrombus appears useful for identifying rare stroke etiologies such as fungal infection.

Open access

Rapid presentation of a de novo intracranial aneurysm: illustrative case

Anthony Diaz, Jimin Shin, and Ketan R Bulsara

BACKGROUND

Intracranial aneurysms are prevalent, particularly with advancing age. De novo aneurysms, occurring independently from the initial lesion, pose a unique challenge because of their unpredictable nature. Although risk factors such as female sex, smoking history, and hypertension have been proposed, the mechanisms underlying de novo aneurysm development remain unclear.

OBSERVATIONS

A 79-year-old female developed a de novo saccular aneurysm within a year after management of a ruptured vertebral artery dissecting aneurysm. Her complex clinical course involved subarachnoid hemorrhage with diffuse vasospasm, stent occlusion of a dissecting aneurysm, discovery of a right 7- to 8-mm de novo middle cerebral artery aneurysm at the 1-year magnetic resonance angiography follow-up, and successful coil embolization.

LESSONS

This rare occurrence challenges established timelines, as most de novo aneurysms manifest over a longer interval. Studies have attempted to identify risk factors, yet consensus remains elusive, particularly regarding the influence of treatment modality on de novo formation rates.

This unique case urges reconsideration of posttreatment surveillance protocols, proposing shorter intervals for imaging and more vigilant follow-up strategies to detect asymptomatic de novo aneurysms. Timelier identification could significantly impact patient outcomes by averting potential ruptures. This emphasizes the need for further research to delineate effective monitoring and preventive measures for these enigmatic lesions.

Open access

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case

Tatsuya Mori, Hidehito Kimura, Atsushi Fujita, Kosuke Hayashi, Tatsuo Hori, Masahiro Sugihara, Yusuke Ikeuchi, Masaaki Kohta, Akio Tomiyama, and Takashi Sasayama

BACKGROUND

The treatment of vertebrobasilar junction (VBJ) aneurysms is challenging. Although flow diverters (FDs) are a possible treatment option, geometrical conditions hinder intervention. VBJ aneurysms possess dual inflow vessels from the bilateral vertebral arteries (VAs), one of which is ideally occluded prior to FD treatment. However, it remains unclear which VA should be occluded.

OBSERVATIONS

A 75-year-old male with a growing VBJ complex aneurysm exhibiting invagination toward the brainstem and causing perifocal edema required intervention. Preoperative computational fluid dynamics (CFD) analysis demonstrated that left VA occlusion would result in more stagnant flow and less impingement of flow than right VA occlusion. According to the simulated strategy, surgical clipping of the left VA just proximal to the aneurysm was performed, followed by FD placement from the basilar artery trunk to the right VA. The patient demonstrated tolerance of the VA occlusion, and follow-up computed tomography angiography at 18 months after FD treatment confirmed the disappearance of the aneurysm.

LESSONS

Preoperative flow dynamics simulations using CFD analysis can reveal an optimal treatment strategy involving a hybrid surgery that combines FD placement and direct surgical occlusion for a VBJ complex aneurysm.

Open access

Retrograde thrombectomy of acute common carotid artery occlusion with mobile thrombus: illustrative cases

Yukiya Okune, Hitoshi Fukuda, Toshiki Matsuoka, Yo Nishimoto, Keita Matsuoka, Naoki Fukui, 1 PhD, Satoru Hayashi, Tetsuya Ueba, and 1 PhD

BACKGROUND

Acute embolic occlusion of the common carotid artery (CCA) alone is rare. However, once it occurs, recanalization is challenging due to the large volume of the clot, larger diameter of the CCA, and risk of procedure-related distal embolism into the intracranial arteries.

OBSERVATIONS

The authors report two cases of acute embolic occlusion of CCA alone, caused by a cardiac embolus trapped at the proximal end of a preexisting atherosclerotic plaque at the cervical carotid bifurcation. In both cases, the CCA was successfully recanalized using retrograde thrombectomy in a hybrid operating room. In case 1, a 78-year-old male with acute right CCA occlusion underwent retrograde thrombectomy, where the cervical carotid bifurcation was exposed and incised, and the entire embolus was retrieved with forceps. Despite successful revascularization, massive bleeding from the CCA just after the retrieval remained a concern. In case 2, a 79-year-old female with acute right CCA occlusion underwent retrograde thrombectomy in the same manner. Because manual retrieval failed, a Fogarty balloon catheter inserted from the arteriotomy successfully retrieved the entire thrombus with minimal blood loss.

LESSONS

Retrograde thrombectomy through the arteriotomy of the cervical carotid bifurcation safely and effectively recanalizes acute embolic occlusion of the CCA alone.

Open access

Cerebral arterial vasospasm complicating supratentorial meningioma resection: illustrative cases

Andrew C Pickles, John T Tsiang, Alexandria A Pecoraro, Nathan C Pecoraro, Ronak H Jani, Brandon J Bond, Anand V Germanwala, Joseph C Serrone, and Vikram C Prabhu

BACKGROUND

Cerebral arterial vasospasm is a rare complication after supratentorial meningioma resection. The pathophysiology of this condition may be similar to vasospasm after aneurysmal subarachnoid hemorrhage, and treatment options may be similar.

OBSERVATIONS

The authors present two cases of cerebral vasospasm after supratentorial meningioma resection and perform a systematic literature review of similar cases.

LESSONS

Cerebral arterial vasospasm after supratentorial meningioma resection may be associated with significant morbidity due to cerebral ischemia if not addressed in a timely manner. Treatment paradigms may be adopted from the management of arterial vasospasm associated with subarachnoid hemorrhage.

Open access

A large cirsoid aneurysm of the scalp with multiple arterial supply: illustrative case

Soumya Pahari, Paawan Bahadur Bhandari, Bibek Bhattarai, Purushottam Baniya, Stuti Yadav, Prarthana Subedi, and Sarbind Mandal

BACKGROUND

Cirsoid aneurysm of the scalp is a rare arteriovenous fistula having a traumatic, congenital, iatrogenic, or idiopathic etiology. Its presentation can range from a small swelling to a large pulsatile mass with tinnitus, headache, and scalp necrosis.

OBSERVATIONS

A 67-year-old female presented with a gradually increasing swelling on her forehead and head since childhood and no history of trauma. Examination revealed 12 × 5 cm tortuous midline swelling. Computed tomography angiography revealed a mass of tortuous vessels in the right frontoparietal region of the scalp with no bony defect or intracranial extension. Contrast-enhanced computed tomography of the head showed no intracranial pathology. The diagnosis of cirsoid aneurysm was made, and surgery was planned.

A bicoronal incision was made. The feeding arteries were dissected and ligated. The nidus was carefully separated, cauterized, and excised in toto. Inadvertently, a buttonhole in the skin was created while dissecting the nidus, which was sutured. The patient developed a small area of scalp necrosis on the 10th postoperative day, which was debrided and sutured. At the 6-month follow-up, no signs of recurrence were present.

LESSONS

A large cirsoid aneurysm of the scalp with multiple arterial supplies can be treated successfully with surgery. Meticulous dissection and hemostasis are warranted to avoid perioperative complications.