Objective: Use of a catheter exchange technique for wide-necked large basilar tip aneurysms in which placement of a balloon catheter across the aneurysmal neck is diffi cult is described. Case Report: A 71-year-old woman presenting with severe headache and vomiting was diagnosed with a subarachnoid hemorrhage by CT on admission. Preoperative angiography indicated a large saccular aneurysm at the tip of the basilar artery, and coil embolization was performed. As the broad neck of the aneurysm was located between the basilar and left posterior cerebral arteries, a neck remodelling technique was necessary. However, placement of a balloon catheter was extremely complicated, and endovascular treatment failed, despite the use of different kinds of microguidewires and microcatheters on the fi rst attempt. On the second attempt, a catheter exchange technique was used and the balloon catheter was able to be easily positioned. Successful embolization was achieved using the neck remodelling technique. Technique: First, a soft microcatheter was navigated through the basilar artery to the left posterior cerebral artery using a flexible microguidewire. Tips of the microguidewire and microcatheter were advanced to the distal part of the left posterior cerebral artery for stable positioning. The microguidewire was then exchanged for a long microguidewire, which was advanced into the microcatheter. The microcatheter was then removed over the wire. Next, a balloon catheter was advanced over the long microguidewire and positioned. Finary, coil embolization was achieved safely in the aneurysmal sac using the neck remodelling technique. Conclusion: A technique to bypass the aneurysmal neck to perform balloon-assisted endovascular treatment of large aneurysms with broad necks in which other methods fail to obtain access distal to the aneurysm was described. For cases in which placement of a balloon catheter is diffi cult, the catheter exchange technique is considered to be highly effective.
Transoral carotid ultrasonography (TOCU) is a powerful tool for evaluating the high internal carotid artery (ICA). Multiple reports have documented its excellent ability to show dissection of the high ICA. Superb microvascular imaging (SMI) is a new Doppler imaging technique that reduced motion artifacts and allows visualization of low-velocity blood flow in vessels. A 45-year-old man with aphasia and right hemiplegia was brought to our hospital. MRI showed acute cerebral infarction, and he was treated by recombinant tissue plasminogen activator (rt-PA). A carotid angiogram showed the dissection of the left extracranial ICA, and carotid artery stenting of the left ICA was performed. Postoperative SMI-TOCU showed that blood flow was preserved with no stenosis. It seemed that a part was missing. This was caused by slight turbulence caused by the step of the stent. The present case suggests that post-procedure evaluation by SMI-TOCU for carotid artery stenting in ICA dissection may be useful.
Summary: Treatment of ruptured vertebral dissecting aneurysms involving the posterior inferior cerebellar artery (PICA) still poses a challenge because of the necessity of revascularization of the PICA. Below we report the case of a ruptured vertebral dissecting aneurysm involving the PICA treated with endovascular coil embolization and without a revascularization procedure. A 38-year-old man was admitted to our hospital with subarachnoid hemorrhage caused by a right vertebral dissecting aneurysm involving the origin of the PICA.A right vertebral angiogram clearly revealed that the entry was at the distal part of the dissecting aneurysm medial-inferiorly, and that the PICA had arisen at the proximal part of the dissecting aneurysm lateral-superiorly in the early arterial phase. Furthermore, it was evident that the contrast medium had moved from the middle to the lower section inside the dissection lumen in the late arterial phase. We embolized the dissecting lumen and entry with coils assisted by flow control of the ipsilateral vertebral artery (VA). Thereafter, we preserved the PICA by framing and filling the coils while maintaining blood flow of the VA. We embolized the distal part of the dissecting aneurysm with coils additionally via the contralateral VA, and we selectively obliterated the dissecting aneurysm finally without employing a revascularization procedure. No post-procedural ischemic event occurred in this case. During the follow-up period, there were no occurrences of rebleeding or ischemic events, and no additional surgical procedures were required. The PICA, which maintained its patency during the procedures, was clearly visible for a long time by magnetic resonance angiography (MRA) examination.When VA dissecting aneurysms involving the PICA with selective coil embolization and without branch revascularization are treated, it is important to identify the entry. In addition, selective
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