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.
A 25 year old woman presented with progressive pain in the anterior aspect of her left thigh. Neurologically, no objective abnormality was identified. Neuroimaging studies including cine magnetic resonance imaging MRI , magnetic resonance MR myelography, and computed tomography CT myelography showed an extradural cystic mass, probably containing cerebral spinal fluid, at the left lateral intracanalicular space from vertebral levels T12 L2. Although the above methods failed to visualize any dural defect, 3D Turbo SE MRI revealed a possible dural defect adjacent to the left L1 nerve root where neural tissue was somewhat incarcerated. Using a minimally invasive posterior approach L1 hemilaminectomy with partial hemilaminectomy of T12 and L2 , the cyst wall was removed as much as possible. Neural tissue, presumably the cauda equina, protruded into the cyst cavity through the small dural defect. After removing the neural tissue into the dural canal, the dural defect was simply sutured. Fibrin glue was used to reinforce this suture for water tightness. Microscopically, the cyst wall consisted of fibrous tissue with an inner single cell lining. Soon after the surgery, her pain was relieved. No recurrence has been observed so far. In order to carry out minimally invasive surgery for the treatment of an extradural arachnoid cyst, it was necessary to identify dural defect s. However, even by using cine MRI, MR myelography, or CT myelography, the definitive diagnosis was difficult. In our case, 3D Turbo SE MRI was useful for detecting a dural defect. 3D Turbo SE MRI can show multi angle images in a shorter examination time. In view of the form of the dural canal, 3D Turbo SE MRI is feasible in the assessment of a dural defect. Therefore, this neuroimaging method seems to be an indispensable tool for the diagnosis of extradural extra arachnoid cysts.
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