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.
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
要旨頭蓋形成術直後に脳浮腫と脳出血を認めた症例を報告する。症例は84歳,男性。くも膜下出血に対し開頭クリッピング術,外減圧術が施行され,第58病日に頭蓋形成術が施行された。術中は問題なく手術が終了したが,術直後の頭部CTにて脳浮腫,脳出血を認めた。その後浮腫は進行したが追加手術を施行することなく,浮腫は改善し神経症状は術前と変わらないまで改善し安定した。手術前後でperfusion MRIを施行し,病側の脳血流量・脳血液量が健側比で上昇を認め,無症候性のsinking skin flap syndrome(SSFS)であったと考えられた。頭蓋形成術直後に脳浮腫や脳出血を呈する原因は再灌流,自動調整能の低下,SSFS,皮下ドレーンによる陰圧,静脈鬱滞,正中偏位からの復元による血管損傷,アレルギー反応が原因と考えられる。この合併症による致死率は高い。頭蓋形成術は比較的容易な手術であり,合併症の多くは痙攣,感染,硬膜外血腫であるが,脳浮腫や脳出血が生じることも念頭に置き,術前に十分な説明をする必要があると考えられた。
Pulmonary embolism and deep vein thrombosis are often accompanied by an elevated D-dimer, and can cause paradoxical embolism in patients with a patent foramen ovale. We report the case of a patient with a patent foramen ovale in whom discovery of the embolic source was delayed by with low D-dimer elevation. A 52-year-old man was admitted with cerebellar infarction of the posterior inferior cerebellar artery resulting in a right thalamus infarction after 6 days, as well as a left vertebral artery acute occlusion after 8 days. He underwent thrombectomy by intravascular surgery. We diagnosed him with embolism from the removed thrombus, and transesophageal echocardiography revealed a patent foramen ovale. Pulmonary embolism and deep vein thrombosis were found upon further investigation, and he was started on anticoagulation therapy. Paradoxical embolism associated with patent foramen ovale is included in recent years as one etiology of embolic stroke of undetermined source (ESUS). Embolic source scrutiny is essential because of the cases with pulmonary embolism and deep vein thrombosis are existed with low D-dimer elevation.
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