We encountered a rare case of massive epistaxis resulting from a small ruptured non-traumatic cavernous internal carotid artery aneurysm associated a bony defect in the wall of the posterior lateral wall of the sphenoid sinus. We presented successful diagnosis and treatment with a balloon-assisted neck-plasty coil embolization. A 74-year-old Japanese man was admitted following recurrent massive epistaxis. There was no history of trauma, surgery, radiotherapy, infection, or tumor. Radiographic imaging demonstrated a bony defect in the wall of the posterior lateral wall of the sphenoid sinus that allowed the aneurysm to ruptured into the nasal cavity rather than intracranially. After rupture, the patient presented with epistaxis that resulted in systemic hypotension. This aneurysm can be managed rapidly using endovascular techniques of a balloon-assisted neck-plasty coil embolization. The present case report highlights the rarity of a small non-traumatic cavernous ICA aneurysm causing massive epistaxis. Clinicians should be aware of this possibility, as a high index of suspicion is required for proper diagnosis. Internal carotid angiography should be performed, particularly in patients with refractory epistaxis. Aneurysms in this location are usually amenable to endovascular treatment. Coil embolization using a microballoon-assisted neck-plasty technique can result in immediate hemostasis, parent artery preservation, and successful long-term aneurysm occlusion.
Cerebral vasospasm is an unelucidated complication of subarachnoid hemorrhage. Various treatments exist against cerebral vasospasms however, consensus on the optimal treatment is lacking. We use clazosentan, which is used to prevent cerebral vasospasm, with multidrug combinations. In this study, we aimed to clarify the initial results of using clazosentan in multidrug combinations in the real world. We retrospectively investigated 54 patients who were treated for subarachnoid hemorrhage and received clazosentan. We compared the results of these patients on the basis of two groups: those with good outcomes (modified Rankin scale score: 0–3) and poor outcomes (4–6) at discharge. Among the patients, poor outcome was observed in 19 patients (35.2 %). Angiographic vasospasms occurred in 10 patients (good outcome [n = 6] vs. poor outcome [n = 4]; p = 0.73), and symptomatic vasospasms occurred in 4 patients (n = 2 vs. n = 2, p = 0.61). The incidence of pleural effusion (28.6 % vs. 73.7 %, p < 0.01) and the mean daily fluid balance (303.5 mL/day vs. 785.4 mL/day, p < 0.01) were higher in the poor outcome group. Pleural effusion and high positive balance may be associated with poor outcome. However, the number of cases examined was small; therefore, further large-scale studies with a bigger sample size are needed.
We report on a patient with choriocarcinoma in the pineal region who was successfully treated with stereotactic radiation therapy (SRT). The increased level of serum human chorionic gonadotropin (HCG) was lowered during chemotherapy with etoposide, cisplatin, and ifosfamide. However, HCG was not normalized and magnetic resonance images still showed an enhanced tumor mass with gadolinium. The patient underwent SRT of 40 Gy at an 80% isodose line per 10 fractions over two weeks, followed by conventional craniospinal irradiation of 32.4 Gy. The level of HCG dropped below the detection limit. The patient has been in good condition for more than four years after the completion of treatment, without any signs of recurrence. We propose SRT as a valid treatment option for malignant germ cell tumors in the pineal region.
Advances in vascular reconstruction devices and coil technologies have made coil embolization a popular and effective strategy for treatment of relatively wide-neck cerebral aneurysms. However, coil protrusion occurs occasionally, and little is known about the frequency, the risk factors and the risk of thrombo-embolic complications.We assessed the frequency and the risk factors for coil protrusion in 330 unruptured aneurysm embolization cases, and examined the occurrence of cerebral infarction by diffusion-weighted magnetic resonance imaging (DW-MRI).Forty-four instances of coil protrusion were encountered during coil embolization (13.3% of cases), but incidence was reduced to 33 (10% of cases) by balloon press or insertion of the next coil. Coil protrusion occurred more frequently during the last phase of the procedure, and both a wide neck (large fundus to neck ratio) (OR = 1.84, P = 0.03) and an inadequately stable neck frame (OR = 5.49, P = 0.0007) increased protrusion risk. Coil protrusions did not increase the incidence of high-intensity lesions (infarcts) on DW-MRI (33.3% vs 29% of cases with no coil protrusion). However, longer operation time did increase infarct risk (P = 0.0003). Thus, tail or loop type coil protrusion did not increase the risk of thrombo-embolic complications, if adequate blood flow was maintained.Coil protrusion tended to occur more frequently in cases of wide-neck aneurysms with loose neck framing. Moderate and less coil protrusion carries no additional thrombo-embolic risk, if blood flow is maintained, which can be aided by additional post-operative antiplatelet therapy.
Acute subdural hemorrhage caused by ruptured cerebral aneurysms is rare. Herein, we report an atypical case of subdural hemorrhage caused by ruptured anterior communicating artery aneurysm in a 49-year-old woman. Computed tomography revealed subarachnoid, intracerebral, and subdural hemorrhages. After the treatment with endovascular coiling significantly decreased the patient's subdural hemorrhage. However, the subdural hemorrhage revealed and became iso-attenuation compared with the white matter on the 11th day, and hypo-attenuation on the 19th day. On the 33rd day, this subdural hemorrhage completely resolved after discontinuation of dual antiplatelet therapy. Due to rapid changes in the radiologic features of SDH, frequent computed tomography scans at least once a week may be needed especially in patients who receive antiplatelet therapy during the vasospasm phase.
Dural arteriovenous fistula (d-AVF) is relatively rare. Some cases of atypical locations are often difficult to distinguish from other vascular disorders or tumors because those d-AVFs show various onsets, such as subcortical bleeding and venous infarctions. We encountered two cases of d-AVF with severe brain edema that took adequate time to distinguish from brain tumors. A 68-year-old man visited his local physician complaining of dizziness. He was diagnosed with a cerebral infarction due to the presence of an abnormal cerebellar signal on magnetic resonance imaging (MRI) and was treated by drip infusion. However, he did not recover and was admitted to our hospital with suspicion of a brain tumor. A 75-year-old woman with an onset of progressive dementia and gait disturbance showed severe edema of the right-front temporal lobe on MRI. Both these cases were examined by single photon emission computed tomography or positron emission tomography and were scheduled for craniotomy and biopsy based on the diagnosis of brain tumor. We performed pre-operative angiography and found d-AVFs. We embolized the d-AVFs with liquid material and both patients recovered well. Brain edema from d-AVF or a tumor can be distinguished by carefully reading the MRI with findings such as the distribution of the edemas, differences on diffusion-weighted images, and contrast-enhanced images. Therefore, it is important to provide initial accurate diagnoses to prevent patient mistrust and irreversible disease conditions.
We report a patient with intracranial hypertension associated with venous sinus stenosis due to tumor compression. Embolization of tumor feeding blood vessels reduced the tumor volume, improved venous sinus stenosis, and alleviated the symptoms of intracranial hypertension.The patient was a 46-year-old woman with chronic headache and blurred vision. Magnetic resonance venography (MRV) revealed stenosis of the right transverse-sigmoid sinus. Intracranial hypertension was diagnosed by lumbar puncture. A high-intensity 2-cm tumor was detected on T2-weighted magnetic resonance imaging (MRI), and the homogenously enhanced tumor was adjacent to the right transverse-sigmoid sinus. Cerebral angiography demonstrated tumor staining mainly from the right occipital artery (OA). Collateral venous flow was minimal. In such cases, resection and reconstruction of the involved sinus segment have a high risk of venous infarction. Accordingly, percutaneous transluminal angioplasty (PTA) was performed, but dilation of the stenosis was poor. Thus, feeder occlusion of the tumor was added and lumboperitoneal (LP) shunt was placed, alleviating the headache and blurred vision. Ten months later, reduction of the tumor volume and improvement of sinus stenosis were observed, and the LP-shunt system was removed. A decrease in tumor volume via feeder occlusion may lead to partial sinus decompression and increased venous flow, resulting in long-term clinical remission.Transverse-sigmoid sinus stenosis can be a cause of intracranial hypertension, albeit rare. Embolization of the tumor is considered to be a treatment option for patients who cannot undergo resection.
Two elderly female patients with carotid-cavernous fistulas (CCFs) were treated by transvenous embolization through a transfemoral superior ophthalmic vein approach via the facial vein. Complete occlusion of CCFs was not achieved with this technique exclusively, but the technique was effective in these cases. This technique provides an alternative to other transvenous approaches for the treatment of CCFs.
Background: Coil embolization is increasingly becoming the surgical intervention of choice for cerebral aneurysms, particularly for those in the posterior circulation. However, in cases where it is difficult to perform coil embolization, microsurgical clipping is still required. Case Description: We present a case of a high-positioned, ruptured, recurrent basilar tip aneurysm treated with a combination of microsurgical clipping through the trans-lamina terminalis approach and endovascular procedure. The technical considerations of this approach are discussed. Conclusion: Microsurgical clipping through the trans-lamina terminalis approach combined with an endovascular technique can be effective for basilar tip aneurysms. This approach is particularly useful for high-positioned, small, anterior projective aneurysms and cases with dilation of the third ventricle due to hydrocephalus or clot.
Abstract Microcatheters for neuroendovascular procedure especially for embolization of aneurysms are essential tools. Each catheter has it's own property for use. However there is very little literature about the character and mechanism of microcatheters. With steam shaping, they are often deformed and shortened. We herein present technical problems associated with the shaping of microcatheters. We have to understand the potential risk of complications related to microcatheters.
