Ikki Kajiwara

Combined surgical and endovascular treatment of complex cerebrovascular diseases in the hybrid operating room

Background Although most neurovascular diseases can be treated either by microsurgical or endovascular means, a subset of patients may require a combined approach. Patient transfer from the operating room (OR) to the angiosuite has been a fundamental drawback of this type of approach. Objective The purpose of this study is to report our clinical experience performing combined surgical and endovascular procedures for neurovascular diseases in the hybrid OR. Methods 29 patients with neurovascular diseases underwent combined endovascular and surgical procedures in a single session: 16 were scheduled combined treatment and 13 were emergency combined procedures. Of the emergency cases, three were rescue surgeries after endovascular complications. Three patients had ruptured intracranial aneurysms, eight had unruptured intracranial aneurysms, eight had arteriovenous malformations and eight had arteriovenous fistulae; two patients had either a spinal tumor or dural arteriovenous fistulae. Results All combined procedures were performed in a single session without changing the patients surgical position. In cases of ruptured arteriovenous malformations or aneurysms with hematoma, an emergency embolization was performed to assist the surgical procedure. Combined superficial temporal artery–middle cerebral artery (STA–MCA) bypass followed by endovascular parent artery trapping were successfully performed for complex large or giant aneurysms. There were two periprocedural ischemic complications. Of the three patients who underwent surgical rescue after endovascular complications, two remained intact and one died despite immediate surgical procedures. Conclusion A combined endovascular and surgical approach conducted in a hybrid OR provides a new strategy for the treatment of complex neurovascular diseases.

Hybrid Operating Room for Combined Neuroendovascular and Endoscopic Treatment of Ruptured Cerebral Aneurysms with Intraventricular Hemorrhage

BACKGROUND Intraventricular hemorrhages (IVHs) caused by ruptured cerebral aneurysms often have poor outcomes. Treatment challenges include comorbidities, increased intracranial pressure caused by IVH, and risk of rebleeding. CASE DESCRIPTION Two cases of severe IVH accompanied by acute hydrocephalus caused by ruptured aneurysm were treated with coil embolization followed by endoscopic hematoma evacuation as a single treatment session in a hybrid operating room (OR) equipped with a multipurpose angio biplane system. The first case was an 84-year-old woman with a ruptured basilar top aneurysm, who presented with Hunt and Hess (H&H) grade 5 subarachnoid hemorrhage (SAH) with packed IVH. The second case was a 43-year-old man with a ruptured anterior communicating artery aneurysm who presented with H&H grade 5 SAH with packed IVH. In both cases, endovascular coil embolization was performed first to prevent intraoperative bleeding. The coiled aneurysms suddenly appeared on the screen of the endoscope during the hematoma removal, which could have led to massive rebleeding if not treated previously. Neither patient needed a reinsertion of the ventricular drainage or developed chronic hydrocephalus during hospitalization. The hybrid OR enabled the 2 treatment approaches to be performed without the need to transfer the patient, thereby minimizing the transition time between the modalities. Intraoperative cone-beam computed tomography contributed to the evaluation of residual clots. CONCLUSIONS A hybrid OR may contribute to a combined neuroendoscopic and endovascular treatment for ruptured cerebral aneurysms with severe intraventricular hemorrhage.

O-001 A Novel Metal Artefact Removal Software for C-arm CT; A Novel Imaging Modality to Analyze Aneurysms Treated with Stent Assisted Coil Embolization

Purpose Stent assisted coil embolization recently became a common treatment strategy for the wide neck aneurysms. Normal digital subtraction angiography (DSA), however, does not allow visualization of the deployed stents. With a combination of novel Metal Artefact Removal software (MAR) and C-arm CT, the coil mass, stent, and contrast material can be differentiated. In this study, experimental aneurysms were treated with stent assisted coil embolization and image analysis was performed using the C-arm CT and MAR. I. V. injection of the contrast to obtain the images was also performed. Methods A total of 12 experimental aneurysms were created in 6 swine. The aneurysms were treated with coil embolization using stent assisted technique. High Resolution (HR) C-arm CT with intra-arterial injection of the contrast dye (20%) was performed immediately after the treatment and obtained images were processed with MAR. Intra venous contrast injection (non-diluted) from femoral vein was also performed in 3 swine. Visualization of the residual aneurysms as well as coil loops protruded into the stent lumen was evaluated. Two patients previously treated with stent assisted coil embolization underwent the same image acquisition protocol, and the obtained images were evaluated. Results Coil loops protruded into the stent lumen, which were not visible before the MAR due to the significant metal artefact, were well visualised after the MAR. Likewise, Contrast filling into the residual aneurism was observed after the MAR in every aneurysm. Intravenous injection of the contrast material reproduced similar image quality as compared to the intra arterial injections. The C-arm CT images of the two patients showed remarkable reduction of the metal artefacts after the MAR processing. Conclusions The combination of the C-arm CT and MAR enables the differentiation of the coil mass, stent and contrast material by markedly reducing the metal artefact produced by the coils. This novel image modality may contribute to the evaluation of aneurysms treated with stent assisted coil embolization. Abstract O-001 Figure 1 Disclosures I. Yuki: 1; C; Siemens Grant. Y. Kambayashi: 1; C; Siemens Grant. A. Ikemura: 1; C; Siemens Grant. I. Kan: 1; C; Siemens Grant. Y. Abe: None. A. Mohamed: 5; C; Siemens Japan KK. C. Dahmani: 5; C; Siemens Japan KK. T. Ishibashi: 1; C; Siemens Grant. I. Kajiwara: 1; C; Siemens Grant. K. Nishimura: 1; C; Siemens Grant. Y. Murayama: 1; C; Siemens Grant.

Concomitant Intracranial and Lumbar Chronic Subdural Hematoma Treated by Fluoroscopic Guided Lumbar Puncture: A Case Report and Literature Review

A 40-year-old man presented with a severe headache, lower back pain, and lower abdominal pain 1 month after a head injury caused by falling. Computed tomography (CT) of the head demonstrated bilateral chronic subdural hematoma (CSDH) with a significant amount in the left frontoparietal region. At the same time, magnetic resonance imaging (MRI) of the lumbar spine also revealed CSDH from L2 to S1 level. A simple drainage for the intracranial CSDH on the left side was performed. Postoperatively, the headache was improved; however, the lower back and abdominal pain persisted. Aspiration of the liquefied spinal subdural hematoma was performed by a lumbar puncture under fluoroscopic guidance. The clinical symptoms were dramatically improved postoperatively. Concomitant intracranial and spinal CSDH is considerably rare so only 23 cases including the present case have been reported in the literature so far. The etiology and therapeutic strategy were discussed with a review of the literature. Therapeutic strategy is not established for these two concomitant lesions. Conservative follow-up was chosen for 14 cases, resulting in a favorable clinical outcome. Although surgical evacuation of lumbosacral CSDH was performed in seven cases, an alteration of cerebrospinal fluid (CSF) pressure following spinal surgery should be reminded because of the intracranial lesion. Since CSDH is well liquefied in both intracranial and spinal lesion, a less invasive approach is recommended not only for an intracranial lesion but also for spinal lesion. Fluoroscopic-guided lumbar puncture for lumbosacral CSDH following burr hole surgery for intracranial CSDH could be a recommended strategy.

Spinal Extradural Arteriovenous Fistula with Cowden Syndrome: A Case Report and Literature Review Regarding Pathogenesis and Therapeutic Strategy

We report the case of a patient with a spinal extradural arteriovenous fistula (AVF) associated with Cowden syndrome (CS) that was successfully treated by endovascular surgery. CS is an autosomal dominant disorder associated with diverse symptoms caused by a deleterious mutation in the phosphatase and tensin homolog (PTEN) gene. A 67-year-old woman was diagnosed with CS based on her medical history of multiple cancers for which she underwent abdominal surgery, macrocephaly, Lhermitte-Duclos disease, and facial papules. Her genetic testing demonstrated a PTEN mutation. She presented with progressive paraparesis and her MRI of the thoracolumbar spine showed the spinal cord edema along with flow voids. A spinal angiogram demonstrated a spinal extradural AVF with the perimedullary drainage. The AVF was successfully treated by endovascular surgery. The PTEN mutation can accelerate angiogenesis; thus, vascular anomalies are one of the diagnostic criteria of CS. However, only two cases of vascular anomalies involving the spinal cord in patients with CS have been reported previously. As the present case, both cases had a history of abdominal or retroperitoneal cancer. The PTEN mutation accompanied with abdominal surgery might have caused this vascular anomaly as the consequences of venous congestion around the thoracolumbar spine. A spinal extradural AVF should be considered in patients with CS who present with myelopathy, especially when the patient has a history of abdominal or retroperitoneal surgery. Regarding the treatment strategy, endovascular surgery should be considered because surgical insult could prompt secondary vascular anomalies resulting from neovascularization due to the PTEN mutation.

E-051 Combination of Contrast Enhanced Time-Resolved 3D MRA and 3D Neuroimaging Software for the Evaluation of Brain Aneurysms Treated with Coil Embolisation

Purpose To improve the visualisation of residual neck in the aneurysms treated with coil embolisation utilising the time-resolved contrast enhanced magnetic resonance angiography (4D MRA). Materials and Methods A total of 11 patients who underwent coil embolisation of brain aneurysm underwent 1.5 Tesla 4D MRA one year after the procedure. Of these, 6 patients were treated with stent assisted technique. The image information obtained from the 4D MRA was re-processed utilising a 3D Neuroimaging software (TeraRecon, Inc.) and compared to the images obtained from the cerebral angiograms. Results Six patients showed major recanalisation and five patients showed minimal residual neck of the treated aneurysm in the cerebral angiogram. The 4D MRA images obtained from each patient was consistent with the images from the cerebral angiogram. The susceptibility artifact induced by the coils and stents was significantly reduced as compared to the images of contrast enhanced time of flight (CE-TOF) images. The re-processed 3D images of 4D MRA in the Neuroimaging software showed great reproducibility of angiographical findings obtained from the cerebral angiograms. Conclusion The combination of the 4D MRA and utilisation of the 3D Neuroimaging software showed great visualisation of residual aneurysm. This imaging method can be a good alternative for the post-procedure follow up angiograms in the patients who underwent coil embolisation. Abstract E-051 Figure 1 Disclosures A. Ikemura: None. I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Nishimura: None. I. Kan: None. Y. Murayama: None.

O-015 Double Catheter Technique : A Potential Alternative For The Stent Assisted Coil Embolisation For Wide Neck Aneurysms

Background and Purpose Double catheter coil embolisation (DCC) technique has been used for the treatment of wide neck aneurysms. Unlike Stent assisted Coil Embolisation (SAC), DCC does not require long term post-treatment anti-platelet therapy. Whether or not DCC can reduce the procedure related complications in SAC is not clear. In this series, consecutive unruptured wide neck aneurysm patients were treated primarily with the DCC. SAC was only used as a rescue therapy when the coil mass in the aneurysm was considered to be unstable. Clinical as well as angiographical outcomes of those who treated with DCC were reviewed. Methods A total of 597 unruptured aneurysm patients were treated in our institution between 2006 and 2012. Of these, 144 patients with wide neck (neck size >4.0 or dome-neck ratio<2.0) saccular aneurysm were primarily treated with DCC. Dual antiplatelet therapy was initiated 3 days prior to the procedure. If the treatment was completed with DCC, single antiplatelet therapy was continued for one month and then discontinued. Follow up MRI was performed at 3,6, and 12 months after the treatment. An angiogram was performed at 1 year, and the surveillance MRIs with every 6 to 12 months were continued. Results A total of 129 patients were treated with DCC only, and 5 patients were shifted to the SAC based on the intra-procedural findings. The average neck size and the average dome-neck ratio of the treated aneurysms were 6mm and 1.3 respectively. Every aneurysm treated with DCC was successfully embolised. Intra-operative hemorrhagic event occurred in 2 cases. There was no intra-operative thrombo-embolic event. During the average follow up period of 809 days, post operative symptomatic ischaemic events were seen in two cases (1.6%) and post operative hemorrhagic event (procedure unrelated) was seen in 1 case (0.8%). Permanent morbidity and mortality throughout was 2.4% and 0.8% respectively. Recanalisation that required re-treatment was seen in 14.7% but there was no procedure related complication during the re-treatment. Conclusion The angiographic outcomes of the aneurysms treated with DCC in this series were comparable to the historical controls of the wide neck aneurysms treated with other adjunctive techniques. To minimise procedure related ischaemic/haemorrhagic event associated with the SAC, DCC may be a potential candidate of alternative treatment. Abstract O-015 Figure 1 Disclosures I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Misaki: None. K. Nishimura: None. A. Ikemura: None. T. Abe: None. Y. Murayama: None.