Yoshifumi Konishi

Aneurysms associated with moyamoya disease.

Seven cases of moyamoya disease accompanied by an aneurysm were studied. The patients, two males and five females, were 13 to 57 years old (average, 32). The cases were classified into two groups: Group A (five cases), in which the aneurysm was located within the moyamoya vessels, and Group B (two cases), in which the aneurysm was located within the circle of Willis and remote from the moyamoya vessels. In all Group A cases, the presenting episode was intracerebral and intraventricular hemorrhage due to rupture of the aneurysm. One patient suffered two separate attacks. In this case, the aneurysm disappeared spontaneously. In one of the two Group B cases, there was hemorrhage from an anterior communicating artery aneurysm. In the other case, with a basilar-superior cerebellar artery aneurysm, there was hemorrhage from the moyamoya vessels.

Congenital fistula of the dural carotid-cavernous sinus: case report and review of the literature.

The case of a 2-month-old boy with a congenital fistula of the dural carotid-cavernous sinus is presented. This is a rare vascular anomaly in infancy, and it may cause acute changes in vision. The child was initially followed up for 1 year to see if spontaneous thrombosis would occur. The symptoms persisted, however, and intravascular surgery using platinum coils was performed for closure. After treatment, the symptoms completely resolved. Literature pertaining to this anomaly has been reviewed with particular emphasis on dural fistulas of the cavernous, transverse, sigmoid, and straight sinuses in infancy.

Treatment of vasospasm by balloon angioplasty: experimental studies and clinical experiences

The vasodilation mode and degree of the invasion caused by balloon angioplasty were experimentally examined. Assessment by light microscopy and scanning electron microscopy demonstrated that the invasion to the implanted arterial wall, taken from a patient who died from vasospasm, was minimized by the use of the balloon under the condition at 1 atm, 10 times for 10 seconds. Furthermore, we applied angioplasty to eight patients who developed severe vasospasm after subarachnoid haemorrhage, and five showed improvement in neurophysiological (transcranial Doppler sonography), neuroradiological, and clinical examinations. In addition, blood vessels obtained from one patient who died 10 days after angioplasty, demonstrated similar findings to those of the experimental studies. It can be said that angioplasty will be one of the effective therapeutic methods to manage vasospasm when it is applied under the conditions mentioned above.

A therapy against vasospasm after subarachnoidal haemorrhage: clinical experience of balloon angioplasty

Vasospasm is a phenomenon often present in human cases after subarachnoidal haemorrhage. Its aetiology and pathophysiology are unknown. As a result, cases of vasospasm do not respond to any known pharmacological therapy. We present in this paper, a practical application of intravascular surgery for vasospasm. In this procedure the requirement for a portable digital subtraction unit, transcranial Doppler sonography, and being able to determine quickly the neurological state of the patient are very important points. The use of monitoring equipment is especially indispensable during the carrying out of percutaneous transluminal angioplasty (PTA), which should be performed as soon as possible after the occurrence of vasospasm. The case of a 54-year-old male patient suffering from a ruptured anterior cerebral artery aneurysm was studied. Neck clipping was performed on the second day. On the fifth day the neurological state was stupor, and transcranial Doppler sonography (TCD) revealed a flow velocity of over 100 cm s-1. PTA was performed on the sixth day. The bilateral middle cerebral artery was dilated and the flow velocity slowed to within the normal range. The neurological state improved to clouding of consciousness after PTA. On the eighteenth day, the patients consciousness and bilateral carotid angiograms revealed the vessels to be dilated still. It was concluded that PTA therapy, and the use of a portable digital subtraction unit and TCD sonography, for vasospasm caused by subarachnoidal haemorrhage is useful and effective.

A combined surgical and endovascular treatment for a case with five vertebro-basilar aneurysms and bilateral internal carotid artery occlusions

BACKGROUND Whereas multiple aneurysms may be found in 20% of patients in whom one aneurysm is discovered, the identification of five vertebrobasilar aneurysms is distinctly rare. We described such a case treated by surgical and endovascular method. CASE DESCRIPTION A case of multiple aneurysms treated with combined surgical clipping and intravascular surgery is described. Five separate posterior circulation aneurysms and bilateral internal carotid artery occlusion were identified in one patient. Three of the aneurysms were treated surgically. Access to the fourth aneurysm was deemed difficult because of its location and because of the previously placed surgical clips; this aneurysm was treated by endovascular approaches that provided optimum therapy in this unusual multiple aneurysms case. CONCLUSIONS We have described an unusual case of multiple posterior circulation aneurysms in the setting of bilateral internal carotid occlusions, treated by a combination of surgical and endovascular therapies. We will be able to provide safer treatment for such difficult cases in the future.

Pediatric high-flow, cervical spinal, macro-arteriovenous fistula, treated with the endovascular cotton candy glue injection technique

Case reportA 3-year-old boy presented to our hospital with progressive neurological deficits. Spinal magnetic resonance imaging (MRI) revealed a perimedullary macro-arteriovenous fistula (PMAVF) resulting in a large venous pouch within the parenchyma of the lower cervical spinal cord.Transarterial varix embolization of the fistula from the venous side was performed using N-butyl cyanoacrylate with tantalum powder. Postembolization angiography confirmed obliteration of the fistula, and MRI revealed thrombosis and reduction in size of the venous component. The patient’s clinical symptoms were reduced dramatically following the intervention, and no neurological complications occurred due to the treatment. The prognosis of spinal PMAVF depends primarily on the presence of medullar signs and symptoms and on time to treatment. The volume of the venous pouch after the intervention was markedly reduced, and complete clinical recovery was obtained. Urgent endovascular intervention, as seen in this case, is considered first-line therapy and aims to decrease the risk of neurological sequela.

Applications and Roles of Coil Embolization and/or Clipping in the Treatment of Cerebral Aneurysm.

We retrospectively analysed to demonstrate the selection of the treatment modality and its efficacy in our department. Subjects of the present study comprised patients in whom coil embolization was abandoned due to such reasons as broad neck, whom coil embolization was performed for residual aneurysm following incomplete clipping or recurrent cerebral aneurysm, whom coil embolization was performed after coil compaction, whom coil embolization and clipping were performed for the treatment of multiple cerebral aneurysms. In the treatment of cerebral aneurysm, selecting proper techniques by considering the characteristics of clipping and coil embolization is desirable. In other words, strategizing therapy by taking advantages of the merits of clipping and coil embolization is important.

Optimum coil insertion speed of various coils in brain aneurysm embolization in vitro.

A coil must comprise material with shape memory to perform optimal coil embolization. To achieve this, the alloy characteristics of the coil (hardness, shape, and thickness) must be understood. In this experiment, a catheter was fixed in the bright position and the movement of the coil was observed under a constant rate of insertion; the optimal insertion rate during clinical use was investigated. The first coil insertion speed was evaluated using simulated aneurysms in an in vivo arterial model. The results showed that the insertion force relates to the deployment shape of the coil, that the feedback through the force indicator using sound is very effective, and that the recorder is useful for analysis of coil embolization. The inserted coils during aneurysm embolization were able to wind uniformly within the aneurysm due to a variety of factors (guiding or micro-catheter position and kick-back phenomenon such as delivery wire). Optimal speed is achieved with proper coil design, which allows the coil to be inserted into the aneurysm. The shape and size of the aneurysm can help determine the necessary size and design of the coil that should be used during the optimal speed range. Aneurysm wall and coil characteristics are considered, along with the friction state of the coil (hardness, shape, and thickness), leading to improvements in safety during the insertion procedure at optimum speed.

Neonatal Dural Arteriovenous Fistula at the Confluence Presenting with Paralysis of the Orbicularis Oris Muscle

A male neonate presented a dural arteriovenous fistula (DAVF) at the confluence with paralysis of the orbicularis oris muscle. The interesting features in our case were the clinical symptoms (orbicularis oris muscle paralysis at birth), angioarchitecture (high-flow arteriovenous shunts at the confluence) and the size and hemodynamic flow (mid-sized venous pouch) of the fistula. Additionally, the embolization technique (i.e., occipital artery approach, closing shunts with pure glue) automatically resulted in the immediate and complete closure of accessory feeders without any additional treatment, and the midterm clinical outcome was good. We succeeded improving the symptoms of a neonate with a congenital high-flow DAVF by closing a fistula using a small amount of glue.

High-flow Neonatal Macrocerebral Arteriovenous Fistulas in Hereditary Hemorrhagic Telangiectasia.

Although some cases of vein of Galen aneurysmal malformation (VGAM) present initial clinical symptoms such as cardiopulmonary disturbance in the neonatal period, pial arteriovenous fistula is very seldom present as a clinical symptom immediately after birth. A neonatal patient, the first-born to his family, presented with tachypnea postpartum. This baby had a family history of hereditary hemorrhagic telangiectasia. A cerebral MR image revealed multiple macrocerebral arteriovenous fistulas (MCAVFs), resulting in a large partially thrombosed venous pouch within the cerebral cortex. Trans-arterial embolizations of the main two fistulas were performed using N-butyl cyanoacrylate (NBCA) with tantalum powder six months after birth. Post-embolization angiography confirmed the obliteration of the fistulas and magnetic resonance imaging (MRI) revealed thrombosis and reduction in size of the venous component. His tachypnea disappeared completely. There were no neurological complications due to the treatment. The prognosis of multiple MCAVFs mainly depends on the presence of medullar signs and symptoms and a delay before treatment. Pure glue endovascular intervention, as used in our case, is considered to be the first therapeutic choice to decrease the risk of neurological consequences.