Yuzo Hori

Treatment of mandibular arteriovenous malformation by transvenous embolization: A case report.

Arteriovenous malformations (AVMs) of the mandible are relatively rare and potentially life‐threatening lesions. Treatment is usually difficult. This study presents a case with high‐flow AVM of the mandible in which most of the AVM were occluded by transvenous coil embolization.

Endovascular recanalization of acute intracranial vertebrobasilar artery occlusion using local fibrinolysis and additional balloon angioplasty

IntroductionVertebrobasilar artery occlusion (VBO) produces high mortality and morbidity due to low recanalization rate utilization in endovascular therapy. The use of percutaneous transluminal angioplasty (PTA) to improve recanalization rate additional to local intra-arterial fibrinolysis (LIF) was investigated in this study. Results obtained following recanalization therapy in acute intracranial VBO are reported.MethodsEighteen consecutive patients with acute VBO underwent LIF with or without PTA, from August 2000 to May 2006. Eight patients were treated using LIF alone, and ten required additional PTA. Rate of recanalization, neurological status before treatment, and clinical outcomes were evaluated.ResultsOf 18 patients, 17 achieved recanalization. One procedure-related complication of subarachnoid hemorrhage occurred. Overall survival rate was 94.4% at discharge. Seven patients achieved good outcomes [modified Rankin scale (mRS) 0–2], and the other 11 had poor outcomes (mRS 3–6). Five of six patients who scored 9–14 on the Glasgow Coma Scale (GCS) before treatment displayed good outcomes, whereas ten of 12 patients who scored 3–8 on the GCS showed poor outcomes. GCS prior to treatment showed a statistically significant correlation to outcomes (p < 0.05). Moreover, the National Institutes of Health Stroke Scale (NIHSS) before treatment correlated well with mRS (correlation coefficient 0.487). No statistical difference between the good and poor outcome groups was observed for the duration of symptoms, age, etiology, and occlusion site.ConclusionsEndovascular recanalization can reduce mortality and morbidity of acute VBO. Good GCS and NIHSS scores prior to treatment can predict the efficacy of endovascular recanalization.

The anterior medullary-anterior pontomesencephalic venous system and its bridging veins communicating to the dural sinuses: normal anatomy and drainage routes from dural arteriovenous fistulas

IntroductionWe evaluated the normal venous anatomy of the anterior medullary/anterior pontomesencephalic venous (AMV/APMV) system and bridging veins connected to the dural sinuses using magnetic resonance (MR) imaging and demonstrated cases of dural arteriovenous fistulas (DAVFs) with bridging venous drainage.Materials and methodsMR images obtained using a 3D gradient echo sequence in 70 patients without lesions affecting the deep or posterior venous channels were reviewed to evaluate the normal anatomy of the AMV/APMV system and bridging veins. MR images and digital subtraction angiography in 80 cases with intracranial or craniocervical junction DAVFs were reviewed to evaluate the bridging venous drainage from DAVFs.ResultsMR images clearly revealed AMV/APMV in 35 cases. Fifteen cases showed a direct connection between AMV and APMV, while 15 cases showed an indirect communication via the transverse pontine vein or the bridging vein. In the five remaining cases, the AMV and APMV end separately to the bridging vein or the transverse pontine vein. Bridging veins were identified in 34 cases, connecting to the cavernous sinus in 33, to the suboccipital cavernous sinus in 11, and the inferior petrosal sinus in five cases. In 80 DAVF cases, seven of 40 cavernous sinus DAVFs, two craniocervical junction DAVFs, and one inferior petrosal sinus DAVF drained via bridging veins to the brain stem.ConclusionThe AMV/APMV and bridging veins showed various anatomies and frequently showed a connection to the cavernous sinus. Knowledge of the venous anatomy is helpful for the diagnosis and intravascular treatment of DAVFs.

Selective Transvenous Embolization of Dural Arteriovenous Fistulas Involving the Hypoglossal Canal

The hypoglossal canal contains a venous plexus that connects the inferior petrous sinus, condylar vein, jugular vein and paravertebral plexus. The venous plexus is one of the venous drainage routes of the posterior skull base. Only a few cases of dural arteriovenous fistulas (AVFs) involving the hypoglossal canal have been reported. We describe three cases (a 62-year-old female, a 52-year-old male, and an 83-year-old male) of dural AVFs involving the hypoglossal canal. Symptoms were pulse-synchronous bruit in two cases and proptosis/chemosis in one. All dural AVFs were mainly fed by the ipsilateral ascending pharyngeal artery. Two of three dural AVFs involving the hypoglossal canal mainly drained through the anterior condylar confluence into the inferior petrosal sinus retrogradely with antegrade drainage through the lateral condylar vein. The other one drained through the lateral and posterior condylar veins into the suboccipital cavernous sinus. All dural AVFs were completely occluded by selective transvenous embolization without any complications, and the symptoms disappeared within one week in all cases. Dural AVFs involving the hypoglossal canal can be successfully treated by selective transvenous embolization with critical evaluation of venous anatomy in each case.

Transportal Intravariceal Sclerotherapy with N-Butyl-2-Cyanoacrylate for Gastric Varices

Four patients with gastric varices without catheterizable draining veins through a systemic vein were treated with transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate (NBCA). In all patients, the gastric varices were successfully obliterated with 2-5 mL of NBCA-lipiodol mixture injected via a microcatheter introduced into the varices with transhepatic or transileocolic portal venous access. No complications related to the procedure were encountered. Follow-up gastroendoscopy showed disappearance (n = 3) or marked decrease (n = 1) of the varices. Neither recurrent gastric varices nor variceal bleeding were observed during the follow-up period (6-46 months). Transportal intravariceal sclerotherapy is useful for obliteration of gastric varices in selected cases.

Intrahepatic porto-hepatic venous shunts in Rendu-Osler-Weber disease. Imaging demonstration

This study describes the imaging features of the intrahepatic portohepatic venous (PHV) shunt, which is a potential cause of portosystemic encephalopathy in Rendu-Osler-Weber disease. Six patients with Rendu-Osler-Weber disease (two men, four women; age range 42–73 years) were retrospectively studied. There were two from one family and three from another family. Of these patients, one was diagnosed with definitive portosystemic encephalopathy because of a psychiatric disorder. We retrospectively reviewed the radiological examinations, including abdominal angiography (n=6), three-phase dynamic helical computed tomography (CT; n=3), and conventional enhanced CT (n=1). In one patient, CT during angiography and CT angioportography were also performed. Evaluation was placed on the imaging features of intrahepatic PHV shunts. On angiography, intrahepatic PHV shunts showing multiple and small shunts <5 mm in diameter in an apparent network were detected in all patents. In two patients, a large shunt with a size of either 7 or 10 mm was associated. These intrahepatic PHV shunts were predominantly distributed in the peripheral parenchyma. Intrahepatic PHV shunts would be characterized by small and multiple shunts in an apparent network on the periphery with or without a large shunt.

Development of a New Coaxial Balloon Catheter System for Balloon-Occluded Retrograde Transvenous Obliteration (B-RTO)

PurposeTo develop a new coaxial balloon catheter system and evaluate its clinical feasibility for balloon-occluded retrograde transvenous obliteration (B-RTO).MethodsA coaxial balloon catheter system was constructed with 9 Fr guiding balloon catheter and 5 Fr balloon catheter. A 5 Fr catheter has a high flexibility and can be coaxially inserted into the guiding catheter in advance. The catheter balloons are made of natural rubber and can be inflated to 2 cm (guiding) and 1 cm (5 Fr) maximum diameter. Between July 2003 and April 2005, 8 consecutive patients (6 men, 2 women; age range 33–72 years, mean age 55.5 years) underwent B-RTO using the balloon catheter system. Five percent ethanolamine oleate iopamidol (EOI) was used as sclerosing agent. The procedures, including maneuverability of the catheter, amount of injected sclerosing agent, necessity for coil embolization of collateral draining veins, and initial clinical results, were evaluated retrospectively. The occlusion rate was assessed by postcontrast CT within 2 weeks after B-RTO.ResultsThe balloon catheter could be advanced into the proximal potion of the gastrorenal shunt beyond the collateral draining vein in all cases. The amount of injected EOI ranged from 3 to 34 ml. Coil embolization of the collateral draining vein was required in 2 cases. Complete obliteration of gastric varices on initial follow-up CT was obtained in 7 cases. The remaining case required re-treatment that resulted in complete obstruction of the varices after the second B-RTO. No procedure-related complications were observed.ConclusionB-RTO using the new coaxial balloon catheter is feasible. Gastric varices can be treated more simply by using this catheter system.

Radiotherapy combined with transarterial infusion chemotherapy and concurrent infusion of a vasoconstrictor agent for nonresectable advanced hepatic hilar duct carcinoma

The treatment of patients with advanced hepatic hilar duct carcinoma is a challenging problem. The current study was performed to evaluate the outcome of patients with advanced hepatic hilar duct carcinoma who received external beam radiotherapy (EBRT) combined with transarterial chemotherapy and infusion of a vasoconstrictor.

Maxillary Artery: Functional and Imaging Anatomy for Safe and Effective Transcatheter Treatment

The maxillary artery is a terminal branch of the external carotid artery. Although the main maxillary artery trunk and most of its branches course within the extracranial space and supply the organs and muscles of the head and neck, other surrounding soft tissues, and the oral and rhinosinusal cavities, other branches supply the dura mater and cranial nerve and can anastomose to the internal carotid artery (ICA). Various pathologic conditions of the intracranial, head, and neck regions can involve the branches of the maxillary artery. Many of these diseases can be treated with endovascular approaches; however, there is a potential risk of complications in the brain parenchyma and cranial nerves related to the meningoneuronal arterial supply and anastomoses to the ICA. Therefore, familiarity with the functional and imaging anatomy of the maxillary artery is essential. In the past, conventional angiography has been the standard imaging technique for depicting the maxillary artery anatomy and related pathologic findings. However, recent advances in computed tomographic, magnetic resonance, and rotational angiography have further elucidated the maxillary artery anatomy by means of three-dimensional representations. Understanding the functional and imaging anatomy of the maxillary artery allows safe and successful transcatheter treatment of pathologic conditions in the maxillary artery territories.

Non-bifurcating carotid artery coexisting with transverse sinus dural arteriovenous fistula.

Dear Sir, Non-bifurcating carotid artery is a very rare anatomical variation of the cervical carotid artery, in which the branches of the external carotid artery (ECA) directly arise from the common carotid artery without forming a bifurcation [1, 2]. Here, we describe a case of isolated transverse sinus dural arteriovenous fistula (AVF) associated with non-bifurcating carotid artery. A 71-year-old man presented with chronic aortic dissection at the thoracic aorta enlarging for the previous 6 months. Brain magnetic resonance angiography was performed for preoperative screening for incidental cerebrovascular diseases and revealed a dural AVF with cortical venous drainage at the right transverse sinus. Although he had no symptoms related to the AVF, endovascular treatment was carried out before the aortic surgery owing to the high risk of aggressive symptoms associated with dural AVFs with cortical venous reflux. Common carotid angiography showed the dural AVF fed by branches of the ECA and non-bifurcating carotid artery, in which the branches of the ECA, including the lingular artery, facial artery, internal maxillary artery, occipital artery (OA), and ascending pharyngeal artery (APA) originated separately from the carotid artery (Fig. 1). Selective angiography of the OA clearly showed the AVF drained via cortical veins with the isolated sinus. The branches of the internal maxillary artery, such as the superficial temporal artery and middle meningeal artery, showed their usual configurations and branching patterns. Transvenous embolization was performed through the occluded sinus with both femoral venous approaches. The sinus was packed with coils, and the AVF disappeared. Non-bifurcating carotid artery, which ascends without forming a bifurcation of the internal carotid artery (ICA) and ECA, is a very rare anatomical variation of the cervical carotid artery [1, 2]. Two hypotheses have been proposed for the development of non-bifurcating carotid artery [3-5]. The first is agenesis of the common stem of the ECA with regression failure of the hyoid artery, and the second is segmental agenesis of the ICA. In the human embryo, the cervical carotid arteries develop by complicated processes of regression, and the communication within the vascular network consists of the ventral aorta, dorsal aorta, aortic arches, and intersegmental arteries. The ventral aorta and dorsal aorta communicate via aortic arches. Among them, the first aortic arch (mandibular artery) further regresses, while the second aortic arch (hyoid artery) continues to the stapedial artery, which produces two branches of the middle meningeal artery and internal maxillary artery. The ICA Neuroradiology (2009) 51:697–698 DOI 10.1007/s00234-009-0542-7