Hiroaki Neki

Flow diverter stent (FDS) deployment in neuroendovascular therapy carries a risk of vessel injury related to unintended distal advancement of the delivery wire, particularly in cases with distal aneurysms. Safe control of wire behavior during deployment remains challenging. We describe a deployment strategy using a distal access catheter (DAC) to mitigate this risk. We report a case of a 79-year-old man with multiple intracranial aneurysms, including a symptomatic large aneurysm of the right internal carotid artery and an additional distal aneurysm at the middle cerebral artery bifurcation. A Surpass Evolve Flow Diverter (Stryker, Kalamazoo, MI, USA) was deployed in the right internal carotid artery. The device was initially deployed using the standard technique; however, the deployment strategy was subsequently changed to release the device within the DAC, followed by gradual unsheathing of the catheter, to mitigate the risk of distal advancement of the delivery wire. The FDS was successfully deployed without distal wire migration or vessel injury. The postoperative course was uneventful, with no procedure-related complications. This case highlights a practical rescue strategy for situations in which distal wire control during FDS deployment is particularly important. Deploying an FDS within a DAC and releasing it by unsheathing may help mitigate the risk of uncontrolled distal wire advancement and enhance procedural safety in carefully selected complex cases with distal aneurysms.

Background: Arteriovenous malformation (AVM) and developmental venous anomaly (DVA) rarely coexist. Developing a surgical strategy to treat this co-occurrence is difficult due to the unclear pathogenesis. We report the use of super-selective digital subtraction angiography (DSA) and Three-dimensional (3D) rotational digital subtraction venography (DSV) to develop a surgical strategy for complex AVM draining into a DVA. Case Description: A 58-year-old woman presented with left hemiparesis and unconsciousness. Plain and contrast computed tomography showed a right frontal subcortical hematoma and a heterogeneous contrast lesion anterior to the hematoma, leading to a dilated vessel. The hematoma was removed due to worsening unconsciousness. DSA revealed a right frontal AVM of Spetzler-Martin grade 2 with superficial drainage into a DVA, and 3D-DSV revealed that the intermediate part of the DVA involved normal parenchyma. Interventional transarterial embolization and surgical nidus removal were planned. Preoperative super-selective DSA showed two medullary veins draining from the AVM into the DVA. Thus, we decided to separate the two medullary veins from the nidus. Postoperative angiography revealed complete removal of the AVM and preservation of the DVA. Conclusion: Treating a complex AVM draining into a DVA is challenging; surgeons have to remove only the AVM portion and preserve the DVA. Super-selective DSA and 3D rotational DSV were performed to develop the surgical strategy.

Dolichoectasia is a rare arterial condition characterized by the dilatation, tortuosity, and elongation of cerebral blood vessels. The vertebrobasilar artery and internal carotid artery are the common sites of dolichoectasia. However, dolichoectasia of the branch arteries, such as the ophthalmic artery (OA), is extremely rare. To the best of our knowledge, this is the first case of ophthalmic dolichoectasia that was successfully treated with endovascular internal coil trapping. A 54-year-old female patient presented with transient left ophthalmalgia and visual disturbance. Magnetic resonance imaging revealed a dilated and elongated left OA compressing the optic nerve at the entrance of the optic canal. However, a previous image that was taken 17 years back revealed that the OA was normal, which suggested the change in dolichoectasia was acquired. Cerebral angiography showed that the dilated and tortuous OA was running from the ophthalmic segment of the left internal carotid artery into the orbit. The symptoms could have been attributed to the direct compression of the dolichoectatic OA in the optic canal. A sufficient anastomosis between the central retinal artery and the middle meningeal artery was identified on external carotid angiography with balloon occlusion of the internal carotid artery. Endovascular treatment with internal trapping of the OA was performed due to ophthalmic symptom progression. Internal coil trapping of the OA was performed at the short segment between the OA bifurcation and the entrance of the optic canal. As expected, the central retinal artery was supplied via the middle meningeal artery after the treatment. The transient visual disturbance was immediately resolved. Ophthalmalgia worsened temporarily after the treatment. However, it completely resolved after several days of oral corticosteroid therapy. Postoperative angiography showed that the origin of the OA was occluded and that the OA in the optic canal was shrunk. The flow of the central retinal arteries via the middle meningeal artery was preserved. OA dolichoectasia is rare, and its pathogenesis and long-term visual prognosis are still unknown. However, endovascular therapy can improve symptom by releasing the pressure site in the optic canal.

Background Dolichoectasia is a rare arterial condition characterized by the dilatation, tortuosity, and elongation of cerebral blood vessels. The vertebrobasilar artery and internal carotid artery are the common sites of dolichoectasia. However, dolichoectasia of the branch arteries, such as the ophthalmic artery (OA), is extremely rare. To the best of our knowledge, this is the first case of ophthalmic dolichoectasia that was successfully treated with endovascular internal coil trapping. Case presentation: A 54-year-old female patient presented with transient left ophthalmalgia and visual disturbance. Magnetic resonance imaging revealed a dilated and elongated left OA compressing the optic nerve at the entrance of the optic canal. However, a previous image that was taken 17 years back revealed that the OA was normal, which suggested the change in dolichoectasia was acquired. Cerebral angiography showed that the dilated and tortuous OA was running from the bifurcation of the left internal carotid artery into the orbit. The symptoms could have been attributed to the direct compression of the dolichoectatic OA in the optic canal. A sufficient anastomosis between the central retinal artery and the middle meningeal artery was identified on external carotid angiography with balloon occlusion of the internal carotid artery. Endovascular treatment with internal trapping of the OA was performed due to ophthalmic symptom progression. Internal coil trapping of the OA was performed at the short segment between the OA bifurcation and the entrance of the optic canal. As expected, the central retinal artery was supplied via the middle meningeal artery after the treatment. The transient visual disturbance was immediately resolved. Ophthalmalgia worsened temporarily after the treatment. However, it completely resolved after several days of oral corticosteroid therapy. Postoperative angiography showed that the origin of the OA was occluded and that the OA in the optic canal was shrunk. The flow of the central retinal arteries via the middle meningeal artery was preserved. Conclusions The ophthalmic artery dolichoectasia is rare, and pathogenesis and long-term visual prognosis are still unknown. However, endovascular therapy can improve symptom by releasing the pressure site in the optic canal.

Background: Although the relationship between dural arteriovenous fistula (dAVF) and cerebral venous thrombosis (CVT) has been reported, the etiology has not been clarified. Here, we report a case of de novo dAVF after mechanical thrombectomy for CVT and discuss the underlying mechanism. Case Description: A 61-year-old woman presented with a gradually worsening headache and was diagnosed with severe CVT. Mechanical thrombectomy was performed for the CVT because of progressive neurological deterioration despite anticoagulation therapy. Two years after the initial treatment, angiography revealed a de novo dAVF with a direct shunt of the left convexity cortical vein. Transarterial embolization with Onyx was performed and the shunt was completely obliterated. Conclusion: In this report, we describe a case of de novo dAVF with CVT that was treated with mechanical thrombectomy. Even if CVT improves with mechanical thrombectomy, we must be aware of the occurrence of de novo dAVF.