PHIL Migration to Internal Carotid Artery and Middle Cerebral Artery: Late Mechanical Retrieval with Solitaire AB Stent

AbstractPrecipitating hydrophobic injecting liquid (PHIL) is a novel embolic agent used in the endovascular treatment of arteriovenous malformations (AVM) and arteriovenous fistulas. Complications can occur during embolization with migration of the liquid embolic material to normal vasculature. In these cases, use of a stent retriever is an option for removal of the plug. Herein, we present the case of a patient who presented with a right occipital hemorrhage due to a ruptured occipital AVM fed by the calcarine and parieto-occipital arteries with venous drainage to the straight sinus. Embolization via the anterior circulation through the right posterior communicating artery was attempted but PHIL migrated to right internal carotid artery and middle cerebral artery due to kinking and rupture of the microcatheter. The patient developed mild left hemiparesis. When this complication occurred, no stent retriever was available at our institution and 1 day later, the Solitaire AB stent was used to remove the plug of PHIL successfully, with good reperfusion of the proximal and distal vessels. The patient improved after the procedure and was discharged home without deficit. Mechanical stent retrievers can be used in cases of migration of liquid embolic agents to normal vasculature with good clinical and radiological results.

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The Minipterional Craniotomy for Anterior Circulation Aneurysms: Initial Experience With 72 Patients

Operative Neurosurgery ◽

10.1227/neu.0000000000000348 ◽

2014 ◽

Vol 10 (2) ◽

pp. 200-207 ◽

Cited By ~ 25

Author(s):

Justin M. Caplan ◽

Kyriakos Papadimitriou ◽

Wuyang Yang ◽

Geoffrey P. Colby ◽

Alexander L. Coon ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Average Length ◽

Temporalis Muscle ◽

Anterior Circulation ◽

Pterional Craniotomy ◽

Anterior Circulation Aneurysms

Abstract BACKGROUND: The pterional craniotomy is well established for microsurgical clipping of most anterior circulation aneurysms. The incision and temporalis muscle dissection impacts postoperative recovery and cosmetic outcomes. The minipterional (MPT) craniotomy offers similar microsurgical corridors, with a substantially shorter incision, less muscle dissection, and a smaller craniotomy flap. OBJECTIVE: To report our experience with the MPT craniotomy in select unruptured anterior circulation aneurysms. METHODS: From January 2009 to July 2013, 82 unruptured aneurysms were treated in 72 patients, with 74 MPT craniotomies. Seven patients had multiple aneurysms treated with a single MPT craniotomy. The average patient age was 56 years (range: 24-87). Aneurysms were located along the middle cerebral artery (n = 36), posterior communicating (n = 22), paraophthalmic (n = 22), choroidal (n = 1), and dorsal ICA segments (n = 1). The MPT craniotomy utilized an incision just posterior to the hairline and a single myocutaneous flap. RESULTS: The average aneurysm size was 5.45 mm (range: 1-14). There were no instances of compromised operative corridors requiring craniotomy extension. Three significant early postoperative complications included epidural and subdural hematomas requiring evacuation, and a middle cerebral artery infarction. Average length of hospitalization was 3.96 days (range: 2-20). Two patients required reoperation for wound infections. Average follow-up was 421 days (range: 5-1618). Minimal to no temporalis muscle wasting was noted in 96% of patients. CONCLUSION: The MPT craniotomy is a worthwhile alternative to the standard pterional craniotomy. There were no instances of suboptimal operative corridors and clip applications when the MPT craniotomy was utilized in the treatment of unruptured middle cerebral artery and supraclinoid internal carotid artery aneurysms proximal to the terminal internal carotid artery bifurcation.

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Anterior circulation aneurysms: anatomy and surgical techniques

The Neurosurgeon's Handbook ◽

10.1093/med/9780198570677.003.0451 ◽

2010 ◽

pp. 573-580

Author(s):

George Samandouras

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Anterior Cerebral Artery ◽

Surgical Techniques ◽

Anterior Circulation ◽

Middle Cerebral Artery Aneurysms ◽

Anterior Circulation Aneurysms

Chapter 9.9 covers the anatomy and surgical techniques of anterior circulation aneurysms, internal carotid artery (ICA) aneurysms, anterior cerebral artery aneurysms, and middle cerebral artery aneurysms.

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Extracranial internal carotid artery vasospasm during thrombectomy

The Neuroradiology Journal ◽

10.1177/1971400917731118 ◽

2017 ◽

Vol 31 (3) ◽

pp. 313-316

Author(s):

Isamu Miura ◽

Akitsugu Kawashima ◽

Masataka Hayashi ◽

Akane Tanda ◽

Tomomi Ishikawa ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Stent Retriever ◽

Extracranial Internal Carotid Artery ◽

Acute Cerebral Ischemia ◽

Guiding Catheter ◽

Mechanical Irritation

The use of a stent retriever increases the risk of intracranial vasospasm. Here, we report the case of a man who developed severe vasospasm in a long segment of the extracranial internal carotid artery after mechanical irritation by a stent retriever inserted for the treatment of acute cerebral ischemia. A 47-year-old right-handed man presented with sudden-onset right-sided weakness and difficulty speaking. The patient’s National Institutes of Health Stroke Scale score was 6 and he had an Alberta Stroke Program Early Computed Tomography Score of 9. The patient was started on intravenous alteplase therapy, and an acute thrombectomy was performed. Left internal carotid digital subtraction angiography showed narrowing of the left common and internal carotid arteries and occlusion of the proximal left M1 segment of the middle cerebral artery. A stent retriever was retracted into a guiding catheter placed at the left carotid bulb under continuous suction. Recanalization of the middle cerebral artery was not achieved and there was significant narrowing in a long segment of the extracranial internal carotid artery associated with exacerbation of the patient’s aphasia. The cervical vasospasm improved after nicardipine infusion via the catheter. We encountered vasospasm in a long segment of the extracranial internal carotid artery after mechanical irritation by a stent retriever. If a stent retriever is used in a patient with a narrow extracranial internal carotid artery, consideration should be given to using a Penumbra or smaller guiding catheter located in the distal internal carotid artery to prevent irritation to the cervical vessel wall.

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Rapid identification of a major diffusion/perfusion mismatch in distal internal carotid artery or middle cerebral artery ischemic stroke

BMC Neurology ◽

10.1186/1471-2377-12-132 ◽

2012 ◽

Vol 12 (1) ◽

Cited By ~ 16

Author(s):

Reza Hakimelahi ◽

Albert J Yoo ◽

Julian He ◽

Lee H Schwamm ◽

Michael H Lev ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Rapid Identification ◽

Distal Internal Carotid Artery

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Trapping, dome puncture, and direct suction decompression in conjunction with assistant superficial temporal artery- middle cerebral artery bypass to clip giant internal carotid artery bifurcation aneurysm

Surgical Neurology International ◽

10.25259/sni_462_2019 ◽

2019 ◽

Vol 10 ◽

pp. 205

Author(s):

Seiei Torazawa ◽

Hideaki Ono ◽

Tomohiro Inoue ◽

Takeo Tanishima ◽

Akira Tamura ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Superficial Temporal Artery ◽

Temporal Artery ◽

Optimal Treatment ◽

Aneurysm Neck ◽

Bifurcation Aneurysm

Background: Very large and giant aneurysms (≥20 mm) of the internal carotid artery (ICA) bifurcation (ICAbif) are definitely rare, and optimal treatment is not established. Endovascular treatments are reported as suboptimal due to difficulties of complete occlusion and tendencies to recanalization. Therefore, direct surgery remains an effective strategy if the clipping can be performed safely and reliably, although very difficult. Case Description: Two cases of ICAbif aneurysms (>20 mm) were treated. Prior assistant superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed to avoid ischemic complications during prolonged temporary occlusion of the arteries in both cases. In Case 1 (22-mm aneurysm), the dome was inadvertently torn in applying the clip because trapping had resulted in insufficient decompression. Therefore, in Case 2 (28-mm aneurysm), almost complete trapping of the aneurysm and subsequent dome puncture was performed, and the aneurysm was totally deflated by suction from the incision. This complete aneurysm decompression allowed safe dissection and successful clipping. Conclusion: Trapping, deliberate aneurysm dome puncture, and suction decompression from the incision in conjunction with assistant STA-MCA bypass can achieve complete aneurysm deflation, and these techniques enable safe dissection of the aneurysm and direct clipping of the aneurysm neck. Direct clipping with this technique for very large and giant ICAbif aneurysms may be the optimal treatment choice with the acceptable outcome if endovascular treatment remains suboptimal.

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Blister Aneurysms of the Internal Carotid Artery: Microsurgical Results and Management Strategy

Neurosurgery ◽

10.1227/neu.0000000000001259 ◽

2017 ◽

Vol 80 (2) ◽

pp. 235-247 ◽

Cited By ~ 27

Author(s):

Christopher M. Owen ◽

Nicola Montemurro ◽

Michael T. Lawton

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Treatment Strategy ◽

Internal Carotid ◽

Artery Bypass ◽

External Carotid ◽

Parent Artery ◽

Intraoperative Rupture

Abstract BACKGROUND: Blister aneurysms of the supraclinoid internal carotid artery (ICA) are challenging lesions with high intraoperative rupture rates and significant morbidity. An optimal treatment strategy for these aneurysms has not been established. OBJECTIVE: To analyze treatment strategy, operative techniques, and outcomes in a consecutive 17-year series of ICA blister aneurysms treated microsurgically. METHODS: Seventeen patients underwent blister aneurysm treatment with direct clipping, bypass and trapping, or clip-reinforced wrapping. RESULTS: Twelve aneurysms (71%) were treated with direct surgical clipping. Three patients required bypass: 1 superficial temporal artery to middle cerebral artery bypass, 1 external carotid artery to middle cerebral artery bypass, and 1 ICA to middle cerebral artery bypass. One patient was treated with clip-reinforced wrapping. Initial treatment strategy was enacted 71% of the time. Intraoperative rupture occurred in 7 patients (41%), doubling the rate of a poor outcome (57% vs 30% for patients with and without intraoperative rupture, respectively). Severe vasospasm developed in 9 of 16 patients (56%). Twelve patients (65%) were improved or unchanged after treatment, and 10 patients (59%) had good outcomes (modified Rankin Scale scores of 1 or 2). CONCLUSION: ICA blister aneurysms can be cautiously explored and treated with direct clipping as the first-line technique in the majority of cases. Complete trapping of the parent artery with temporary clips and placing permanent clip blades along normal arterial walls enables clipping that avoids intraoperative aneurysm rupture. Trapping/bypass is used as the second-line treatment, maintaining a low threshold for bypass with extensive or friable pathology of the carotid wall and in patients with incomplete circles of Willis.

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Middle cerebral artery dissections: Differences between isolated and extended dissections of internal carotid artery

Journal of the Neurological Sciences ◽

10.1016/j.jns.2005.03.047 ◽

2005 ◽

Vol 235 (1-2) ◽

pp. 37-44 ◽

Cited By ~ 29

Author(s):

Chin-Hsien Lin ◽

Jiann-Shing Jeng ◽

Ping-Keung Yip

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Internal Carotid

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Critical neurovascular brain anatomy

The Neurosurgeon's Handbook ◽

10.1093/med/9780198570677.003.0390 ◽

2010 ◽

pp. 504-517

Author(s):

George Samandouras

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Basilar Artery ◽

Internal Carotid ◽

Anterior Cerebral Artery ◽

Brain Anatomy ◽

Vertebral Arteries ◽

System P

Chapter 9.1 covers critical neurovascular brain anatomy, including internal carotid artery, the middle cerebral artery, the anterior cerebral artery, the vertebral arteries (VAs), the basilar artery (BA), and the venous system.

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Origins and Pathways of Cerebrovascular Vasoactive Intestinal Polypeptide-Positive Nerves in Rat

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/jcbfm.1988.117 ◽

1988 ◽

Vol 8 (5) ◽

pp. 697-712 ◽

Cited By ~ 182

Author(s):

Norihiro Suzuki ◽

Jan Erik Hardebo ◽

Christer Owman

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Vasoactive Intestinal Polypeptide ◽

Basilar Artery ◽

Internal Carotid ◽

Sphenopalatine Ganglion ◽

Cerebral Blood Vessels ◽

Carotid Canal

In order to clarify the origins and pathways of vasoactive intestinal polypeptide (VlP)-containing nerve fibers in cerebral blood vessels of rat, denervation experiments and retrograde axonal tracing methods (true blue) were used. Numerous VIP-positive nerve cells were recognized in the sphenopalatine ganglion and in a mini-ganglion (internal carotid mini-ganglion) located on the internal carotid artery in the carotid canal, where the parasympathetic greater superficial petrosal nerve is joined by the sympathetic fibers from the internal carotid nerve, to form the Vidian nerve. VIP fiber bridges in the greater deep petrosal nerve and the internal carotid nerve reached the wall of the internal carotid artery. Two weeks after bilateral removal of the sphenopalatine ganglion or sectioning of the structures in the ethmoidal foramen, VIP fibers in the anterior part of the circle of Willis completely disappeared. Very few remained in the middle cerebral artery, the posterior cerebral artery, and rostral two-thirds of the basilar artery, whereas they remained in the caudal one-third of the basilar artery, the vertebral artery, and intracranial and carotid canal segments of the internal carotid artery. One week after application of true blue to the middle cerebral artery, dye accumulated in the ganglion cells in the sphenopalatine, otic and internal carotid mini-ganglion; some of the cells were positive for VIP. The results show that the VIP nerves in rat cerebral blood vessels originate: (a) in the sphenopalatine, and otic ganglion to innervate the circle of Willis and its branches from anterior and caudally and (b) from the internal carotid mini-ganglion to innervate the internal carotid artery at the level of the carotid canal and to some extent its intracranial extensions.

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