Coiling Using Dual Microcatheter Technique—A Novel Approach

Posterior circulation aneurysms are difficult to treat, and if an incorporated artery is arising from the neck of aneurysm, management becomes much more challenging. Here, we are describing a novel technique used to treat a patient with a large, wide-necked left vertebral artery (VA)-posterior inferior cerebellar artery (PICA) junctional aneurysm. PICA seems to be arising from the aneurysm neck, but the aneurysm neck was not very clearly defined. So, we placed a second microcatheter into PICA, which not only allowed the coils to be placed in the aneurysm, without disrupting the flow through PICA but also helpful in assessing the aneurysmal occlusion. This technique allowed coils to be placed successfully without compromising flow through PICA.

Imaging Challenges in the Diagnosis of Anatomical Variations of the Supra-Aortic Vessels: A Case Report and Review of Literature

A 73-year-old woman was referred to our Cardiology Department due to recurrent headaches and dizziness. She had a history of hypertension of 10 years. In the territorial hospital, left internal carotid artery significant stenosis was suspected. Neurological examination and laboratory tests were normal. A neck vascular ultrasound was performed, showing a low bifurcation of the left common carotid artery (CCA) and a hypoplastic left internal carotid artery (ICA) with a sinuous path at the cervical level. Therefore, a computed tomographic (CT) angiography examination of the head and neck vessels was performed. The images confirmed the presence of a hypoplastic left ICA, anatomic variation in the left CCA, and also showed that the left vertebral artery (VA) was stemming directly from the aortic arch, exhibiting a kinking trajectory.

Endonasal Endoscopic and Transoral Approaches to the Craniovertebral Junction and the Clival Region

Introduction: The transoral approach was first described by Kanavel in 1917 to treat injuries of the craniospinal junction. In 2002, Frempong-Boaudu reported 7 adults who underwent endoscopically assisted transoral surgery, this was the first report that endoscope was used in an assisted manner for transoral surgery. In 2005, Kassam published the first report of an EEA being used to perform an odontoidectomy. Method: A descriptive, retrospective and linear study was carried out in 16 patients who underwent surgery using the microsurgical and endoscopic transoral and Extended Endoscopic Endonasal approach in the period from January 2004 to May 2021. Results: The average age of the patients was 45 years and there was a predominance of the male sex (10) with the female one (6). The tumoral pathology (9), 6 cases with histological diagnosis of clivus cordroma and 1 patient with chondrosarcoma, two cases with Meningioma and cholesterol granuloma of clival localization, achieving gross total resection in 2 of them and in the rest subtotal resection, all improved neurological symptoms. Complications, partial dehiscence of the velopalatine surgical wound 1 case, 1 lesion of the left vertebral artery and 1 case decompensated Diabetes Mellitus and hemoneumothorax during stay in the ICU, which death 7 days after surgery and 1 CSF fistula. Conclusions: Both, the transoral and endonasal endoscopic approaches have their precise indications in each particular case, having their indications well defined. To achieve this, we must have neuroimaging studies and be able to correctly define the selection of the surgical approach.

Transposition of Isolated Left Vertebral Artery in Hybrid Thoracic Endovascular Aortic Repair

Objectives: The aim of this study was to present our experience with the management of isolated left vertebral artery (ILVA) during complex thoracic aortic pathology treated with the hybrid thoracic endovascular aortic repair.Methods: This is a single-center, respective cohort study. Between June 2016 and June 2020, 13 patients (12 men; median age 60 years old, range 42–72 years old) who underwent hybrid procedures were identified with ILVA in our center. Demographics, imaging features, operation details, and follow-up in these patients were collected and analyzed.Results: In this study, all patients received the hybrid procedure, and the primary technical success rate was 100%. There were no in-hospital deaths. Complication occurred in two (15.4%) patients. One patient suffered from contrast-induced acute kidney injury (CI-AKI) and recovered before discharge. Another patient required reintervention for acute left-lower-limb ischemia, which was successfully treated using Fogarty catheter embolectomy. Immediate vagus/recurrent laryngeal never palsy, lymphocele, and chylothorax were not observed. The median duration of follow-up was 22 months (range, 13–29 months). No neurologic deficits, bypass occlusion, or ILVA occlusion or stenosis were observed during the follow-up. No aortic rupture, cerebrovascular accident, or spinal cord ischemia was observed during the follow-up period.Conclusions: Our limited experience reveals that hybrid procedures [thoracic endovascular aortic repair (TEVAR), ILVA transposition, and left common carotid artery-left subclavian artery (LCCA-LSA) bypass] are relatively safe, feasible, and durable for the treatment of thoracic aortic pathology with ILVA. However, further technique durability and larger studies with long-term follow-up periods are warranted.

Arteria vertebralis thrombosis egy 7 éves gyermekben

Összefoglaló. Az agyi érrendszer elzáródásos panaszai elsősorban felnőttkorban jelentkeznek, nem ritkák azonban gyermekek esetében sem. A gyermekkori stroke gyakorisága 2,5/1 000 000 fő; ilyenkor általában az arteria carotis interna vagy az arteria cerebri media érintett. Az ischaemiás stroke-ok 25%-a a hátsó keringési rendszer területén keletkezik. Az arteria vertebralis extracranialis szakaszának stenosisa 18%-ban a jobb oldalon, 22,3%-ban a bal oldalon észlelhető. Esetünkben egy 7 éves kisfiú kórtörténetét mutatjuk be, aki facialis paresis, súlyosbodó ataxia és somnolentia tüneteivel került egy megyei kórház gyermek intenzív osztályára. A készült kontrasztos koponya angiográfiás MR-vizsgálaton akut ischaemiás elváltozások voltak láthatók, valamint sejteni lehetett, hogy a bal oldali arteria vertebralis gracilisabb; a hypoplasia azonban csak a beteg egyetemi centrumba kerülése után, az ott elvégzett, a nyaki erekre is kiterjedő TOF - (time of flight) angiográfia és nyaki ultrahang készítését követően bizonyosodott be. A beállított gyógyszeres kezelések hatására az ischaemiát okozó artériás thrombus feloldódott, majd megkezdődött a rehabilitáció folyamata, melynek során a beteg állapota nagymértékben javult. A gyermek kórházba kerülése előtt hónapokkal észlelt, magatartás- és figyelembeli zavarainak romlása felveti a már korábban bekövetkező átmeneti ischaemiás periódusok lehetőségét is. A hátsó keringési rendszert érintő stroke-ok etiológiája változó, többször kerültek már leírásra különböző háttérrel. Esetünkben a fejlődési rendellenesség – ’bow hunter’ szindróma tűnik a legvalószínűbbnek. A készült dinamikus nyaki ultrahangvizsgálat is erre utaló eredményt adott. Időintervallumon belül szóba jöhet az arteria vertebralis thrombosis kezelése endovascularis módszerek segítségével is. Ennek kivitelezhetősége érdekében azonban fontos a mielőbbi pontos diagnózis felállítása a megfelelő képalkotó vizsgálatok segítségével és a betegnek a kezelésére felkészült centrumba juttatása. Orv Hetil. 2021; 162(47): 1902–1907. Summary. Cerebrovascular obstruction primarily affects adults, but it is not uncommon in children either. The incidence of childhood stroke is 2.5/1 000 000 population, usually affecting the internal carotid artery or the middle cerebral artery. The posterior circulatory system is involved in 25% of ischemic strokes. Stenosis of the extracranial section of the vertebral artery is demonstrated in 18% on the right side and 22.3% on the left side. We present the case history of a 7-year-old boy who was admitted to the pediatric intensive care unit of a county hospital with symptoms of facial palsy, progrediating ataxia and somnolence. Contrast-enhanced angiographic MR images of the skull revealed acute ischemic lesions and suggested stenosis of the left vertebral artery, then it was confirmed by TOF (time of flight) angiography of vessels of the neck and cervical ultrasound examination. The arterial thrombus causing ischaemia was eliminated by drug treatment and the rehabilitation process could be started. The patient’s condition improved considerably following that. Deterioration in behavioral and attentional problems of the patient, which had been realised months prior to hospitalisation, raises the possibility of earlier ischemic periods. The etiology of strokes affecting the posterior circulatory system has been described with different backgrounds. In the presented case, a developmental disorder – bow hunter’s syndrome seems to be the most likely one. The result of dynamic cervical ultrasound examination also supported this theory. Treatment of vertebral artery thrombosis with endovascular methods may also be considered within a time interval. However, to make it feasible, it is important to establish an accurate diagnosis as soon as possible by appropriate imaging studies, and to transfer the patient to a specialised center. Orv Hetil. 2021; 162(47): 1902–1907.

Endovascular treatment of tandemic occlusions in acute ischemic stroke

The observation of endovascular treatment of acute tandem occlusion of internal carotid artery (ICA), anterior cerebral artery (ACA) and middle cerebral artery (MCA) in combination with the thrombosis of the right ICA and the critical stenosis of the left vertebral artery is presented.Man, 61 years old. He was delivered to the Center of endovascular neuroradiology, NAMS of Ukraine on January 15, 2021 with an ischemic stroke clinic in the left internal carotid artery basin. He fell ill acutely ‒ against the background of complete well-being, sensorimotor aphasia and right-sided hemiplegia appeared. Upon admission on the NIHSS (National Institutes of Health Stroke Scale) ‒ 18 points. On the performed initial multispiral computed tomography of the brain according to ASPECTS (Alberta Stroke Program Early CT score) ‒ 8 points. In the endovascular operating room, cerebral angiography was performed, followed by surgery aimed at restoring cerebral blood flow. The time from the onset of the disease to the puncture was 330 minutes, the duration of the operation was 135 minutes, thus the time from the onset of the disease to reperfusion was 465 minutes. Angiography revealed acute thrombosis of the left ICA starting from the orifice, M1-segment of the left MCA and A2-segment of the left ACA. Partial compensation of the basin through the supra-block anastomosis (external carotid artery ‒ ICA), as well as from the vertebro-basilar system through the network of leptomeningeal arteries. Collaterals ‒ ACG 3. Thrombosis of the right ICA and critical stenosis (95 %) of the V1-segment of the left vertebral artery were also revealed. The operation was performed ‒ recanalization of thrombosis of the left ICA orifice followed by balloon angioplasty, thrombectomy from the MCA and ACA pools. The end result is eTICI 2c reperfusion. There were no complications during this operation. The patient was discharged the next day (transferred to the neurological department at the place of residence). Control multispiral computed tomography of the brain showed positive dynamics (ASPECTS ‒ 1 point).

Non-Standard Management of Target Vessels With the Inner Branch Arch Endograft: A Single-Center Retrospective Study

Purpose: The purpose of this study was to evaluate early and mid-term results of non-standard management of the supraaortic target vessels with the use of the inner branch arch endograft in a single high-volume center. Material and methods: A single-center retrospective study including all patients undergoing implantation of an inner branch arch endograft from December 2012 to March 2021, who presented a non-standard management of the supraaortic target vessels (any bypass other than a left carotid-subclavian or landing in a dissected target vessel). Technical success, mortality, reinterventions, endoleak (EL), and aortic remodeling at follow-up were analyzed. Results: Twenty-four patients were included. In 17 (71%) cases, the non-standard management was related to innominate artery (IA) compromise (12 with IA dissection, 2 with short IA, 2 with short proximal aortic landing zone that required occlusion of IA, 1 with occluded IA after open arch repair). Two (8%) cases were related to an aberrant right subclavian artery (RSA), 1 patient (4%) due to the concomitant presence of a left vertebral artery (LVA) arising from the arch and an occluded left subclavian artery (LSA), and another patient presented with an occluded LSA distal to a dominant vertebral artery. Three (13%) cases were exclusively related to management in patients with genetic aortic syndromes. Twenty (83%) patients had a previous type A aortic dissection. Ten (42%) patients presented a thoracic or thoracoabdominal aortic aneurysm and 8 (33%) patients an arch aneurysm, 6 of them associated to false lumen (FL) perfusion. There were 2 (8%) perioperative minor strokes, and 1 patient with perioperative mortality. Seven patients presented an early type I endoleak, all resolved at follow-up. Seven patients required reinterventions during follow-up (7 reinterventions related to continuous false lumen perfusion, 3 related to Type Ia endoleak, 2 related to surgical bypass). All patients who presented with FL perfusion had complete FL thrombosis at follow-up. No patient presented aneurysm growth at follow-up. Conclusions: The use of the inner branch arch endograft with a non-standard management of the supraaortic target vessels is a possible option. Despite a high reintervention rate, regression or stability of the aneurysmal diameter was achieved in all the patients with follow-up.