Middle meningeal artery embolization for chronic subdural hematoma with cerebrospinal fluid hypovolemia: A report of 2 cases

BACKGROUND

Chronic subdural hematoma (CSDH) with cerebrospinal fluid hypovolemia syndrome (CHS) remains refractory to standard treatment with hematoma drainage by burr hole and irrigation and/or epidural blood patch. Previously, we reported the utility of middle meningeal artery (MMA) embolization for intractable CSDH. In this study, we present the usefulness of MMA embolization as a treatment for CSDHs with CHSs.

CASES

We present two cases of CSDHs with CHSs occurring in patients, 1 treated with burr hole craniotomy and irrigation, and the other treated with the epidural blood patch. Both patients exhibited similar-appearing bilateral relatively-thin hematomas, hyperplasia, and enhanced contrast effects in the dura mater, and extradural hygroma in the cervical portion on enhanced magnetic resonance imaging scans. Also, to reviewing prior literature and imaging findings, they had already undergone conventional treatment. We added MMA embolization treatment and they followed a good course.

RESULTS

Despite the known intractable outcomes of patients with CSDHs with CHSs, MMA embolization worked well in the current case series.

CONCLUSION

MMA embolization might be considered as a preferred therapeutic option for CSDHs with CHSs in order to buy time before the epidural blood patch starts working.

Recanalisation of the internal carotid artery via the vasa vasorum after coil occlusion

Antegrade recanalisation of a completely occluded internal carotid artery (ICA) via the vasa vasorum is extremely rare. Here, we report such a case after proximal endovascular coiling in a case of dissected (i.e. non-atherosclerotic) ICA. A 42-year-old man presented with thromboembolic stroke of the left frontal lobe owing to pseudo-occlusion of the left ICA manifesting as motor aphasia and right hemiparesis. There were abundant floating thrombi in the petrous portion of the left ICA. Because of good collateral flow in the left middle cerebral artery territory through the anterior communicating artery and external carotid artery system, endovascular coil embolisation of the left ICA was performed for prevention of further thromboembolic stroke. The patient showed progressive recovery following endovascular treatment, and was discharged with mild right hemiparesis 1 month later. He maintained a regimen of aspirin and physical rehabilitation. At follow-up, 38 months later, the patient was asymptomatic. Angiography demonstrated occlusion of the left ICA and multiple serpiginous vessels originating from the proximal internal and external carotid arteries and which filled the ICA distal to the occlusion. This case suggests that an ICA occluded by proximal coil embolisation-even in a non-atherosclerotic case-might be recanalised via the vasa vasorum.

Endovascular treatment of aneurysmal subarachnoid hemorrhage associated with bilateral common carotid artery occlusion

SUMMARY

Cases of aneurysm associated with the occlusion of both common carotid arteries are very rare.We present a case of ruptured aneurysms of the basilar bifurcation and posterior cerebral artery coexisting with bilateral common carotid artery occlusion, successfully treated by endovascular coil embolization with a double-balloon remodeling technique. Finally, we review the literature. A 62-year-old woman presented with severe headache; a computed tomography scan demonstrated subarachnoid hemorrhage. Angiography revealed that the bilateral common carotid arteries were occluded. The muscle branches of the vertebral arteries had anastomosed to the bilateral external carotid arteries. Bilateral posterior communicating arteries had developed and supplied the bilateral internal carotid arteries. Two aneurysms (a saccular aneurysm of the P1 portion of the left posterior cerebral artery and a wide-necked aneurysm of the basilar bifurcation) were also observed. Endovascular embolization of the aneurysms was successfully performed using a double-balloon remodeling technique. The patient made a full recovery after treatment, and the aneurysms remained obliterated 12 months after embolization. We believe that this is the first report of ruptured aneurysms associated with bilateral common carotid artery occlusion successfully treated by endovascular coiling. The double-balloon remodeling technique was useful for treatment of wide-necked basilar bifurcation aneurysm.

Unusual variant of persistent primitive hypoglossal artery

Here, we present a case of an unusual variant of a persistent primitive hypoglossal artery, which was found incidentally during an examination for a hypertensive thalamic haemorrhage. The anastomotic vessel arose from the external carotid artery and joined the vertebral artery through the hypoglossal canal. The embryology of the anomaly is briefly discussed.

Early embolization for ruptured aneurysm in acute stage of subarachnoid hemorrhage with neurogenic pulmonary edema

SUMMARY

Four cases of ruptured aneurysmal subarachnoid hemorrhage (SAH) presented with severe neurogenic pulmonary edema (NPE). On admission, two patients were grade IV and two were grade V according to Hunt and Hess grading. All patients needed respiratory management with the assistance of a ventilator. Three of them underwent endovascular treatment for the ruptured aneurysms within three days from onset after ensuring hemodynamic stability. Immediately after the endovascular treatment, lumbar spinal drainage was inserted in all the patients. The pulmonary edema findings disappeared rapidly after the respiratory management. The results were good recovery in two, and moderate disability in two. We concluded that early embolization of ruptured aneurysm and placement of spinal drainage is a satisfactory option for severe SAH with NPE.

Embolization of cerebral arteriovenous malformations with cellulose acetate polymer. Histological study of the resected specimens

SUMMARY

To test the usefulness of a cellulose acetate polymer(CAP) solution for brain arteriovenous malformations (AVMs), we analyzed the clinical and histological results of patients with AVMs embolized using CAP solution. We reviewed the cases of six patients with cerebral AVMs treated by embolization prior to surgical resection. We used two types of CAP solutions, CAP-M and CAP-L, which are mixtures of 250 mg of solid CAP and 1800 or 2250 mg of bismuth trioxide dissolved in 5.5 or 7.0 ml of dimethyl sulfoxide, respectively. All patients underwent surgical resection 1 to 37 days after the embolization procedure. Resected specimens were fixed in formalin and stained for light microscopic examination. Eighteen feeding vessels were embolized. The reduction rate of the nidus volume was between 20% and nearly 100%. Mild ischemic deficits occurred in one patients but there were no hemorrhagic complications related to the embolization procedures. All AVMs were completely resected by surgery. Direct inspection at surgery revealed that there was no apparent swelling or hematomas in the normal brain areas adjacent to the nidus, and the AVMs were soft enough to be easily retracted. The histological examinations disclosed no or mild inflammatory reactions within two weeks after embolization. The internal elastic lamina was preserved in every case. Recanalization of embolized vessels was not observed until 37 days after embolization. CAP solution is a safe and useful embolic agent for brain AVMs. Further study is needed to resolve the issue of recanalization.

Combined use of cellulose acetate polymer and retrievable platinum coils for the thrombosis of cervical carotid aneurysms

Cellulose acetate polymer (CAP) solution is a new liquid embolic material, and it has been used clinically for the thrombosis of cerebral aneurysms. The purpose of the study was to test a method of aneurysm treatment. In an experimental model, retrievable interlocking detachable coils (IDCs) were used to create an intraaneurysmal frame or prop and then CAP was injected into 20 experimentally induced canine cervical aneurysms. Intraaneurysmal thrombosis was induced 1 week after aneurysm creation. Complete thrombosis was attempted in 12 aneurysms, and partial thrombosis was attempted in 4. Four other aneurysms served as controls. Follow-up angiography was performed for up to 8 weeks, and with the exception of 4 aneurysms, which were kept for a 2-year long-term follow-up study, the aneurysms were then harvested for histological examination. Thrombosis was successfully achieved in all cases except for 2 enlarged aneurysms that were initially partially thrombosed. No thromboembolism to distal vessels was observed. No compaction or shift of the CAP-IDC complex occurred even after 2 years. Histologically, CAP and IDCs conformed to the massive thrombotic complex without any fragmentation. By creating a frame or prop with retrievable microcoils, we were able to inject the CAP implies a comparison safely and precisely than has been previously reported. Our findings suggest that this method will be useful for the treatment of cerebral aneurysms.

Experimental study of intracisternal administration of tissue-type plasminogen activator followed by cerebrospinal fluid drainage in the ultra-early stage of subarachnoid haemorrhage

This experimental study evaluated the effect of intrathecal injection of tissue-type plasminogen activator followed by cisternal drainage in the ultra-early stage of aneurysmal subarachnoid haemorrhage to prevent vasospasm. Twenty Japanese white rabbits were divided into five groups. Either tPA (groups A, B, and E) or saline (groups C and D) was injected intrathecally 1 hour (groups A, B, C, and D) or 21 hours (group E) after the intrathecal injection of blood. Cerebrospinal fluid was drained 2, 4, and 6 hours after the intrathecal injection of blood (groups A, C, and E). On day 4, the angiographic caliber of the basilar artery in each group was as follows (mean +/- SD): A, 85.9 +/- 5.0%; B, 74.6 +/- 5.3%; C, 69.1 +/- 2.7%; D, 64.0 +/- 4.9%; E, 80.2 +/- 2.7% (compared with baseline). In the two groups in which CSF was drained (groups A and C), fibrinolysis with tPA significantly suppressed vasospasm. In the two groups treated with tPA (groups A and B), cisternal drainage significantly suppressed vasospasm. In the two groups treated with saline (groups C and D), however, cisternal drainage did not suppress vasospasm. Examination of the series of CSF samples (groups A and C) showed that fibrinolysis with tPA effectively cleared clots early. In the two groups treated with tPA and CSF drainage (groups A and E), early removal of subarachnoid clots reduced the degree of vasospasm. Early fibrinolysis with tPA and early removal of subarachnoid clots by drainage is effective for preventing vasospasm.

Embolization of cerebral arteriovenous malformations with cellulose acetate polymer: a clinical, radiological, and histological study

OBJECTIVE

A cellulose acetate polymer (CAP) solution was hypothesized to be useful for the embolization of arteriovenous malformations (AVMs). To investigate this possibility, we analyzed the clinical, radiological, and histological results of patients with AVMs embolized by using a CAP solution.

METHODS

We reviewed the cases of 11 patients with AVMs treated by embolization before surgical resection. We used two types of CAP solutions, CAP-M and CAP-L, which are mixtures of 250 mg of solid CAP and 1800 or 2250 mg of bismuth trioxide dissolved in 5.5 or 7.0 ml of dimethyl sulfoxide, respectively. After the embolization procedure, percent reduction of the nidus volume was measured, and thereafter, the clinical course and computed tomographic scans and/or magnetic resonance imaging scans were evaluated. All patients underwent surgical resection 1 to 51 days after embolization. Resected specimens were stained for light microscopic examination.

RESULTS

Thirty-nine feeding vessels were embolized. The reduction rate of the nidus volume ranged from 20% to nearly 100%. Transient and persistent ischemic deficits occurred in three patients and one patient, respectively, and there were no hemorrhagic complications. All AVMs but one were completely resected by surgery. The embolized AVMs were soft enough to be easily cut and retracted. The histological examinations disclosed no or mild inflammatory reactions within 2 weeks after embolization. The internal elastic lamina was preserved in every case. Recanalization through the cast of the CAP mass was not observed until 51 days after embolization.

CONCLUSION

CAP solution is a safe and useful embolic agent for AVMs.

Partial thrombosis of canine carotid bifurcation aneurysms with cellulose acetate polymer

OBJECTIVE

To investigate the usefulness of a cellulose acetate polymer (CAP) solution for partial thrombosis of aneurysms.

METHODS

We created 14 canine cervical carotid bifurcation aneurysms, 11 of which were subsequently thrombosed partially with CAP solution. We then conducted angiographic and histological investigations.

RESULTS

Nine aneurysms were thrombosed 50 to 70% by volume, although a significant crescent crevice between the aneurysmal sac and the CAP mass was left in four of the aneurysms. In the remaining two aneurysms in which a crescent crevice had been seen in the initial stage of CAP injection, 80% and more than 95% thrombosis were needed to occlude the crevice, respectively. Follow-up angiograms of the seven aneurysms with no crescent crevice revealed no shifts of position of the CAP mass toward the bottom of the aneurysm sac, but slight ballooning of the remnants was observed in two of them. The angiograms of the other four aneurysms with significant crescent crevices demonstrated rupture with a massive hematoma in one and shifts of the CAP mass with marked enlargement of remnants in three. Histologically, the seven aneurysms with no enlarged remnants had newly developed membranes consisting of endothelium, infiltrated spindle-shaped cells, collagen, and elastic fibers. In contrast, in the three markedly enlarged aneurysms, there were only recent clots between the CAP mass and the aneurysm lumen and no development of endothelium.

CONCLUSION

Partial thrombosis with CAP solution is useful to keep aneurysms in a stable configuration, unless a crescent crevice has been left.

Long-term results of surgically treated moyamoya disease

Various surgical procedures have been tried for patients with Moyamoya disease. The most effective treatment, however, is still controversial. We retrospectively evaluated the long-term results of 71 patients (26 men and 45 women) with Moyamoya disease surgically treated in our institute. They consisted of 56 pediatric patients (younger than 15 years) and 15 adult patients. Symptoms in all patients were due to cerebral ischemia. We did 123 operations on 119 hemispheres: 18 superficial temporal artery--middle cerebral artery (STA-MCA) anastomoses, six STA-MCA anastomoses with indirect bypass (IB), 41 encephalo-duro-arterio-synangiosis (EDAS), 29 encephalo-duro-arterio-myo-synangiosis (EDAMS) and 29 ribbon EDAMS. Average follow-up periods for each procedure were: 7 years for STA-MCA anastomosis, 6.2 years for STA-MCA anastomosis with indirect bypass, 11 years for EDAS, 5.6 years for EDAMS and 2.6 years for ribbon EDAMS, respectively. The results of each procedure were satisfactory because the preoperative transient ischemic attacks disappeared. Analysis of follow-up angiograms shows excellent filling of the ACA and MCA territory in the patients undergoing ribbon EDAMS. However, long-term follow-up study shows that about 10% of the patients had severe difficulty in social or school life because of intellectual impairment.

Long-term follow-up study of patients with unilateral moyamoya disease

Although a number of cases of unilateral Moyamoya disease have been reported, the natural history of this disease remains unclear. The clinical features of 17 patients initially diagnosed with unilateral Moyamoya disease at our hospital are reported. Age at onset was 3-45 years (mean, 13.5). Of these 12 cases had onset of symptoms in childhood and five had onset in adulthood. Seven were male and 10 were female. An ischemic attack was the initial episode in ten of the 12 pediatric cases, two of the five adult cases presented with intraventricular hemorrhage. Of the 12 pediatric patients six developed contralateral lesions between 4 and 34 months (mean, 20) after the diagnosis of a unilateral lesion. The remaining six pediatric patients and all adult patients did not develop lesions on the normal side. The mean age at onset for patients later developing contralateral lesions was 6.2 years. The pediatric cases remaining unilateral was 7.7 years. The normal hemisphere of three of the pediatric patients has remained unchanged on repeated follow-up angiograms for over 10 years. Young children tended to develop the vascular pathology bilaterally. However, there were some pediatric cases whose normal or atypical sides remained unchanged without development of bilateral lesions.

Early treatment of subarachnoid hemorrhage after preventing rerupture of an aneurysm

Twelve patients with Hunt and Hess neurological Grades III to V underwent thrombosis of aneurysms using cellulose acetate polymer within 23 hours of aneurysm rupture. On computerized tomography (CT), nine of these patients had difuse or localized thick subarachnoid blood clots, two had diffuse thin clots and one had intraventricular clots. Immediately after thrombosis, all patients were administered tissue plasminogen activator (TPA) through spinal or ventricular catheters. The pressure of the lumbar cerebrospinal fluid was maintained at 100 to 150 mm H2O. The TPA was given as multiple injections of 2 mg on Day 0 and 1 to 2 mg on the following 1 to 2 days. In two patients the second injection of TPA was not given because of severe brain damage resulting from the initial subarachnoid hemorrhage. Ten patients showed complete clearance of the cisternal clot on CT within 72 hours after thrombosis. Seven partially thrombosed aneurysms and five multiple aneurysms were clipped during delayed surgery. Only one patient experienced mild vasospasm as shown on the follow-up angiogram. Eight patients improved clinically and had a good recovery, two had severe disability, and two died. Urgent thrombosis of a ruptured aneurysm followed by immediate postthrombotic administration of TPA may be a safe and reasonable means of preventing vasospasm and improving patient outcome.

Histochemical demonstration of free radicals (H2O2) in ischemic brain edema and protective effects of human recombinant superoxide dismutase on ischemic neuronal damage

A new histofluorescence method by HPAA (p-hydroxyphenyl acetic acid) for free radicals in the brain tissue was devised to study neuronal damage induced by ischemia. Cerebral ischemia was produced in rats by injection of plastic microspheres and arachidonic acid (AA) into the right carotid artery. The concentration of malondialdehyde (MDA; free radical) in cerebral cortex of aminotriazol (an H2O2-dependent inhibitor of catalase) treated rats 2 h after stroke was 6.33 times the level before infarction, while the concentration of MDA in h-r SOD (free radical-scavenging enzyme) treated rats 2 h after stroke was significantly lower than in untreated rats. The histochemical findings demonstrated marked H2O2 production around blood vessels occluded by microspheres in the cerebral cortex of the aminotriazole treated rats 2 h after stroke together with disruption of the BBB. Light microscopical findings demonstrated extensive edematous changes in the aminotriazole treated rats 2 h after stroke, while pathological damage in SOD treated rat brains was absent or minimal. We conclude that free radicals are formed during ischemia, and that AA appears to be a major source of activated oxygen radicals. The findings indicate that SOD is protective against ischemia-induced neuronal damage.