- 著者
- Miyahito Kugai Takehiro Suyama Masahiko Kitano Yoshiko Tominaga Shinsuke Tominaga
- 出版者
- The Japanese Society for Neuroendovascular Therapy
- 雑誌
- Journal of Neuroendovascular Therapy (ISSN:18824072)
- 巻号頁・発行日
- pp.cr.2022-0032, (Released:2022-08-10)
- 参考文献数
- 21
Objective: Treatment of large posterior cerebral artery (PCA) aneurysm involving the P1–P2 segment is difficult by both neurosurgery and endovascular treatment. Balloon occlusion test (BOT) to identify precise peripheral collateral flow is difficult prior to parent artery occlusion (PAO). Besides, PAO at the aneurysm at this location can cause peripheral cortical infarction of the occipital and temporal lobes and/or perforator infarction involving the midbrain and thalamus perfused by the perforating artery arising from the P1–P2 segment. However, detection of the perforator during PAO is difficult.Case Presentation: The patient was a 49-year-old woman. At the age of 43 years, a right large PCA aneurysm was discovered in the right P1–P2 segment. A simple technique coiling was performed. As recurrence was identified 1 year later, embolization was performed using a same procedure. Since further recurrences were later found, a third round of treatment was planned. Somatosensory-evoked potential (SEP) was recorded as intraoperative electrophysiological monitoring. Tortuosity of the right PCA was observed at the aneurysm neck and the distal right PCA could not be secured. We could neither perform stent-assisted coil embolization nor BOT in the right PCA. Hence, we inflated the balloon in the basilar artery and checked the collateral circulation routes retrograde into the right PCA from the right middle cerebral artery via a leptomeningeal anastomosis. PAO was performed on the right P1–P2 segment at the aneurysm neck. The signal of the SEP was not decreased, and the aneurysm was not visualized. Another coil was added to strengthen the PAO to the right P1 segment, which decreased the SEP amplitude in the extremities by 3 minutes after. As the last coil was thought to be occluding the perforator branching from the right P1 segment, it was removed without detaching. The SEP amplitude began to improve and recovered by 9 minutes after. There was no postoperative deficit. No recurrence of aneurysm was observed on MRA 9 months postoperatively.Conclusion: During PAO at the P1 segment of large PCA aneurysm involving the P1–P2 segment, SEP may be helpful to prevent perforator infarction, even if perforating artery originating from the proximal portion of the aneurysm was not detected by angiography.
- 著者
- Miyahito Kugai Takehiro Suyama Masahiko Kitano Yoshiko Tominaga Shinsuke Tominaga
- 出版者
- The Japanese Society for Neuroendovascular Therapy
- 雑誌
- Journal of Neuroendovascular Therapy (ISSN:18824072)
- 巻号頁・発行日
- vol.14, no.9, pp.381-389, 2020 (Released:2020-09-20)
- 参考文献数
- 20
Objective: In cases of cerebral arteriovenous malformation (AVM) in which perforators are involved as feeder, hemostasis is difficult during surgical removal and postoperative hemorrhage may develop. If possible, presurgical embolization should be performed. However, when the anterior choroidal artery (AChA) is the feeder, the risk of embolization is particularly high, and there are few reports describing this situation. Authors report the treatment results of five cases of AVM in which a single operator performed presurgical embolization through the AChA and describe the technique with a review of the literature.Case Presentations: Of the five total cases (three men and two women; average age was 43.4 years [28–68 years]), one case presented with hemorrhage, two with epilepsy, the other ones with headache and trigeminal neuralgia, respectively. The lesions were located in the frontal lobe in one case and in the temporal lobe in four cases. On the Spetzler-Martin (SM) grading scale, four cases were grade III and one was grade IV. The eloquent area was involved within the nidus in four cases. Multimodal treatment was planned because all cases were high-grade AVM. Authors thought that performing presurgical embolization through the AChA would reduce the overall risk of treatment and performed the presurgical embolization. The embolization was possible in all cases, and the AVM was not angiographycally visible through the AChA in three cases. The blood flow through the AChA was reduced in two cases. All cases were awake immediately after embolization and no case had neurological symptom after embolization. CT or MRI after embolization revealed asymptomatic infarction in two cases. The AVM was removed safely without difficulty including hemostasis.Conclusion: In this series, there were no morbidity and embolization was performed relatively safely. Embolization through the AChA was suggested to be an effective treatment, but careful consideration is required in each individual case.