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1.  Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage Associated with Bilateral Common Carotid Artery Occlusion 
Interventional Neuroradiology  2009;14(4):447-452.
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.
PMCID: PMC3313813  PMID: 20557745
bilateral common carotid artery occlusion, cerebral aneurysm, endovascular coiling, balloon neck remodeling
2.  Unusual Intracranial Stent Navigation through the Circle of Willis in a Patient with Recurrent Basilar Tip Aneurysm during Stent-Assisted Coiling 
Interventional Neuroradiology  2009;15(1):81-86.
We describe a case of unusual Enterprise stent navigation through the Circle of Willis in a patient with a basilar tip aneurysm, left internal carotid artery (ICA) occlusion and previous right ICA stenting. Basilar tip aneurysms are known for their therapeutic challenges, especially when the posterior cerebral arteries (PCAs) are incorporated in the aneurysm neck. This becomes more technically demanding if the vertebral artery does not offer a route for stent navigation.
We undertook stent-assisted coiling using the horizontal stenting of posterior cerebral arteries via both the posterior and anterior communicating artery navigation. This was necessary because the vertebral arteries were very tortuous, hence not suitable for stent navigation due to their small size and stenosis at their origin. Another compounding factor was the anatomy of the aneurysm neck in relation to the T-shaped origin of both P1 PCAs from the basilar artery.
The right ICA was stented previously and the whole navigation was done through this stented artery as the opposite left ICA was occluded at the bifurcation. In addition, there was no visualized posterior communicating artery (PCOM) on the right side, so following navigation through the anterior communicating artery (ACOM) the left PCOM artery was catheterized to reach the PCAs. After horizontal placement of stent, coiling was performed for the residual aneurysm.
The outcome of this intervention revealed successful placement of the Enterprise stent in bilateral posterior cerebral arteries covering the aneurysm. Further coiling of the basilar artery aneurysm was done with a good result. No complication was seen in the angiography suite or later in the course of action.
Horizontal stent placement in wide-necked basilar aneurysms can be performed via the PCOM and ACOM arteries.
PMCID: PMC3306154  PMID: 20465934
Enterprise stent, navigation, circle of Willis
3.  Endovascular Treatment of Bilateral Carotid Artery Occlusion with Concurrent Basilar Apex Aneurysm: A Case Report and Literature Review 
We report a case of successful endovascular treatment of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. An elderly female patient with subarachnoid hemorrhage (SAH) onset was admitted to the hospital. Computed tomography (CT) and digital subtraction angiography (DSA) confirmed the presence of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. Brain blood supply was provided by the bilateral vertebral artery through the basilar artery. We treated the aneurysm with the endovascular approach by embolizing the aneurysm with three coils. The patient recovered well after surgery and showed no recanalization of the aneurysm on a one-year follow-up DSA. We also reviewed six similar cases found with a PUBMED database search (1980-2010), including those with bilateral common carotid artery occlusion. In conclusion, by using the endovascular approach, bilateral carotid artery occlusion with concurrent basilar apex aneurysm was efficiently treated.
PMCID: PMC3074092  PMID: 21487570
carotid artery occlusion; basilar apex aneurysm; endovascular treatment
4.  Thromboembolic Complication Induced Stable Occlusion of a Ruptured Basilar Tip Aneurysm 
Interventional Neuroradiology  2010;16(1):83-88.
We describe a case of a ruptured basilar bifurcation aneurysm that thrombosed during preparation for endovascular therapy as a complication of diagnostic angiogaphy, and showed a favorable evolution during long-term follow-up.
Endogenous thrombosis of ruptured, non giant aneurysms is uncommon. The persistence of occlusion over time in such cases is not well established.
Two weeks after rupture, a 6 x 8 mm basilar bifurcation aneurysm was referred for endovascular treatment. During preparation for endovascular coil occlusion, without having any endovascular material at the level of the basilar artery, a complete thrombotic occlusion of the basilar bifurcation and aneurysm was observed. Given the good collateral circulation for both posterior cerebral arteries no thrombolysis was undertaken. The early follow-up of seven days, three and six months showed a complete recanalization of the basilar artery and remodeling of the basilar bifurcation. The 20 months imaging follow-up demonstrated a small aneurysm regrowth at the prevoius location that remained stable during the follow-up of seven years. Unchanged biological and hemodynamic characteristics. however, may pose an elevated risk of a new aneurysm formation over time, making long-term imaging follow-up, and in case of progression, aneurysm occlusion necessary for the patient.
PMCID: PMC3277964  PMID: 20377984
cerebral aneurysm, subarachnoid hemorrhage, spontaneous thrombosis, wessel wall remodeling, aneurysm regrowth
5.  Ruptured Giant Basilar Artery Aneurysm in a Comatose Adolescent: Successful Obliteration Using Intraoperative SSEP, BAER, and MEP Monitoring 
Interventional Neuroradiology  2006;12(3):237-244.
Giant basilar aneurysms are infrequently seen in children. We present the endovascular management of an adolescent who presented comatose with pinpoint pupils due to a ruptured giant basilar trunk aneurysm. A noncontrast head CT disclosed a large prepontine lesion with brainstem hemorrhage. Catheter angiography showed a 4.5 cm irregular, fusiform basilar trunk aneurysm. With SSEP, BAER, and MEP monitoring, the patient underwent bilateral temporary vertebral artery occlusion, followed by GDC embolization of the aneurysm. Postprocedure internal carotid angiograms showed adequate blood supply to the basilar apex via patent posterior communicating arteries. On postprocedure day two, the patient was following commands.
The remainder of his hospital course was uneventful. Postoperative angiograms showed no residual filling of the aneurysm. At 12 months the patient was neurologically intact and at baseline function as an honor student and follow-up angiogram showed persistent occlusion of the aneurysm from the circulation. Successful endovascular treatment has been considered a less invasive and safer alternative to surgical management of some complex vascular lesions. While most reports on reversing basilar artery flow have been carried out in awake patients with neurological examinations, this is not possible in a patient presenting in a comatose state. This report suggests that SSEPs, BAERs and MEP may be of use in such patients in safely carrying out basilar artery occlusion.
PMCID: PMC3354541  PMID: 20569577
giant basilar aneurysm, aneurysm coiling, SSEP, BAER, MEP
6.  The sutureless excimer laser assisted non-occlusive anastomosis (SELANA); a feasibility study in a pressurized cadaver model 
Acta Neurochirurgica  2010;152(9):1603-1609.
To compare intracranial feasibility of the conventional Excimer laser assisted non-occlusive anastomosis (ELANA) with the new experimental sutureless ELANA (SELANA).
Four pressurized human cadaver heads were bilaterally trepanated, using a combined pterional/pretemporal/transcavernous approach. In each head, seven ELANA anastomoses and seven contralateral SELANA anastomoses were constructed on (1) the proximal PCA/basilar artery (P1 segment/basilar artery; BA), (2) the distal posterior cerebral artery (PCA, P2 segment), (3) the supraclinoidal internal carotid artery (ICA), (4) the ICA bifurcation, (5) the proximal anterior cerebral artery (ACA, A1 segment), (6) the proximal middle cerebral artery (MCA, M1 segment), and (7) the distal MCA (M2 segment).
In total, 26 of 28 ELANA anastomoses (93%) and 22 of 28 SELANA anastomoses (79%) could be completed. Two ELANA anastomoses on the BA could not be finished because of limited space. Six SELANA anastomoses could not be attached because the applicator did not facilitate an angulated anastomosis spot. Of the remaining anastomoses, more ELANA (eight) than SELANA (two) anastomoses could not be realized without manipulation of surrounding structures. The SELANA anastomoses were completed significantly faster than the ELANA, mean difference ranging from 11 min on the M2 to 107 min on the P1/BA.
This comparative study shows potential advantages of the SELANA anastomosis over the ELANA anastomosis because during application, it causes less manipulation of surrounding structures while it is faster and easier. Further preclinical research should be performed in order to improve SELANA feasibility on angulated anastomosis spots and to assess long-term SELANA patency and endothelialization.
PMCID: PMC2927684  PMID: 20589401
Cerebral revascularization; Bypass; ELANA
7.  Basilar Artery Aneurysm at a Persistent Trigeminal Artery Junction 
Interventional Neuroradiology  2011;17(3):343-346.
The trigeminal artery is an anastomosis between the embryonic precursors of the vertebrobasilar and carotid systems, and may persist into adult life. The association of the persistent primitive trigeminal artery (PTA) with cerebral aneurysm is well documented in the literature and, in general, aneurysms are located in the anterior circulation. We describe a patient who presented with a panencephalic Fisher III subarachnoid hemorrhage due to rupture of an intracranial aneurysm. Digital arteriography showed a saccular aneurysm in the middle third of the basilar artery, adjacent to the junction with a persistent trigeminal artery. She was submitted to endovascular treatment with embolization of the basilar artery aneurysm with coils. Aneurysms at the PTA junction with the basilar artery are rare. This paper describes a case of PTA associated with an aneurysm in the basilar artery at PTA junction and briefly reviews the literature.
PMCID: PMC3396038  PMID: 22005697
trigeminal artery, basilar artery, aneurysm, subarachnoid hemorrhage
8.  Initial Experience with the New Double-lumen Scepter Balloon Catheter for Treatment of Wide-necked Aneurysms 
Korean Journal of Radiology  2013;14(5):832-840.
A new double-lumen balloon catheter was being developed for the treatment of cerebral aneurysms. The purpose of this study is to report our initial experience of a double-lumen balloon catheter for the treatment of wide-necked aneurysms.
Materials and Methods
Seventeen patients (mean age, 63 years; range, 45-80 years) with wide-necked, with or without a branch-incorporated aneurysms, (10 ruptured and 9 unruptured) were treated with balloon-assisted coil embolization using a double-lumen balloon catheter (Scepter C™ or Scepter XC™) for 7 months after being introduced to our country. Locations of the aneurysms were posterior communicating artery (n = 7), anterior communicating artery or A2 (n = 7), middle cerebral artery (MCA) bifurcation (n = 3), basilar artery tip (n = 1) and anterior choroidal artery (n = 1). The initial clinical and angiographic outcomes were retrospectively evaluated.
Coil embolization was successfully completed in all 19 aneurysms, resulting in complete occlusions (n = 18) or residual neck (n = 1). In one procedure, a thrombus formation was detected at the neck portion of the ruptured MCA bifurcation aneurysm near to the end of the procedure. It was completely resolved with an intra-arterial infusion of Glycoprotein IIb/IIIa inhibitor (Tirofiban, 1.0 mg) without any clinical sequela. There were no treatment-related events in the remaining 18 aneurysms. At discharge, functional neurological state improved in 11 patients (10 patients with ruptured aneurysm and 1 with unruptured aneurysm presenting with mass symptoms) and 6 patients with unruptured aneurysms had no newly developed symptoms.
In this preliminary case series, the newly developed double-lumen Scepter balloon appears to be a safe and convenient device for coil embolization of wide-necked aneurysms.
PMCID: PMC3772268  PMID: 24043982
Intracranial aneurysm; Coil embolization; Balloon
9.  Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow 
Internal carotid artery (ICA) trapping can be used for treating intracranial giant aneurysm, blood blister-like aneurysms and ICA rupture during the surgery. We present a novel ICA trapping technique which can be used with insufficient collaterals flow via anterior communicating artery (AcoA) and posterior communicating artery (PcoA). A patient was admitted with severe headache and the cerebral angiography demonstrated a typical blood blister-like aneurysm at the contralateral side of PcoA. For trapping the aneurysm, the first clip was placed at the ICA just proximal to the aneurysm whereas the distal clip was placed obliquely proximal to the origin of the PcoA to preserve blood flow from the PcoA to the distal ICA. The patient was completely recovered with good collaterals filling to the right ICA territories via AcoA and PcoA. This technique may be an effective treatment option for trapping the aneurysm, especially when the PcoA preservation is mandatory.
PMCID: PMC2682127  PMID: 19444357
Blood-blister like aneurysm; Internal carotid artery; Trapping; Subarachnoid hemorrhage
10.  Glue Embolization of Ruptured Anterior Thalamoperforating Artery Aneurysm in Patient with Both Internal Carotid Arteries Occlusion 
Thalamoperforating artery aneurysms are rarely reported in the literature. We report an extremely rare case of ruptured distal anterior thalamoperforating artery aneurysm which was treated by endovascular obliteration in a patient with occlusion of both the internal carotid arteries (ICAs) : A 72-year-old woman presented with severe headache and loss of consciousness. Initial level of consciousness at the time of admission was drowsy and the Glasgow Coma Scale score was 14. Brain computed tomography (CT) scan was performed which revealed intracerebral hemorrhage in right basal ganglia, subarachnoid hemorrhage, and intraventricular hemorrhage. The location of the aneurysm was identified as within the globus pallidus on CT angiogram. Conventional cerebral angiogram demonstrated occlusion of both the ICAs just distal to the fetal type of posterior communicating artery and the aneurysm was arising from right anterior thalamoperforating artery (ATPA). A microcatheter was navigated into ATPA and the ATPA proximal to aneurysm was embolized with 20% glue. Post-procedural ICA angiogram demonstrated no contrast filling of the aneurysm sac. The patient was discharged without any neurologic deficit. Endovascular treatment of ATPA aneurysm is probably a more feasible and safe treatment modality than surgical clipping because of the deep seated location of aneurysm and the possibility of brain retraction injury during surgical operation.
PMCID: PMC3115150  PMID: 21716902
Anterior thalamoperforating artery; Aneurysm; Glue embolization
11.  Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms 
Interventional Neuroradiology  2011;17(1):36-48.
This report evaluated the short and midterm results of the safety and effectiveness of the treatment technique with hybrid and non-hybrid Y-configured, dual stent-assisted coil embolization of wide-neck intracranial aneurysms, and reviewed the literature concerning this technique.
Nine patients, eight with unruptured and one with ruptured aneurysms were included in the study. Of aneurysms embolized with a hybrid (with two different stents) and non-hybrid (with two identical stents) technique, three were located in the anterior communicating artery, three at the tip and one at the distal site of basilar artery, and two in the middle cerebral artery. All aneurysms included the orifices of bifurcation vessels. All aneurysms were stented and embolized during the same session. While Neuroform and Enterprise stents were used in the hybrid technique, two Enterprise stents were used in the non-hybrid technique.
Dual Y-stent assisted coil embolization was performed successfully in eight of nine patients (88.9%), including five patients (55.6%) with hybrid and three patients (33.3%) with non-hybrid technique. No procedural complication, no mortality and no minor or major neurological complications were seen during the angiographic or clinical follow-up. When an attempt was made at passing the second stent through the first Enterprise stent, the stent protruded inside the aneurysm in one patient (11.1%).
Hybrid or non-hybrid dual Y-stent-assisted coil embolization in the treatment of ruptured or unruptured wide-neck and complex intracranial aneurysms is a safe and effective method from the viewpoint of short and midterm results.
PMCID: PMC3278021  PMID: 21561557
intracranial aneurysm, stent, therapeutic embolization
12.  Sequential sidelong balloon remodeling technique in coil embolization of a wide-necked basilar tip aneurysm 
The use of balloon remodeling technique for coil embolization has developed into a safe alternative to stent assisted coil embolization for wide-necked aneurysms. Dual antiplatelet therapy when a stent is placed for assistance in the treatment of ruptured aneurysms is of concern. There are cases in which a single balloon seems insufficient to protect from coil herniation, like when two vessels are in the proximity of the side of the aneurysm neck. Techniques using two balloons for remodeling have been described; however, dual vascular access may be required. A case is presented in which a ruptured basilar tip wide-necked aneurysm was treated with a single balloon, using a sequential sidelong balloon remodeling technique. Complete embolization of the aneurysm was achieved maintaining patency of bilateral posterior cerebral arteries.
PMCID: PMC3694000  PMID: 23826436
13.  Left Internal Carotid Artery Agenesis Associated with Basilar and Left Vertebral Artery Aneurysm 
Agenesis of the internal carotid artery (ICA) is a rare congenital anomaly. Most of the patients are asymptomatic and it is usually discovered incidentally by computed tomography (CT) or magnetic resonance imaging (MRI). There is close association of the cranial aneurysms and subarachnoid hemorrhage with ICA agenesis. We present a case of a 61-year-old male with left ICA agenesis associated with basilar artery and left vertebral artery aneurysms. The patient complained of headaches and numbness on the right-side of the face. Physical examination showed high blood pressure (210/90 mmHg). Neurological examination revealed nystagmus and decreased sensation on the right-side of the face. Agenesis of left ICA, left carotid canal with basilar and left vertebral artery aneurysms were demonstrated incidentally using CT, MRI, and digital subtraction angiography, as a part of an evaluation for suspected cerebrovascular accident.
PMCID: PMC3261594  PMID: 22267995
Agenesis; basilar artery aneurysm; internal carotid artery
14.  Coil Embolization for Ruptured Cerebral Aneurysms of 2×3 mm Diameter 
Interventional Neuroradiology  2006;12(Suppl 1):97-100.
Small ruptured cerebral aneurysms, such as those of 2×3 mm diameter, are considered to be difficult to embolize by detachable coils because of the risk of procedural perforation of the aneurysms. We have treated these small aneurysms and report the techniques and pitfalls of these embolizations. Twenty-four patients with ruptured cerebral aneurysms of 2×3 mm diameter were intended for treatment by coil embolization. Before coil embolization, three-dimensional digital subtraction angiography was performed, and the simulation of the volume embolization ratio (VER) was performed in all patients, except for the first basilar artery aneurysm patient. The tip of the microcatheter was steam-shaped several times and was placed on the neck of the aneurysm. A balloon neck remodeling technique was used for two aneurysms. GDC 10 softs and soft SRs were used for the first ten aneurysms, and Ultrasofts were used for the last eleven aneurysms. Out of twenty-four aneurysm embolizations, we aborted the procedure in three cases, because of a failure in catheterization; we performed clipping surgery for these cases. For the first case of a basilar tip aneurysm, the aneurysm was perforated, due to the use of too long a coil and the insertion of the tip of the microcatheter into the aneurysmal dome. Minor infarction occurred in one patient.
The mean VER was 33.9%, and two aneurysms recanalized, and out of these one needed a second embolization. Six months postoperatively, 81% of patients had made in a good recovery or had a moderate disability. We recommend the following techniques to embolize aneurysms of 2×3 mm diameter: the tip of the microcatheter should be stabilized on the aneurysmal neck by steam shaping of the micro-catheter, GDC 10 soft and Ultrasoft should be selected for use, and the simulation of the VER should be performed before embolization to select coils of a suitable length.
PMCID: PMC3387975  PMID: 20569610
subarachnoid haemorrhage, cerebral aneurysm, endovascular surgery
15.  A case of unilateral moyamoya disease suffered from intracerebral hemorrhage due to the rupture of cerebral aneurysm, which appeared seven years later 
Whether unilateral moyamoya disease (MMD), confirmed by steno-occlusive lesion at the terminal portion of internal carotid artery with formation of moyamoya vessels unilaterally and normal or equivocal findings contralaterally, is an early form of definite (bilateral) MMD remains controversial. It is well-known that adult patients with MMD tend to suffer from cerebral hemorrhage, occasionally due to the rupture of aneurysm arising from moyamoya vessel.
Case Description:
A 61-year-old woman was diagnosed as unilateral MMD incidentally and followed by magnetic resonance imaging annually. Seven years after the diagnosis, cerebral aneurysm appeared on the moyamoya vessel. Before further examination, the aneurysm ruptured and resulted in massive cerebral hemorrhage.
Even in the unilateral MMD, cerebral hemorrhage may occur due to the rupture of cerebral aneurysm. Careful follow-up is recommended and early treatment is required once cerebral aneurysm is detected.
PMCID: PMC3589846  PMID: 23493840
Cerebral aneurysm; Intracerebral hemorrhage; moyamoya disease; Unilateral
16.  Non-aneurysmal subarachnoid hemorrhage as presentation of moyamoya disease in an adult 
The presentation of moyamoya disease (MMD) as an aneurysmal subarachnoid hemorrhage (SAH) is relatively frequent and in the absence of aneurysms is extremely rare.
Case Description:
A 53-year-old male patient suddenly developed severe headache associated with dysarthria and an altered state of consciousness. At the time of admission, he was found drowsy with global aphasia, stiff neck, right hemiparesis and right Babinski's sign. A non-contrast brain computed tomography was performed and a small bleeding in the subarachnoid space over the left frontal and parietal cortex was observed. Four-vessel cerebral angiography showed bilateral stenosis of the internal carotid arteries, with multiple tortuous vessels branching from the anterior and middle cerebral arteries. These abnormal vessels were anastomosing with branches from the posterior cerebral and middle meningeal arteries. With this information, a diagnosis of MMD was made. A three-dimensional reconstruction from digital angiography ruled out aneurysms or vascular malformations. After 4 weeks, another angiography was performed and remained the same as previous one.
Clinical and radiological characteristics of this case are consistent with previous reports, supporting the theory that non-aneurysmal SAH in MMD is caused by rupture of fragile moyamoya vessels.
PMCID: PMC3130362  PMID: 21748033
Moyamoya; subarachnoid hemorrhage; vascular anastomosis
17.  Association between Internal Carotid Artery Morphometry and Posterior Communicating Artery Aneurysm 
Yonsei Medical Journal  2007;48(4):634-638.
The goal of this study was to directly measure the association between the internal carotid artery (ICA) morphometry and the presence of ICA-posterior communicating artery (PCOM) aneurysm.
Materials and Methods
The authors intraoperatively measured the length of the supraclinoid ICA because it is impossible to radiologically determine the exact location of the anterior clinoid process. We used an image analyzer with a CT angiogram to measure the angle between the skull midline and the terminal segment of the ICA (ICA angle), as well as the diameter of the ICA. The lengths and diameters of the supraclinoid ICA and the ICA angle were compared among PCOM aneurysms, anterior communicating artery (ACOM) aneurysms, and middle cerebral artery (MCA) bifurcation aneurysms (n = 27 each). Additionally, the lengths and the diameters of M1 and A1 were compared for each aneurysm.
The lengths of the supraclinoid ICA were 11.9 ± 2.3mm. The lengths of the supraclinoid ICA in patients with ICA-PCOM aneurysms (9.7 ± 2.8mm) were shorter than those of patients with ACOM aneurysms (13.8 ± 2.2mm, Student's t-test, p < 0.001) and with MCA bifurcation aneurysms (12.2 ± 1.9 mm, Student's t-test, p < 0.001). The diameters of the supraclinoid ICA and A1 in patients with ACOM aneurysms were larger than those in patients with MCA bifurcation aneurysms (Student's t-test, p < 0.05). There were no significant differences in the lengths of M1 and A1, ICA angle, or diameter of M1 for each aneurysm.
These results suggest that the relatively shorter length of the supraclinoid ICA may be a novel risk factor for the development of ICA-PCOM aneurysm with higher hemodynamic stress.
PMCID: PMC2628055  PMID: 17722235
Internal carotid artery; morphometry; cerebral aneurysm
18.  Efficacy and Limitations of the Neuroform Stent System for Intracranial Aneurysms 
Interventional Neuroradiology  2008;10(Suppl 2):62-68.
We performed aneurysm embolization in seven patients using a self-expandable Neuroform stent (Boston Scientific/Target, Fremont, CA) and coils to cover the aneurysm neck and fill the aneurysm sac. Seven patients with an average age of 45 were treated in the period from October 2002 to July 2003.
The aneurysm lesions involved the basilar trunk in one case, the basilar-superior cerebellar artery in one case, the internal carotid artery in four cases, and the middle cerebral artery in one case. The ruptured lesions involved the internal carotid artery in one case and the middle cerebral artery in one case. We used a Neuroform stent measuring 4.5 × 20 mm in four cases, 4.5 × 15 mm in two cases, 3.5 × 20 mm in one case, and 3.5 × 15 mm in one case. We performed aneurysm coil embolization after Neuroform stenting in all cases without development of neurological deficits caused by the interventional procedure.
In performing these procedures, we investigated the efficacy and limitations of the Neuroform stent system for intracranial aneurysms. The advantages of Neuroform self-expanding stents include better flexibility and adaptability to different vessel sizes, but this stent system presents various technical difficulties during delivery.
PMCID: PMC3522224  PMID: 20587252
intracranial aneurysm, broad neck aneurysm, Neuroform stent and coils
19.  Carotid Blowout Treated by Direct Percutaneous Puncture of Internal Carotid Artery with Temporary Balloon Occlusion 
Interventional Neuroradiology  2006;11(4):349-354.
Direct percutaneous puncture of a cervical carotid pseudoaneurysm for coil placement or acrylic embolization is described for the endovascular management of acute carotid blowout. However, direct puncture of the internal carotid artery (ICA) for the endovascular management of carotid blowout has not been described.
We report a difficult case of acute carotid blowout syndrome in a patient who had radiation-induced occlusion of the right common carotid artery with vasculopathy and pseudoaneurysm in the right cervical ICA. Collaterals from the branches of the controlateral external carotid artery (ECA) anastomosed with branches of right ECA supplied the vasculopathy. We performed direct percutaneous puncture of the bulb of the right ICA using a spinal needle and placed fiber coils to occlude antegrade flow of the artery. During the injection of a mixture of N-butyl cyanoacrylate and lipiodol oil for embolization of the remaining carotid bulb, we transiently inflated an occlusion balloon in the controlateral common carotid artery to further arrest antegrade flow in the ICA. The vasculopathy and pseudoaneurysm of the right cervical ICA were successfully embolized, with preservation of the distal branches of the right ICA.
PMCID: PMC3399751  PMID: 20584447
carotid blowout, balloon occlusion, direct percutaneous puncture
20.  An Unusual Case of Fibromuscular Dysplasia with Bilateral Renal Macroaneurysms: Three-year Outcome After Endovascular Treatment 
Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-inflammatory and non-atherosclerotic disease that affects arterial walls, leading to stenosis of small and medium-sized arteries. FMD mostly involves renal and intracranial arteries and only in few patients is associated with macroaneurysms (RAAs). We present the case of a 45-years old woman with recent history of grade 2 hypertension that suffered of subarachnoid haemorrhage due to rupture of a basilar artery aneurysm. The cerebral aneurysm was immediately treated by coil embolization and an abdominal angio-CT scan was performed to investigate the presence of renovascular hypertension. The exam showed the presence of FMD of the renal arteries associated with presence of bilateral RAAs. Due to the high risk of rupture, the bigger aneurysm (2,5 cm diameter) present on the left artery was immediately treated by coil embolization. The fusiform aneurysm, present on the right renal artery, was instead treated one year later by using two flow diverter stents. After three years, an angiographic study showed that both cerebral and renal aneurysms were excluded from the blood flow without evidence of arterial restenosis.
PMCID: PMC3772574  PMID: 24044026
fibromuscular dysplasia; bilateral renal macroaneurysms; hypertension; endovascular treatment.
21.  Successful Coil Embolization for a "Three-Hump" Internal Carotid Artery Anterior Wall Aneurysm 
Interventional Neuroradiology  2007;12(4):345-350.
We describe an unusually shaped aneurysm arising from the anterior wall of the internal carotid artery (ICA) that was treated successfully with Guglielmi detachable coils (GDCs). A 38-year-old woman presented with sudden onset of headache and was transferred to our hospital. Computed tomography revealed thin subarachnoid hemorrhage in the basal cisterns. Three-dimensional rotational angiography clearly showed a "three-hump" anterior wall aneurysm of the ICA. The two distal humps of the aneurysm were successfully obliterated with GDCs, but the proximal hump was too small to treat by coil embolization. The patient was discharged without neurological deficit. Anterior wall (blisterlike) aneurysms of the ICA have a high risk of rupture due to fragility of the wall. These aneurysms are considered difficult to manage by traditional surgical approaches. Our experience suggests that endovascular GDC embolization is a good alternative treatment modality for patients with such an aneurysm.
PMCID: PMC3354606  PMID: 20569593
subarachnoid hemorrhage, anterior wall aneurysm, three-hump aneurysm, internal carotid artery, Guglielmi detachable coil
22.  Development of 'De novo' Aneurysm after Therapeutic Carotid Occlusion 
Carotid occlusion is an inevitable therapeutic modality for the treatment of complex aneurysms such as giant, traumatic, and intracavernous aneurysms. Late complications of carotid occlusion include 'de novo' aneurysm formation at a distant site because of hemodynamic changes in the circle of Willis. We report a case of de novo aneurysm in a vessel that appeared to be normal on initial angiography. The patient developed an anterior communicating artery aneurysm and marked growth of a basilar bifurcation aneurysm 9 years after trapping of the left internal carotid artery for the treatment of a ruptured large saccular aneurysm involving ophthalmic and cavernous segments. We propose that patients who undergo therapeutic carotid occlusion should be periodically followed by magnetic resonance angiography or computed tomographic angiography to evaluate the possibility of de novo aneurysm formation; this advice is in line with previous reports.
PMCID: PMC2682120  PMID: 19444350
De novo aneurysm; Carotid occlusion; Late complication; Magnetic resonance angiography; Computed tomographic angiography
23.  Intracranial Hemodynamic Changes During Adult Moyamoya Disease Progression 
Background and purpose
This study evaluated the changes in blood flow velocity in the anterior and posterior intracranial circulations according to the progression of moyamoya disease in adult patients.
We evaluated Suzuki's angiographic stage and mean blood flow velocity (MBFV) changes in intracranial vessels from both sides in 19 adult moyamoya patients. We then analyzed the linearity of MBFV changes from early to late moyamoya stages in each intracranial vessel using piecewise linear regression models.
The MBFV in the middle cerebral artery, terminal internal carotid artery, and anterior cerebral artery increased non linearly until stage III, and then decreased progressively up to stage VI. The ophthalmic artery also showed nonlinear velocity changes, with an increase in MBFV up to stage IV, followed by a decrease in MBFV up to stage VI. The MBFV of the basilar artery increased linearly from a normal velocity at an early moyamoya stage to a stenotic velocity at a late stage. There was no statistically significant regression model for the relationship between the MBFV in the posterior cerebral artery and moyamoya stage.
The nonlinear and/or linear MBFV changes associated with variable intracranial vessels might be useful in initial and follow-up evaluations of different stages of moyamoya disease.
PMCID: PMC2686870  PMID: 19513306
Moyamoya disease; Transcranial Doppler; Cerebral blood flow
24.  Preoperative Embolization of Brain Tumor with Pial Artery or Dural Branch of Internal Carotid Artery as Feeding Artery 
Interventional Neuroradiology  2006;12(Suppl 1):246-251.
This study evaluated the clinical usefulness of preoperative embolization of the pial artery or dural branch of the internal carotid artery (ICA) for brain tumor. Subjects comprised 17 patients with large hypervascular brain tumors who underwent preoperative selective embolization. Micro-catheters (2- or 1.7-F) and shapeable hydrophilic micro-guide wires were used for pial artery (branching from the posterior or anterior cerebral artery) or ICA dural branch embolization.
Embolization was performed under digital subtraction fluoroscopy with Polyvinyl alcohol (PVA) particles (150-250 mm) and/or liquid coil. Tumor resection was performed immediately or the day after embolization. Digital subtraction angiography (DSA) before and after endovascular devascularization, blood loss during tumor resection, and clinical outcome were evaluated. All endovascular procedures were technically successful. Post-embolization DSA revealed either a disappearance or a marked decrease of the tumor stain in all cases. Control of intraoperative bleeding was easily accomplished, and intraoperative blood loss was low. Preoperative particle embolization of the feeding artery from the cortical artery or ICA dural branch is safe and effective as adjuvant therapy before tumor resection.
PMCID: PMC3387962  PMID: 20569641
brain tumor, ICA; dural branch, cortical artery, feeder embolization
25.  Multimodal Treatment for Complex Intracranial Aneurysms: Clinical Research 
For patients with giant or dissecting aneurysm, multimodal treatment consisting extracranial-intracranial bypass surgery plus clip or coil for parent artery occlusion may be necessary. In this study, the safety and efficacy of multimodal treatment in 15 patients with complex aneurysms were evaluated retrospectively.
From January 1995 to June 2007, the authors treated 15 complex aneurysms that were unable to be clipped or coiled. Among them, nine patitents had unruptured aneurysms and 6 had ruptured aneurysms. Aneurysms were located in the internal cerebral artery (ICA) in 11 patients (4 in the dorsal wall, 4 in the terminal ICA, 1 in the paraclinoid, and 2 in the cavernous ICA), in the middle cerebral artery (MCA) in 2, and in the posterior circulation in two patients
Fifteen patients with complex aneurysms were treated with bypass surgery previously. Thirteen patients were treated with external carotid middle cerebral artery (ECA-MCA) anastomosis, and one patient with superficial temporal to posterior cerebral artery (STA-PCA) and another patient with occipital artery to posterior inferior cerebellar artery (OA-PICA) anastomosis. Parent artery occlusion was then performed with a clip in 9 patients, with a coil in 4, with balloon plus coil in one patient. All 15 aneurysms were successfully treated with clip or coil combined with bypass surgery. Follow-up angiograms showed good patency of anastomotic site in 10 out of 11 patients, and perfusion study showed sufficient perfusion in 6 out of 9 patients.
These findings indicate that for patients with complex aneurysms, clip or coil for parent vessel occlusion with additive bypass surgery can successfully exclude the aneurysm from the neurovascular circulatory system.
PMCID: PMC2612569  PMID: 19119468
Aneurysm; Clip; Coil; Bypass

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