T2 Star weighted MR angiography (SWAN) showed microbleeds in the left white matter, indicating...
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T2 Star weighted MR angiography (SWAN) showed microbleeds in the left white matter, indicating endothelial damage and blood brain barrier disruption. Perfusion-MRI showed no area of decreased CBF. After procedure,peri- aneurysmal edema gradually remissions Purpose : Post embolization high intensity signal areas in FLAIR MRI images (HISA) are infrequent. Pathogenesis of HISA that appeared following endovascular treatment was poorly understood. In this presentation,we demonstrated 6 cases of cerebral lesion after coil embolization, and the mechanism of lesion appearance was discussed. Case １ 74 y.o. Female Case3 58 y.o. Female Case2 78 y.o. Female Lesion ： Lt.IC-PC. AN. neck/dome/depth(mm) ： 8.21/12.62/14.38 Unrupture Procedure ： Balloon Assist Contrast agent ： Iohexol 223ml VER ： 27.7% neck remnant Bioactive coil ： used （ unlabel and coil maigration to parent artery ） 頭頭 MRI 頭頭頭頭頭頭頭頭 ： Lesion ： A com. AN. neck/dome/depth(mm) ： unknown Unrupture Lesion ： Lt.BA-SCA AN. neck/dome/depth(mm) ： 7.07/7.77/9.81 Rupture → SAH Hunt and Hess 2/Fisher 4 Procedure ： unknown Contrast agent ： unknown VER ： unknown neck remnant Bioactive coil ： unknown POD1264 re- embolization Procedure ： single catheter Bioactive coil ： none Procedure ： single catheter Contrast agent ： Iohexol 143ml VER ： 28.4% neck remnant Bioactive coil ： none POD391 re- embolization Procedure ： Balloon Assist Bioactive coil ： used B-MRI ： peri-aneurysmal edema was found, and exacerbated gradually. B-MRI ： coil compaction and peri-aneurysmal edema are found. The edema was exacerbated gradually B-MRI ： coil compaction, peri-aneurysmal edema, and brainstem compression are found. POD385 POD6 POD566 POD1206 POD1889 POD7 POD92 POD329 POD536 １． Department of Endovascular Neurosurgery ＠ International Medical Center,Saitama Medical University ２． Department of Neurology @ Nara City Hospital ASNR 2015 EP-99 High Intensity Signal Areas in FLAIR MRI (HISA) after Coil Embolization to Cerebral Aneurysms: Case series Yoshiaki Kakehi, Eisuke Tukagoshi, Jun Niimi, Hiroaki Neki, Nahoko Uemiya, Koji Mizogami, Shinya Kohyama , Fumitaka Yamane, Shoichiro Ishihara Conclusions : The mechanisms of HISAs after coil embolization were unknown, the adverse in ammatory reactions were proposed. Some of these cases seem to be curable in use of fl steroid, we should take care of not only to the appearance of neurologic deficits but HISA in brain parenchyma. Case4 58 y.o. Female Lesion ： Lt.IC-Oph A. AN. neck/dome/depth(mm) ： 5.33/7.28/5.49 Unrupture Procedure ： Balloon Assist Contrast agent ： Iohexol 316ml VER ： 21.9% Complete obliteration Bioactive coil ： none On POD39, higher brain dysfunction was developed. MMSE 25/30. The cerebrospinal fluid exhibited a protein level at 46 mg/dL. ・ The mechanism of blood brain barrier disruption could be explained with contrast agents causing endothelial cell shrinkage and opening of tight junctions. In the territory of the artery disrupted blood brain barrier, white matter exposure to allergen. At that time, we think T-cell activation is induced, and allergens of each cases induced an ADEM-like reaction with a T cell–mediated autoimmune process. The CSF results lend further credence to this hypothesis. ・ The unilateral involvement could be explained by the fact that the BBB disruption was limited to areas of higher and more intense contact with contrast agents. ・ In case4, platinum or Iohexol are predicted as allergen. And in case5, nickel, involved the stent used for coil embolization assist, is predicted as allergen by patch testing, not platinum, because this symptom was’nt found at Postoperative CT: Case6 63 y.o. Female Lesion ： Rt.IC-PC. AN. neck/dome/depth(mm) ： 3.31/11.9/13.1 Unrupture Procedure ： Double Catheter Contrast agent ： Iohexol 57ml VER ： 43.4% complete obliteration Bioactive coil ： none Although there were no symptoms, f/u MRI showed multiple lesions in the white matter and occipital cortex in the territory of the right middle cerebral artery (MCA). Perfusion-MRI showed decreased CBF within the lesions. POD239 re- embolization Procedure ： Balloon Assist Bioactive coil ： used Discussion of pathology in case4 and 5 ADEM-LIKE REACTION ANEURYSM COILING Leonardo et al. Neurosurgery 66:, 2010 Discussion of pathology in case6 Delayed thrombus formation due to a coil loop migration into the parent artery Discussion of pathology in case1, case2, and case3 Postembolization perianeurysmal edema ・ Although mimicking case 4 and 5, rt. parietal cortex was involved in HISA in FWI. Besides, P-MRI showed decrease in cerebral blood flow at the lesion, and the protein in cerebrospinal fluid was normal, different from case4 and 5. ・ We think the HISA in this case is due to thrombus with small coil loop migration into the parent artery. POD39 POD58 POD90 Extravasation of contrast agent was found,indicati ng blood brain barrier disruption. Post operative CT didn’t show extravasation of contrast agent and edema of cortex. POD132 POD140 POD253 Case5 39 y.o. Female Lesion ： Rt.IC- dorsal. AN. neck/dome/depth(mm) ： 4.8/4.6/3.2 Unrupture Procedure ： Stent Assist Contrast agent ： Iopamidol 50ml VER ： 23.9% Body filling Bioactive coil ： none Postoperative CT: Edema of right cortex was found, not entirely Blood Brain Barrier disruption. POD27 POD38 POD45 POD1630 After procedure,peri- aneurysmal edema gradually remissions After procedure,peri-aneurysmal edema remissions transiently, but coil compaction and aneurysm expansion were found gradually, and peri-aneurysmal edema was exacerbated. MRI showed multiple lesions in the left white matter were found. We have no COI with regard to our presentation. After administration of intravenous methyl-prednisolone at a dose of 1,000 mg/day for 3 days, the symptoms were almost completely resolved. MRI showed a reduction in the size of the lesions. Perfusion-MRI showed no areas of decreased CBF. On POD27, the patient got an epileptic seizure. MRI showed multiple lesions in the left white matter. The cerebrospinal fluid exhibited a protein level at 58 mg/dL. After administration of intravenous methyl- prednisolone at a dose of 1,000 mg/day for 3 days/weeks, for 3weeks, MRI demonstrated almost complete resolution. The cerebrospinal fluid exhibited a normal protein level. Followed closely without treatment, the leisons gradually remissions. small coil loop migration into the parent artery. Past Hitory : At 37 y.o. SAH with left vertebral artery dissection, performed parent artery embolization. Refference s Kyriakos, et al. Neurology 84.1 (2015): 97-99. Horie, Nobutaka, et al. Journal of neurosurgery 106.5 (2007): 916-920. DEUS-SILVA, Leonardo, et al. Neurosurgery, 2010, 66.1: E222-E223. Cohen, José E., et al. Journal of Clinical Neuroscience 19.3 (2012): 474-476. Craven, I., et al. AJNR 30.10 (2009): 1998-2000. ・ The development of postembolization perianeurysmal edema has been reported infrequently. ・ The edema is likely to develop around partially thrombosed aneurysms as well as large or giant aneurysms. In our cases, case1 and 2 were large aneurysm, and case 3 is partially thrombosed aneurysms. ・ A signi cant proportion of patients who develop postembolization perianeurysmal edema are most likely asymptomatic, fi as well as our 3 cases. ・ Pulsatile blood flow, hemorrhaging within the aneurysm wall, the inflammatory process, and endothelial growth factor in the aneurysm wall have also been proposed as factors that may play a role in the development of such edema. Especially, the pulsatile blood flow when striking the coils may result in a regrowth of the aneurysm and may also be transmitted to the aneurysm wall via the coils, thus leading to the perianeurysmal edema. It is reported that perianeurysmal edema is associated with aneurysm recanalization and regrowth. In our all 3 cases, coil compaction was found. In case1, and 2 , aneurysm recanalization was found, and in case3, aneurysm regrowth was found,too. ・ Treatment options for perianeurysmal edema may include conservative management in asymptomatic patients, the use of steroids and other anti-edematous medications in symptomatic patients. Because the edema is associated with recanalization and regrowth, further embolization or neck clipping were performed frequently. In our cases, we performed re-embolization. In case 1,and 2, after procedure, MRI showed remission of perianeurysmal edema, but in case 3, remission was transient.
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Transcript of T2 Star weighted MR angiography (SWAN) showed microbleeds in the left white matter, indicating...
T2 Star weighted MR angiography (SWAN) showed microbleeds in the left white matter, indicating endothelial damage and blood brain barrier disruption. Perfusion-MRI showed no area of decreased CBF.
After procedure,peri-aneurysmal edema gradually remissions
Purpose : Post embolization high intensity signal areas in FLAIR MRI images (HISA) are infrequent. Pathogenesis of HISA that appeared following endovascular treatment was poorly understood. In this presentation,we demonstrated 6 cases of cerebral lesion after coil embolization, and the mechanism of lesion appearance was discussed.
Case １ 74 y.o. Female
Case3 58 y.o. Female
Case2 78 y.o. Female
Lesion ： Lt.IC-PC. AN. neck/dome/depth(mm) ： 8.21/12.62/14.38Unrupture
Procedure ： Balloon AssistContrast agent ： Iohexol 223ml VER ： 27.7% neck remnantBioactive coil ： used（ unlabel and coil maigration to parent artery ）
頭部 MRI ：白質病変やや軽減
Lesion ： A com. AN. neck/dome/depth(mm) ： unknownUnrupture
Lesion ： Lt.BA-SCA AN. neck/dome/depth(mm) ： 7.07/7.77/9.81Rupture → SAH Hunt and Hess 2/Fisher 4
Procedure ： unknownContrast agent ： unknown VER ： unknown neck remnantBioactive coil ： unknown
POD1264 re-embolization
Procedure ： single catheter
Bioactive coil ： none
Procedure ： single catheterContrast agent ： Iohexol 143ml VER ： 28.4% neck remnantBioactive coil ： none
POD391 re-embolization
Procedure ： Balloon Assist
Bioactive coil ： used
B-MRI ： peri-aneurysmal edema was found, and exacerbated gradually.
B-MRI ： coil compaction and
peri-aneurysmal edema are found.
The edema was exacerbated gradually
B-MRI ： coil compaction, peri-
aneurysmal edema, and
brainstem compression are
found. POD385POD6 POD566
POD1206 POD1889
POD7 POD92 POD329 POD536
１． Department of Endovascular Neurosurgery ＠ International Medical Center,Saitama Medical University ２． Department of Neurology @ Nara City Hospital
ASNR 2015EP-99
High Intensity Signal Areas in FLAIR MRI (HISA) after Coil Embolization to Cerebral Aneurysms: Case series
Yoshiaki Kakehi, Eisuke Tukagoshi, Jun Niimi, Hiroaki Neki, Nahoko Uemiya, Koji Mizogami, Shinya Kohyama , Fumitaka Yamane, Shoichiro Ishihara
Conclusions : The mechanisms of HISAs after coil embolization were unknown, the adverse inflammatory reactions were proposed. Some of these cases seem to be curable in use of steroid, we should take care of not only to the appearance of neurologic deficits but HISA in brain parenchyma.
Case4 58 y.o. Female
Lesion ： Lt.IC-Oph A. AN. neck/dome/depth(mm) ： 5.33/7.28/5.49UnruptureProcedure ： Balloon AssistContrast agent ：Iohexol 316ml VER ： 21.9% Complete obliterationBioactive coil ： none
On POD39, higher brain dysfunction was developed. MMSE 25/30. The cerebrospinal fluid exhibited a protein level at 46 mg/dL.
・ The mechanism of blood brain barrier disruption could be explained with contrast agents causing endothelial cell shrinkage and opening of tight junctions. In the territory of the artery disrupted blood brain barrier, white matter exposure to allergen. At that time, we think T-cell activation is induced, and allergens of each cases induced an ADEM-like reaction with a T cell–mediated autoimmune process. The CSF results lend further credence to this hypothesis. ・ The unilateral involvement could be explained by the fact that the BBB disruption was limited to areas of higher and more intense contact with contrast agents.・ In case4, platinum or Iohexol are predicted as allergen. And in case5, nickel, involved the stent used for coil embolization assist, is predicted as allergen by patch testing, not platinum, because this symptom was’nt found at post coil embolisation to Lt. VA dissection with SAH.
Postoperative CT:
Case6 63 y.o. Female Lesion ： Rt.IC-PC. AN. neck/dome/depth(mm) ： 3.31/11.9/13.1Unrupture
Procedure ： Double CatheterContrast agent ： Iohexol 57ml VER ： 43.4% complete obliterationBioactive coil ： none
Although there were no symptoms,f/u MRI showed multiple lesions in the white matter and occipital cortex in the territory of the right middle cerebral artery (MCA). Perfusion-MRI showed decreased CBF within the lesions.
POD239 re-embolization
Procedure ： Balloon
Assist
Bioactive coil ： used
Discussion of pathology in case4 and 5 ADEM-LIKE REACTION ANEURYSM COILING Leonardo et al. Neurosurgery 66:, 2010
Discussion of pathology in case6 Delayed thrombus formation due to a coil loop migration into the parent artery
Discussion of pathology in case1, case2, and case3 Postembolization perianeurysmal edema
・ Although mimicking case 4 and 5, rt. parietal cortex was involved in HISA in FWI. Besides, P-MRI showed decrease in cerebral blood flow at the lesion, and the protein in cerebrospinal fluid was normal, different from case4 and 5. ・ We think the HISA in this case is due to thrombus with small coil loop migration into the parent artery.
POD39 POD58 POD90
Extravasation of contrast agent was found,indicating blood brain barrier disruption.
Post operative CT didn’t show extravasation of contrast agent and edema of cortex.
POD132 POD140POD253
Case5 39 y.o. Female
Lesion ： Rt.IC-dorsal. AN. neck/dome/depth(mm) ： 4.8/4.6/3.2 Unrupture
Procedure ： Stent AssistContrast agent： Iopamidol 50ml VER ： 23.9% Body fillingBioactive coil ： none
Postoperative CT:
Edema of right cortex was found, not entirely Blood Brain Barrier disruption.
POD27 POD38 POD45
POD1630
After procedure,peri-aneurysmal edema gradually remissions
After procedure,peri-aneurysmal edema remissions transiently, but coil compaction and aneurysm expansion were found gradually, and peri-aneurysmal edema was exacerbated.
MRI showed multiple lesions in the left white matter were found.
We have no COI with regard to our presentation.
After administration of intravenous methyl-prednisolone at a dose of 1,000 mg/day for 3 days, the symptoms were almost completely resolved. MRI showed a reduction in the size of the lesions.Perfusion-MRI showed no areas of decreased CBF.
On POD27, the patient got an epileptic seizure. MRI showed multiple lesions in the left white matter.The cerebrospinal fluid exhibited a protein level at 58 mg/dL.
After administration of intravenous methyl-prednisolone at a dose of 1,000 mg/day for 3 days/weeks, for 3weeks, MRI demonstrated almost complete resolution.
The cerebrospinal fluid exhibited a normal protein level.
Followed closely without treatment, the leisons gradually remissions.
small coil loop migration into the parent artery.
Past Hitory : At 37 y.o.SAH with left vertebral artery dissection, performed parent artery embolization.
Refferences Kyriakos, et al. Neurology 84.1 (2015): 97-99. Horie, Nobutaka, et al. Journal of neurosurgery 106.5 (2007): 916-920. DEUS-SILVA, Leonardo, et al. Neurosurgery, 2010, 66.1: E222-E223.
Cohen, José E., et al. Journal of Clinical Neuroscience 19.3 (2012): 474-476. Craven, I., et al. AJNR 30.10 (2009): 1998-2000.
・ The development of postembolization perianeurysmal edema has been reported infrequently. ・ The edema is likely to develop around partially thrombosed aneurysms as well as large or giant aneurysms. In our cases, case1 and 2 were large aneurysm, and case 3 is partially thrombosed aneurysms.・ A significant proportion of patients who develop postembolization perianeurysmal edema are most likely asymptomatic, as well as our 3 cases.・ Pulsatile blood flow, hemorrhaging within the aneurysm wall, the inflammatory process, and endothelial growth factor in the aneurysm wall have also been proposed as factors that may play a role in the development of such edema. Especially, the pulsatile blood flow when striking the coils may result in a regrowth of the aneurysm and may also be transmitted to the aneurysm wall via the coils, thus leading to the perianeurysmal edema. It is reported that perianeurysmal edema is associated with aneurysm recanalization and regrowth. In our all 3 cases, coil compaction was found. In case1, and 2 , aneurysm recanalization was found, and in case3, aneurysm regrowth was found,too.・ Treatment options for perianeurysmal edema may include conservative management in asymptomatic patients, the use of steroids and other anti-edematous medications in symptomatic patients. Because the edema is associated with recanalization and regrowth, further embolization or neck clipping were performed frequently. In our cases, we performed re-embolization. In case 1,and 2, after procedure, MRI showed remission of perianeurysmal edema, but in case 3, remission was transient.
