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Neuroendovascular therapy is a collective term of treatment which performing the treatment for vascular lesion at intracranial or cervical part without cutting affected area directly with using fine-bore tubes (micro catheter 1mm+) named as catheter. Originally this method is evolved from test method named as cerebral angiography which takes an image picture of brain blood vessel using catheter and contrast agent. Blood vessels of entire body are all connected via main artery so that catheter is inserted into large blood vessel through the surface of the body, such as base of foot or inner elbow (at the groin, wrist, upper arm, cervical part), then advance it to brain vessel, and treat the disease using several tools (coil, catheter with stasis/extension balloon (called as balloon catheter), metal tube called as stent) or drug (thrombolytic agent, blood-vessel dilator, anticancer agent).
The merit of this treatment is, in comparison with the typical surgical operation like craniotomy, invasion to patient is extremely less, it is able to reach to brain with no effects to surrounded brain cell even at the center part of brain. Also, hospitalization period is less, it is able to perform local anesthesia so that it can conduct to the aged person, like person who has risk for anesthesia having problem at the heart or lung. However to say, there is a risk for complication exists in any diseases, and there is a case which the disease cannot be cured by this treatment only.
Cerebral angiography has started in 1930 by Egas Moniz, and Selective angiography is invented by Seldinger SI in 1953. As for Cerebrovascular treatment, they say that Luesenhop AJ and SpenceWT had first start using silicon small ball for the occlusion of cerebral arteriovenous malformation in 1960. The development of Cerebral Aneurysm embolization Material follows. In 1991, detachable coil (GDC coil) is invented by Gugliemi G. And because of its safety and stabled obliteration, embolization of cerebral aneurysm has drastically improved (In Japan, it has launched in 1997). By this epoch-making event, cerebral aneurysm embolism, which had been conducted for surgery difficult diseases only, become broadly performed with getting away from its restricted limits.
Other than cerebral aneurysm embolism, there are reconstruction of blood circulation (PTA: Percutaneous Trans-luminal Angioplasty) which widen the narrowed blood vessel performed in earlier days for cardiovascular area/stent placement (stenting), local thrombus dissolution therapy/thrombectomy which dissolve or remove blood clot stuck in blood vessel and recover the blood flow, super-selective drug therapy which the drug is injected directly into affected area. Target of embolism are Cerebral and spinal arteriovenous malformations, Cerebral aneurysm, Dural arteriovenous fistula, Tumor lesion, and the target of reconstruction of blood circulations are Cerebral artery stenosis, Acute cerebral infarction, Cerebral vascular spasm after subarachnoid hemorrhage.
Shown below are the explanation of blood vessel treatment by each disease.
Cerebral Aneurysm is a bump developed on blood vessel which shows the symptom of loss of life or serious after effect by subarachnoid when broken or shows symptom of paralysis due to the compression depend on its size even with not broken. Area where blood vessel wall of the bump becomes thin, becomes easy to break by blood flow or blood pressure. If possible, it is better and desirable that the bump is detected before it breaks, then treatment of blocking blood flow into bump. In fact, there are two method available for the bump treatment. The one is by craniotomy and by clipping the blood flow to bump. Or the other is using catheter to block blood flow. In the craniotomy Clipping therapy has a risk of skin incision and direct brain structural damage, and for Catheter surgery, there is a risk of thromboembolic. Complete sure is difficult by either one of two treatments so that there is a case where conservative therapy like blood-pressure management may take place when certain risk comes along.
Firstly, small tube, sheath, is detained in the main vessel of either one in groin, wrist, upper arm or cervical part, and through this sheath, main catheter, in 3mm diameter, is inserted and detained at carotid or vertebral artery. Then through this main catheter, micro-catheter is inserted into bump, then with keeping blood flow in main vessel, embolectomy is conducted to cut off blood flow into the bump. When embolectomy is completed, main catheter is decannulated then microcatheter is decannulated with using seal-up tool for vascular access. After these, prognosis status is monitored in ICU room whether thromboembolic event or bleeding occur.
The reason why treatment for unruptured cerebral aneurysm is necessary is that this disease may be resulted with life-and-death issue and it may be accompanied with serious complication. Once subarachnoid bleeding has occurred, (1) able to get back into society without any problem, (2) alive but with handicapped, (3) loss of life; the proportion of these three are considered as 1/3 each. Rupture rate of unruptured cerebral aneurysm has reported as the research result (1998,2003) of International Unruptured Cerebral Aneurysm Survey (ISUIA) mainly among Westerner. For anterior circulatory aneurysm smaller than 7mm, it is 0.5% or less per annum. In case more than 7mm, depend on the size but it is 0.5% to 8% per annum. For posterior circulatory aneurysm, it has reported that 0.5% to 0.7% in case the size is less 7mm, over 7mm is over few %.
Cohort Research: Front Vision Research (UCAS Japan, 2001/4-2004/4) has conducted in Japan and its result shows, total 5,720 persons among 6,697 Aneurysm patients, 111 patients have onset the subarachnoid bleeding and its annual bleeding rate is 0.95%. Rapture easiness for unruptured cerebral aneurysm is depend on several factors such as, whether aneurysm is anterior or posterior circulation type, aneurysm is at the center or not, irregular shape or not, multiple type or not, complicated with ruptured aneurysm by onset subarachnoid bleeding or not, how about family history, having high-blood pressure or not, and/or smoking or not. When it comes large enough, it may become easy to rupture. But even for small aneurysm, anterior communicating aneurysm or posterior communicating aneurysm, or irregular shape aneurysm may be easy to rupture.
How to treat the coincidentally detected unruptured cerebral aneurysm is decided for the best treatment with the consideration of, the provability of subarachnoid bleeding under the natural course, and the provability of possible complicated disease when treatment is conducted. Preservative treatment which does not treat the bump itself, may be decided either one of followings, craniotomy by clipping, coil embolization by intravascular treatment, or combination of craniotomy clip and coil. Along with the rapid development of MRI(A) at clinical application, discovery rate of unruptured cerebral aneurysm is also getting higher, so that early treatment before rapture is highly recommended.
How to treat the coincidentally detected unruptured cerebral aneurysm is decided for the best treatment with the consideration of, the provability of subarachnoid bleeding under the natural course, and the provability of possible complicated disease when treatment is conducted. Preservative treatment which does not treat the bump itself, may be decided either one of followings, craniotomy by clipping, coil embolization by intravascular treatment, or combination of craniotomy clip and coil. Along with the rapid development of MRI(A) at clinical application, discovery rate of unruptured cerebral aneurysm is also getting higher, so that early treatment before rapture is highly recommended.
Female, age 60. This shows a left carotid artery aneurysm (Neck/Dome/Height=2.48/3.87/25mm) which is small but wide diameter of tubular structure. (Fig.1-a) Form the cervical part with balloon, then coil embolization is performed using a microcatheter. (Fig.1-b,c)
The cause of subarachnoid hemorrhage developed by headache, nausea, vomiting, or altered mentation never experienced before is the ruptured cerebral aneurysm. Comparison research, made by ISAT: International Subarachnoid Aneurysm Trial 2002,2009, of coil embolization and Open-head clipping technique had reviewed 1,073 cases for coil embolization and 1,070 cases for clipping among 2,143 cases of coil or clip selectable patients. Registration has been ceased because care needed/fatality rate is advantageously less (P=0.0019) for coil group 23.7% and clip group 30.6% in the intermediate analysis a year later. Recurrent bleeding from aneurysm treated by coil embolization is a small minority and care not-needed proportion has no difference in both groups among survivors 5 years later. From these facts, coil embolization has found more effective in case both treatments are possible.
Embolization method is similar to the treatment for unruptured brain aneurysm, but systolic arterial pressure must be strictly controlled to below 120mmHg under analgesia/remission or full anesthesia to prevent recurrence bleeding. After the surgery, drip infusion/rehabilitation treatment is conducted to prevent cerebrovascular spasm developed after subarachnoid hemorrhage.
Female, age 66. Wider diameter of tubular structure of ruptured carotid artery-post-traffic aneurysm (Fig.2-b) combined with subarachnoid hemorrhage (Fig.2-a). Cervical part is formed then coil embolization (Fig.2-c,d) has conducted with using two microcatheter.
Arterio-Venous Malformation: AVM is a Nidus (Abnormal Blood Vessel) which primary arterio-venous has shunt caused by developmental anomaly of blood capillary in early fetal life, and half of them has developed by bleeding. There is a case where disease has found at the detail checking for headache or epilepsia or at medical checkup of the brain. Embolization for AVM has been tried with using solid particle or liquid embolism material. For particle, Spongel or Ivalon PVA are used. For liquid, cohesive histoacryl (NBCA: n-butyl-cyanoacrylate) + Lipiodol, non-viscous onyx and EVAL (ethylene vinyl alcohol copolymer) are used. Particle works as temporary embolization of blood vessel so that it does not reach to permanent cure. Liquid embolism material is able to embolize the nidus so that permanent cure may be possible. Permanent cure rate by vascular treatment is around 10%. Embolization before radiation therapy like gamma knife or surgical resection are commonly conducting.
Male, age 59. Ruptured cerebral arterio-venous malformation developed by brain bleeding (Fig.3-a). Embolization (Fig.3-b) has conducted with using liquid embolization material (NBCA Cyanoacrylate) via microcatheter. Embolism block, malformation included, at inflow blood vessel can be seen. Almost all embolism has been cut so that complete embolization has confirmed later days.
Dural Arterio-Venous Fistula is a disease which anastomosis from artery has developed directly in cerebral sinus so that arterial blood flows directly into vein. Vascular noise occurs when arterial blood goes through narrow pass way called Fistula, intravenous infarction caused by venous hypertension, hemorrhage, subarachnoid, or spasm may occur. Normally, it is called as acquired disease because this occurs by the obstruction of sinus or arctation. Symptoms caused by carotid cavernous sinus fistula developed at internal carotid artery siphon part are vascular noise, bulbar conjunctiva congestion and/or double vision. In other part, symptoms are vascular noise, convulsive attack and/or hemorrhage. It becomes less severe with inserting microcatheter to inflow artery and embolize with coil or liquid embolization material and advancing microcatheter to outflow venous sinus part of fistula then embolize the part with coil.
Male, age 52. Transverse sinus part subdural sinus developed by tinnitus (Fig.4-a). Embolization (Fig.4-b,c) is conducted with coil and liquid embolization material (NBCA Cyanoacrylate) via microcatheter. Coil and embolism block of liquid embolization material can be seen. Complete embolization has conducted.
Extension Balloon is the only method to expand at the beginning, but it burns down because the complication disease becomes concern with the blood clot/embolus (debris) develops during surgery. Later, numbers of balloon method are increasing rapidly due to the development of blood clot recovery device. For cervical carotid artery stenosis, Carotid End-Arterectomy (CEA) as standard treatment, which blood vessel is exposed with cutting out neck part by roughly 10cm then remove blood vessel stacked rubbish, a cause of arctation called as atheromatosis, is widely conducted. Research result SAPPHIRE (Stenting and angioplasty with protection in patients at high risk for endarterectomy) 2004 has been reported. Conducted Subjects at 29 facilities in the USA are; (1) over 80% stenosis without symptom, (2) over 50% stenosis with symptom, and these patients are determined as high risk for surgical treatment. 307 patients, determined as surgical treatment is possible, are grouped randomly by lottery test. Occurrence rate of harmful symptom (loss of life, apoplexy, cardiac infarction) within 30 days is 12.6% in CEA group and 5.8% in stent indwelling group. Due to the fact that stent indwelling group shows better result, stent indwelling treatment becomes popular. For the patients who has determined surgical treatment is high risked, blood vessel expansion surgery with indwelling metal tubed stent.
As for the blood clot recovery method, there are proximal part balloon obstruction for narrow area, distal part balloon obstruction and distal part filter indwelling. We have developed original Mouse Trap method of proximal part balloon obstruction. With using this method, we are recovering/filtering the debris and returning such blood back to the body. There is balloon obstruction or filter indwelling for distal part only. With the development of these thrombus prevention device, stent for the origin of carotid artery can be conducted more safely.
Male, age 60. Right cervical artery cervical stenosis (Fig.5-a) developed by left hemiplegia. With temporary blood flow deprivation is conducted at close-up area of stenosis, front extension (Fig.5-b), stent indwelling and rear extension (Fig.5-c) has been conducted (Fig.5-d). For thrombus embolism on lesion section, blood is drawn into the syringe and taken out by filtration, then blood is returned to body.
Female, age 74. Right cervical artery cervical stenosis (Fig.6-a). Blood flow is able to secure at distal part of stenosis so that filter wire, which is able to perform filtration is placed, stent indwelled then conduct rear extension (Fig.6-b) (Fig.6-c)
Balloon blood vessel extension and furthermore stent indwelling is conducted for intracranial arterial stenosis. Intracranial stent come into existence, these methods become really common.
Male, age 75. Basilar Artery Stenosis developed by brain-stem infarction (Fig.7-a). Front extension for narrow part (Fig.7-b) and Cranial internal Vascular stent has indwelled (Fig.7-c).
Thrombolytic therapy is conducted by tPA intravenous dosage within 4.5 hours from the development of Acute phase of cerebral artery obstruction. In case when recanalize does not occur within 1 hour from the treatment and in case it is within 6 hours from development, stent device is used for blood clot recovery.
Male, age 74. Left Carotid Artery Stenosis developed by right hemiplegia and motor aphasia (Fig.8-a). Blood clot recovery (Fig.8-b) has conducted using blood clot recovery stent with indwelling balloon catheter at close part of occlusion area. Complete recanalization (Fig.8-c) has been gained.
In case tumor has metastasized to blood vessel, unexpected bleeding may occur during surgical operation. In order to prevent bleeding at tumor resection, obliteration of feeding artery inflowed to tumor is conducted beforehand with using solid particle or liquid embolization material.
