Fig. 1 Left internal carotid angiograms (, ) and plain craniograms (, ) in case 1. The projection angles of and are identical to those of and, respect

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1 JNET 8: , 2014 テクニカルノート動脈瘤塞栓術中の逸脱コイルに対するサポートカテーテルを使用した対処法 support catheter as an auxiliary tool to cope with a protruded coil during endovascular embolization of an intracranial aneurysm: technical note Masataka YOSHIMUR Shin HIROT Toshitsugu TERKO Natsumi ITO Takamaro TKEI Mutsumi FUJII Shinji YMMOTO epartment of Neurosurgery, Tsuchiura Kyodo General Hospital bstract Objective: We report two cases of coil protrusions which are successfully treated by using support catheters during endovascular treatment of intracranial aneurysms. ase presentation: ase 1. n 81-year-old woman had developed an anterior communicating artery aneurysm besides a ruptured aneurysm. The fourth coil tail protruded into the left 2 during the endovascular surgery. The coil was successfully removed from the aneurysm by using a microsnare while pressing the support catheter tip against the coil mass in order to prevent protrusion of other coils. ase year-old woman was admitted to our hospital due to an unruptured aneurysm located at the left superior cerebellar artery. The ninth coil tail protruded into the basilar artery during the procedure. The coil tail was pushed back into the aneurysmal cavity by using the support catheter and additional coils under microballoon assistance. onclusion: support catheter can be an auxiliary tool to cope with protruded coils quickly, safely, and conveniently in some cases. Key words intracranial aneurysm, endovascular treatment, coil protrusion, support catheter mstkktsm@yahoo.co.jp Received June 8, 2014 ccepted ugust 20, 2014 doi: /jnet.tn 緒言 Fubuki 4.2 Fr Fubuki 2 症例呈示症例 1 患者 81 主訴既往歴現病歴入院時所見 Glasgow coma scale 9 JNET Vol.8 No.5 November

2 Fig. 1 Left internal carotid angiograms (, ) and plain craniograms (, ) in case 1. The projection angles of and are identical to those of and, respectively. The asterisks ( ) show previously embolized posterior communicating artery aneurysm that caused subarachnoid hemorrhage., : Working-angle views. The tip of the Headway 17 catheter is in the aneurysm sac., : The tail of the fourth coil is in the lumen of the left 2 (arrows). The tip of the microcatheter has been kicked out of the aneurysm sac into the left 2 (arrowhead). E3V1M5 World Federation of Neurosurgical Societies grade IV 入院時画像所見 T SH Fisher group 3 T 9 mm 6 mm 入院後経過, T 血管内治療 6.3 mm 3.3 mm 3.0 mm neck 2.5 mm Fig.1 alloon assist Fubuki triple coaxial system 7 Fr Radifocus introducer IIH Fr Roadmaster Fubuki Headway 290 JNET Vol.8 No.5 November 2014

Fig. 2 Plain craniograms during retrieval of the protruded coil in case 1. : The 4.2Fr Fubuki catheter is at the tip of the left internal carotid artery (arrow).

3 Fig. 2 Plain craniograms during retrieval of the protruded coil in case 1. : The 4.2Fr Fubuki catheter is at the tip of the left internal carotid artery (arrow). The microsnare is capturing the coil tail (arrowhead). : The fourth coil is tangled tightly with other coils and cannot be removed without leaving the coil mass intact. Fubuki is slipping into the left 1. : Fubuki is intentionally placed at the neck of the aneurysm to prevent protrusion of other coils out of the aneurysm. : The coil is successfully removed without the coil mass protrusion. 17 preshaped 45 MicroVention TERUMO, Tustin,, US hikai cm Fubuki Headway 17 Orbit Galaxy fill 3 mm 8 cm odman & Shurtleff, Johnson & Johnson, Raynham, M, US first coil Orbit Galaxy extrasoft 2.5 mm 3.5 cm 2.5 mm 2.5 cm 2.5 mm 3.5 cm 2 Fig.1 activated clotting time 250 Headway 17 Prowler Select Plus odman & Shurtleff 2 Fubuki Fig. 2 mplatz Goose Neck Microsnare 4 mm ev3 ovidien, Irvine,, US Fig. 2 Fubuki 1 Fig. 2 Fubuki Fig. 2 Fig. 2 Headway 17 JNET Vol.8 No.5 November

Fig. 3 Post-procedural plain craniograms (, ) and left internal carotid angiograms (, ) in case 1. The projection angles of and are identical to those of and, respectively.

4 Fig. 3 Post-procedural plain craniograms (, ) and left internal carotid angiograms (, ) in case 1. The projection angles of and are identical to those of and, respectively. The figure shows successful obliteration of the aneurysm. Target 360 Ultra 2.5 mm 4 cm Stryker, Kalamazoo, MI, US, Target Helical Ultra 2.5 mm 3 cm Fig. 3 Neck remnant Fig. 3 塞栓術後経過 MRI 53 6 MRI 症例 2 患者 73 主訴既往歴現病歴 MRI 12 mm 73 入院時所見血管内治療経過 11.9 mm 7.7 mm 7.5 mm neck 4.2 mm Fig. 4 balloon assist double catheter technique Penumbra oil 400 P 400 Penumbra, lameda,, US 7Fr 5Fr 292 JNET Vol.8 No.5 November 2014

Fig. 4 Left vertebral angiograms (, ) and plain craniograms (, ) in case 2. The projection angles of and are identical to those of and, respectively., : Working angle views.

5 Fig. 4 Left vertebral angiograms (, ) and plain craniograms (, ) in case 2. The projection angles of and are identical to those of and, respectively., : Working angle views. The tip of the PX Slim catheter is in the aneurysm sac, and Hyperform balloon catheter (4 7 mm) is placed just before the aneurysm., : Perforation of the aneurysm. Part of the eighth coil is beyond the posterior wall of the aneurysm (arrow). Heparin Fr Roadmaster 5Fr Envoy odman & Shurtleff Hyperform 4 mm 7 mm ev3 ovidien 5Fr Envoy neck Fig. 4 PX SLIM 130 Penumbra 7Fr Roadmaster hikai 14 Excelsior SL10 preshaped 45 Stryker P 400 standard 10 mm 30 cm balloon assist standard 8 mm 15 cm complex soft 6 mm 10 cm extra soft 4 mm 6 cm 4 mm 6 cm balloon assist balloon assist extra soft 4 mm 4 cm 2 extra soft 3 mm 5 cm Fig. 4 alloon extra soft 3 mm 5 cm balloon Fig. 5 JNET Vol.8 No.5 November

Fig. 5 Plain craniograms after the perforation. The projection angle of all the figures is identical to that of Fig. 4. : We delivered the ninth coil for hemostasis.

6 Fig. 5 Plain craniograms after the perforation. The projection angle of all the figures is identical to that of Fig. 4. : We delivered the ninth coil for hemostasis. However, part of the coil is beyond the aneurysmal wall (arrow), and the coil tail is in the basilar artery (arrowhead). : The microcathter, which is guided by hikai (0.014 inch) microguidewire is at the orifice of the aneurysm (arrow), and the tip of Fubuki is placed at the tail end of the coil (arrowhead). : Fubuki is pushing the protruded coil tail into the aneurysm. : The coil tail is inside the aneurysm. balloon Fubuki Heparin 2000 PX SLIM 7Fr Roadmaster Fubuki SL10 SL10 Fubuki Fig. 5 Fubuki neck Fig. 5 balloon balloon assist ashmere 4 mm 8 cm 4 mm 8 cm 3 mm 6 cm 3 mm 4 cm 3 mm 4 cm odman & Shurtleff Fig. 6 Neck remant Fig. 6 塞栓術後経過 T SH 3 mm JNET Vol.8 No.5 November 2014

Fig. 6 Post-procedural plain craniograms (, ) and left vertebral angiograms (, ). The projection angles of and are identical to those of and, respectively.

7 Fig. 6 Post-procedural plain craniograms (, ) and left vertebral angiograms (, ). The projection angles of and are identical to those of and, respectively. The figures show successful obliteration of the aneurysm. 考察 1 1, Wide neck 4,5 balloon assist technique stent assist technique 4, bdihalim 3 5,11,12 Yonaha 4 MRI rescue stent 1,9,13 JNET Vol.8 No.5 November

8 1 2 snare 11 simple wire technique 10 Merci retriever oncetric Medical, Mountain View,, US 7,8 Solitaire ev3 ovidien 9 5,7,10,11,14 1 inc 11 balloon 1 balloon Fubuki snare Fubuki Fubuki Stent Sugiu 14 rescue balloon technique 2 Fubuki 2 Fubuki 15,16 2 PX SLIM Fubuki Fubuki Merci retriever Outreach distal access catheter oncentric Medical, Spiotta Onyx ev3 ovidien Onyx cast Newman 17 push-pull 1 push-pull counter traction 1 protect-pull 2 結論 Fubuki 文献 1 Sakai N, Taki W, Yoshimura S, et al. Retrospective survey of endovascular treatment for ruptured intracranial aneurysm in Japan: Retrospective Endovascular Subarachnoid neurysm Treatment (REST) study. Neurol Med hir (Tokyo) 2010; 50: Henkes H, Fischer S, Weber W, et al. Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic 296 JNET Vol.8 No.5 November 2014

9 and clinical results. Neurosurgery 2004; 54: ; discussion bdihalim M, Kim SH, Maud, et al. Short- and intermediate-term angiographic and clinical outcomes of patients with various grades of coil protrusions following embolization of intracranial aneurysms. JNR m J Neuroradiol 2011; 32: Yonaha H, Hyodo, Inaji T, et al. Thromboembolic Events ssociated with oil Protrusion into Parent rteries after G Treatment. Interv Neuroradiol 2006; 12: Luo, hang F, Teng MM, et al. Stent management of coil herniation in embolization of internal carotid aneurysms. JNR m J Neuroradiol 2008; 29: Sourour N, Góngora-Rivera F, iondi. dditional Rescue Stent Placement for Stabilization of a Prolapsed oil during Stent-assisted oil Embolization of a Wide-Neck Intracranial neurysm. Interv Neuroradiol 2006; 12: Kung K, bel TJ, Madhavan KH, et al. Treatment of endovascular coil and stent migration using the merci retriever: report of three cases. ase Rep Med 2012; 2012: Vora N, Thomas, Germanwala, et al. Retrieval of a displaced detachable coil and intracranial stent with an L5 Merci Retriever during endovascular embolization of an intracranial aneurysm. J Neuroimaging 2008; 18: O Hare M, Rogopoulos M, Stracke P, et al. Retrieval of displaced coil using a Solitaire stent. lin Neuroradiol 2010; 20: Lee Y. Use of wire as a snare for endovascular retrieval of displaced or stretched coils: rescue from a technical complication. Neuroradiology 2011; 53: inc H, Kuzeyli K, Kosucu P, et al. Retrieval of prolapsed coils during endovascular treatment of cerebral aneurysms. Neuroradiology 2006; 48: ing, Liu K. Management strategies for intraprocedural coil migration during endovascular treatment of intracranial aneurysms. J Neurointerv Surg 2014; 6: ; 40: Sugiu K, Martin J, Jean, et al. Rescue balloon procedure for an emergency situation during coil embolization for cerebral aneurysms. Technical note. J Neurosurg 2002; 96: olby GP, Lin LM, Huang J, et al. Utilization of the Navien distal intracranial catheter in 78 cases of anterior circulation aneurysm treatment with the Pipeline embolization device. J Neurointerv Surg 2013; 5(Suppl 3): iii16 iii Hauck EF, Tawk RG, Karter NS, et al. Use of the outreach distal access catheter as an intracranial platform facilitates coil embolization of select intracranial aneurysms: technical note. J Neurointerv Surg 2011; 3: Newman, Park MS, Kerber W, et al. Over-thecatheter retrieval of a retained microcatheter following Onyx embolization: a technical report. J Neurointerv Surg 2012; 4: e Spiotta M, Hussain MS, Sivapatham T, et al. The versatile distal access catheter: the leveland linic experience. Neurosurgery 2011; 68: ; discussion JNET 8: , 2014 要旨 snare 2 73 neck balloon JNET Vol.8 No.5 November

JNET 9: , 2015 症例報告スーパー政宗 ( 第二報 ) - 初期臨床経験 - Super-Masamune: initial clinical experience Masayuki EZURA, Naoto KIMURA, Hiroshi UENOHARA Departm

JNET 9: , 2015 症例報告スーパー政宗 ( 第二報 ) - 初期臨床経験 - Super-Masamune: initial clinical experience Masayuki EZURA, Naoto KIMURA, Hiroshi UENOHARA Departm JNET 9:192 196, 2015 症例報告スーパー政宗 ( 第二報 ) - 初期臨床経験 - Super-Masamune: initial clinical experience Masayuki EZURA, Naoto KIMURA, Hiroshi UENOHARA Department of Neurosurgery, NHO Sendai Medical Center Abstract