Yasushi Matsumoto · 2019. 1. 21. · Rhoton AL. Neurosurgery, 2002/ Takahashi S et al. AJNR, 1990/ Zeal AA et al. JNS, 1978 The perforating branches of the AChA passing through the

Kohnan HospitalDepartment of Neuroendovascular Therapy

Yasushi Matsumoto

Tohoku University Graduate School of Medicine

Department of NeurosurgeryHidenori Endo, Teiji Tominaga

27th Society of Neurosurgeons of South Africa Congress 2018

The Japanese Society of Neuroendovascular Therapy

COI Disclosure Information Yasushi Matsumoto

I have the follwing financial relationships to disclose

– Leadership position/advisory role for: GE health care, Fuji systems, Medicos Hirata, Stryker Corporation

– Stockholder in : None

– Patents and royalties from: None

– Honoraria (lecture fee) from:

• GE healthcare

• Stryker Japan

• Medico’s Hirata

• Medtronic Japan

• Century medical

• Takeda Pharmaceutical Limited

• Otuka Pharmaceutical Limited

• Fuji systems

– Honoraria (manuscript fee) from:

– Grant/Research funding from: None

✓Presurgical embolization of cerebral AVMs is

effective, particularly for deep-seated cerebral AVMs

✓However, embolization of the choroidal arteries is

challenging and potentially hazardous

➢Supply eloquent territories

➢Are of small caliber

➢Lack of collateral

Embolization of choroidal arteries

Supplying territories of Choroidal arteries

❖ Anterior choroidal artery (AChA)

Posterior limb of the internal capsule/Optic tract/

Lateral geniculate body/ globus pallidus/cerebral peduncle

❖ Posterior choroidal artery (PChA)

• Medial PChA

Peduncle/tegmentum/geniculate body/colliculi/pulvinar/pineal gland/ medial thalamus

• Lateral PChA

Peduncle/posterior commissure/part of crura/body of the fornix/ lateral geniculate

body/pulvinar/dorsomedial thalamic nucleus/body of the caudate nucleus

Rhoton AL. Neurosurgery, 2002


Anatomical course of AChA

❖ AChA arises distally to the PComAorigin

❖AChA can be divided into 2 segments1. cisternal segment2. plexal segment


Cisternal segment

Plexal segment

❖ AChA arises distally to the PComAorigin

❖ AChA can be divided into 2 segments1. cisternal segment2. plexal segment


Plexal point


❖Characteristics of the lateral angiogram of the ICA1. Cisternal segment : gentle S-shaped course2. Plexal point： steep downward course of a few millimeters,

followed by a sharp posterior turn

Plexal point

Rhoton AL. Neurosurgery, 2002/ Takahashi S et al. AJNR, 1990/ Zeal AA et al. JNS, 1978

ICA BA

Rhoton AL. Neurosurgery, 2002/ Takahashi S et al. AJNR, 1990/ Zeal AA et al. JNS, 1978

❖The perforating branches of the AChA passing through the anterior perforating substance to the globus pallidus and posterior limb of the internal capsule, arise from the cisternal segment and do not receive any significant collateral supply.

❖The catheter tip must be placed beyond the plexal point to avoid serious ischemic complications during AVM embolization through the AChA.


Plexal point

Plexal point= ≒ safety point

Rhoton AL. Neurosurgery, 2002Zeal AA et al. JNS, 1978

① Medial PChA・ origin: P2 > P1・ pineal body → velum interpositum

→ Monro → lateral ventricle・ like ‘3-shape’ in lateral view

② Lateral PChA・ origin: P2 > P3・ inferior horn/trigone

→ lateral ventricle

LPChA

MPChA

Anatomical course of PChA

Rhoton AL. Neurosurgery, 2002Zeal AA et al. JNS, 1978

BA

PCA

MPChA LPChA

Anatomical course of PChANo angiotraphic ‘safety point’

LPChA

MPChA

The aims of this study

To clarify the risk of complications in the endovascular embolization through the choroidal arteries

Elkordy, Endo and Matsumoto. JNS, 2016

Methods（1）

❖ Inclusion criteria：

– 116 consecutive patients with cerebral AVMs treated by endovascular embolization between 2006 and 2014

– Patients who were treated by endovascular embolization through the AChA and/or PChA

Trans arterial embolization：

：

– General anesthesia

– Embolic material：NBCA or Onyx

– Marathon microcahteter

– Chikai 10 or 008 microguidewireElkordy, Endo and Matsumoto. JNS, 2016

Methods（1）

❖ Inclusion criteria：

– 116 consecutive patients with cerebral AVMs treated by endovascular embolization between 2006 and 2014

– Patients who were treated by endovascular embolization through the AChA and/or PChA

❖ Trans arterial embolization：

– General anesthesia

– Embolic material：NBCA or Onyx

– Marathon microcahteter

– Chikai 10 or 008 microguidewire Elkordy, Endo and Matsumoto. JNS, 2016

Methods（2）

❖ Embolization was performed as a palliative procedure

before open surgery or Gamma Knife radiosurgery.

–when flow reduction by embolization of these arterial

supplies was considered effective for surgical removal

–necessary to obliterate intranidal or feeder aneurysms

that were considered likely sites of hemorrhage before GK


Methods（3）

❖ Outcome evaluation：

– Angiographic findings

• Position of the microcatheter

• Degree of the embolic agent reflux

– Postop. MRI/CT

• Hemorrhagic complications

• Ischemic complications

– Postop. neurological status

– Final functional status: mRS

ICA BA

Plexal point


Results: 13/116 cases were included in this study

Results: all cases are ruptured AVMs

Results

N (%)

Target vessel

AChA 8 (61%)

PChA 6 (46%)

Embolic agent

NBCA 5 (38%)

Onyx 8 (62%)

Complications

Hemorrhage 0 (0%)

Ischemia 4 (31%)

Symptoms

Transient 1 (7.7%)

Permanent 1 (7.7%)

❖ 13 cases were included in this study

Results

N (%)

Target vessel

AChA 8 (61%)

PChA 6 (46%)

Embolic agent

NBCA 5 (38%)

Onyx 8 (62%)

Complications

Hemorrhage 0 (0%)

Ischemia 4 (31%)

Symptoms

Transient 1 (7.7%)

Permanent 1 (7.7%)


Mortality: 0%

Results

N (%)

Target vessel

AChA 8 (61%)

PChA 6 (46%)

Embolic agent

NBCA 5 (38%)

Onyx 8 (62%)

Complications

Hemorrhage 0 (0%)

Ischemia 4 (31%)

Symptoms

Transient 1 (7.7%)

Permanent 1 (7.7%)

N (%)

Additional Tx

Resection 9 (69%)

GK 3 (23%)

Observation 1 (7.7%)

Nidus obliteration

Complete 10 (77%)

Partial 3 (23%)


Results

N (%)

Target vessel

AChA 8 (61%)

PChA 6 (46%)

Embolic agent

NBCA 5 (38%)

Onyx 8 (62%)

Complications

Hemorrhage 0 (0%)

Ischemia 4 (31%)

Symptoms

Transient 1 (7.7%)

Permanent 1 (7.7%)

N (%)

Additional Tx

Resection 9 (69%)

GK 3 (23%)

Observation 1 (7.7%)

Nidus obliteration

Complete 10 (77%)

Partial 3 (23%)


Re-bleeding: 0%

46F/ Ruptured, Lt. temporal AVM (SM grade IV)

Preop. T2WI Working angle

Plexal point

The MC tip was advanced distally to go beyond the angiographic plexal point

Preop. T2WI Working angle

Plexal point

tip

Microangiography

Plexal point

catheter

33% NBCA injection


NBCA 33% Post-op. NBCA

Pre POST


DWI (POD1)Catheter position & reflux

Ischemic complication: No

Additional treatment : Open surgery


8 y.o. girl, ruptured AVM

Rt. ICAG

CT

AVM features

Location: rt. temporal cortex – inferior hornFeeder:

1. anterior choroidal a. 2. anterior temporal a.

Drainer: 1. basal vein of Rosenthal2. vein of Labbe

Intranidal aneurysm

Spetzler & Martin Grade: 3 (S2D1E0)

TAEtarget: Intranidal aneurysm

Inranidal AN

Marathon 1.5FChikai 10 + Mirage 0.008 inch

Plexal point



Plexal point

catheter


Intranidal aneurysm has gone!

Inranidal AN

TAEtarget: anterior temporal a.


TAE (Onyx): plug and push


pre

Adequate presurgical embolization

Ischemic complication: No

Additional treatment: Open surgery

mRS score at 6Mos: 0

８F/ Ruptured, Rt. temporal AVM (SM grade III)

Onyx

60M/ Ruptured, Rt. frontal AVM (SM grade II)

Preop. T2WI

Feeder AN→likely site of Hx.

60M/ Rt. frontal AVM (SM grade II)

Catheter positionWorking angle

Plexal point Plexal point

ANcatheter

15% NBCA injection

Catheter position

NBCA 15%

Working angle

Plexal point Plexal point Plexal pointCast

ANcatheter


DWI (POD1)Catheter position & reflux

→ Transient hemipareseis

Emolization-related morbidity: Transient hemiparesis

Additional treatment: GK

mRS score at 6Mos: 3


12F/ Ruptured, Rt. splenial AVM (SM grade II)

Preop. T2WI Feeder: lateral PChA

Catheter positionWorking angle


Catheter positionWorking angleOnyx 18


DWI (POD1)


DWI high lesion : Yes

Emolization-related morbidity : No

Additional treatment : Open surgery

mRS score at 6Mos : 0


Discussions about AChA embolization

Case 2

Case 5

Case 8

Case 3

Case 7

Case 6Case 4

Case 1

Case 2

Case 5

Case 8

Case 3

Case 7

Case 6Case 4

Case 1

Catheter tip position4/8: plexal segment 4/8: plexal segment: proximal to the Plexal point

Case 2

Case 5

Case 8

Case 3

Case 7

Case 6Case 4

Case 1

Ischemic complication


No ischemic complication



Case 2

Case 5

Case 8

Case 3

Case 7

Case 6

Case 1





Suggesting a potential collateral circulation


Conclusions

Elkordy, Endo and Matsumoto. JNS 2016

❖ Ischemic complications are possible following the

embolization of cerebral AVMs through the choroidal artery,

even with modern neurointerventional devices and techniques.

❖ Embolization through the choroidal artery may be an

appropriate treatment option when the risk of surgery is

considered to outweigh the risk of embolization.

Elkordy, Endo and Matsumoto. JNS May 6, 2016

Documents

Yasushi Matsumoto · 2019. 1. 21. · Rhoton AL. Neurosurgery, 2002/ Takahashi S et al. AJNR, 1990/ Zeal AA et al. JNS, 1978 The perforating branches of the AChA passing through the