Yuki Yamamoto, Nobuaki Yamamoto, Ayato Kageyama, Izumi Yamaguchi, Takeshi Miyamoto, Masaaki Korai, Kenji Shimada, Yasushi Takagi and Yuishin Izumi : The Railroad Technique: A Mechanical Thrombectomy Approach Using Serial Deployment of Two Stent Retrievers for Tandem ICA-M1 Embolic Occlusion, Journal of Neuroendovascular Therapy, 19, 1, 0125, 2025.
(Summary)
Tandem occlusions in acute ischemic stroke are usually atherothrombotic; however, in rare cases, they may result from simultaneous emboli at both proximal and distal sites. Embolic tandem occlusions pose challenges for endovascular therapy because single-stent retrievers (SRs) or aspiration approaches often require multiple passes. This report describes a novel technique that uses serially aligned SRs for en bloc retrieval. A 90-year-old woman with atrial fibrillation presented with a National Institutes of Health Stroke Scale (NIHSS) score of 22. Imaging revealed an embolic tandem occlusion of the intracranial internal carotid artery (ICA) and the M1 segment of the middle cerebral artery (MCA), with a large penumbra and no ischemic core. A mechanical thrombectomy was performed. Using a 0.074-inch inner diameter distal access catheter, a microcatheter was guided into the M2 inferior trunk. An SR (4 × 40 mm) was deployed across the M2 trunk from the M1 thrombus, followed by the deployment of another SR (6 × 37 mm) across the ICA thrombus. This "Railroad Technique," in which 2 SRs are deployed in a straight, serial alignment, enabled simultaneous capture and en bloc retrieval of both thrombi in a single pass, resulting in recanalization of the ICA and M1. A 2nd pass with an SR and aspiration catheter resulted in modified thrombolysis in cerebral infarction (mTICI) 2b reperfusion. The patient recovered rapidly. The Railroad Technique may be a feasible option for embolic tandem occlusions with large thrombus volumes and anatomically distant lesions.
Noriya Enomoto, Kazuhito Matsuzaki, Tomohiro Matsuda, Tadashi Yamaguchi, Takeshi Miyamoto, Mami Hanaoka, Natsumi Teshima, Ayato Kageyama, Yuichi Satoh, Tatsuya Haboshi, Masaaki Korai, Kenji Shimada, Hitoshi Niki, Koichi Satoh and Yasushi Takagi : Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma, Acta Neurochirurgica, 166, 1, 272, 2024.
(Summary)
Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.
(Keyword)
Acute subdural hematoma / Decompressive craniectomy / Head trauma / Hinge craniotomy