Comparison of Single- and Multi-Echo Susceptibility-Weighted Imaging in Detecting Cerebral Arteriovenous Shunts: A Preliminary Study.

Purpose: To compare the sensitivities of T2-weighted image (T2WI) and susceptibility-weighted imaging (SWI) in detecting cerebral arteriovenous fistula (AVF), cerebral arteriovenous malformation (AVM), and carotid-cavernous sinus fistula (CCF), and to qualitatively evaluate single-echo SWI (s-SWI) and multi-echo SWI (m-SWI) in characterizing vascular lesions. Materials and Methods: From January 2016 to December 2021, cerebral angiography-proven lesions were recruited. The sensitivities of T2WI and SWI in detecting vascular lesions were compared using McNemar's test. Qualitative evaluations of s-SWI and m-SWI were categorized to be of poor, average, or good quality and compared using Fisher's exact test. Results: A total of 24 patients (mean age: 61 years, 12 female, and 12 male) were enrolled. Twenty patients underwent s-SWI or m-SWI, and four patients underwent both. AVF, AVM, and CCF were diagnosed in 10, 11, and 3 patients, respectively. SWI demonstrated higher sensitivity compared to that of T2WI (82.1% vs. 53.6%, p = 0.013). m-SWI showed better image quality compared to that of s-SWI (good quality, 83.3% vs. 25.0%, p = 0.009). Conclusion: SWI demonstrated a higher sensitivity for detecting cerebral arteriovenous shunts compared to that of T2WI. m-SWI exhibited better image quality compared to that of s-SWI in characterizing vascular lesions.

Biopsy strategies for intermediate and high suspicion thyroid nodules with macrocalcifications.

OBJECTIVES: (1) To find strategies to improve diagnostic performance of ultrasound-guided biopsy of intermediate and high suspicion thyroid nodules with macrocalcifications. (2) To find malignancy rates of nodules with macrocalcification. MATERIALS AND METHODS: From 2018 to 2022, fine-needle aspiration biopsy (FNAB) and core needle biopsy (CNB) were retrospectively evaluated. Macrocalcifications were categorized into three types: intra-nodular, rim and entirely calcified. Diagnostic performance was compared between biopsy modes (FNAB vs. CNB) and FNAB techniques (to-and-fro vs. whirling). Multivariate logistic regression was performed to determine features associated with performance of FNAB. Malignancy rates were calculated according to macrocalcification types. RESULTS: A total of 114 procedures (87 FNAB and 27 CNB) in 89 nodules per 86 patients (mean age, 64 years; 76 women) were performed. Overall, CNB performed better than FNAB (unsatisfactory rate: 3.7% vs. 33.3%, p = .005). For macrocalcification thicker than 2 mm, whirling FNAB technique demonstrated a comparable unsatisfactory rate with statistical trends toward significance (to-and-fro: 69.2% vs. whirling: 27.8%, p = .055). The entirely calcified nodule was associated with poor performance of FNAB (adjusted odds ratio 4.46 [95% CI: 1.19-16.67], p = .027). Overall malignancy was 22.5%, higher in intra-nodular macrocalcification than rim and entirely calcified types (68.4% vs. 21.1% vs. 10.5%, p = .025). CONCLUSION: For the entirely calcified type, CNB should be considered first to improve diagnosis. For other types, FNAB can be performed, and whirling technique may be an alternative technique in thicker macrocalcification. Malignancy in intermediate and high suspicion nodules with macrocalcification have non-negligible rates.

Detection of cerebral aneurysm and intracranial vertebral dissection using non-enhanced magnetic resonance imaging in emergency setting: Emphasis on magnitude image of susceptibility-weighted image.

PURPOSE: To evaluate image features and diagnostic performance of susceptibility-weighted image (SWI) in detection of intracranial vertebral artery dissection (VAD) and unruptured intracranial aneurysm (UIA). MATERIALS AND METHODS: From January 2015 to December 2021, symptomatic patients who underwent 3.0 T MR SWI were recruited. For study group, transfemoral cerebral angiography-proven lesions were included, while 1:1 matched control group with MR angiography were included. Image features of SWI were evaluated. Diagnostic performance and interobserver agreements were calculated for detecting VAD with stenosis and UIA greater than 7 mm. RESULTS: Total of 110 patients (mean age: 60.92 years, female: 60/110) were included. In the study group (N = 55), 21 patients (38.2%) had VAD, while 34 patients (61.8%) had UIA. For SWI-detectable VAD, larger parent artery (PA)-dilatation ratio was observed (1.36 vs. 1.84, p = 0.034). For SWI-detectable UIA, larger PA-dome ratio (1.32 vs. 1.90, p = 0.020) and larger PA-height ratio (1.25 vs. 1.77, p = 0.005) were observed. The diagnostic performance and kappa values for VAD with stenosis were as follow: sensitivity: 91.7 (95% CI: 61.5-99.8); specificity: 93.9 (95% CI: 87.2-97.7); к: 0.80. The diagnostic performance for UIA larger than 7 mm were as follow: sensitivity: 87.5 (95% CI: 47.4-99.7); specificity: 95.1 (95% CI: 88.9-98.4); к: 0.73. CONCLUSION: SWI-detectable lesions were VAD with larger PA-dilatation ratio, and UIA with larger PA-dome ratio, and PA-height ratio. SWI was able to accurately detect VAD with stenosis and UIA larger than 7 mm with substantial interobserver agreements.

Monitoring Radiation Doses during Diagnostic and Therapeutic Neurointerventional Procedures: Multicenter Study for Establishment of Reference Levels.

PURPOSE: To assess patient radiation doses during diagnostic and therapeutic neurointerventional procedures from multiple centers and propose dose reference level (RL). MATERIALS AND METHODS: Consecutive neurointerventional procedures, performed in 22 hospitals from December 2020 to June 2021, were retrospectively studied. We collected data from a sample of 429 diagnostic and 731 therapeutic procedures. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time (FT), and total number of image frames (NI) were obtained. RL were calculated as the 3rd quartiles of the distribution. RESULTS: Analysis of 1160 procedures from 22 hospitals confirmed the large variability in patient dose for similar procedures. RLs in terms of DAP, CAK, FT, and NI were 101.6 Gy·cm2, 711.3 mGy, 13.3 minutes, and 637 frames for cerebral angiography, 199.9 Gy·cm2, 3,458.7 mGy, 57.3 minutes, and 1,000 frames for aneurysm coiling, 225.1 Gy·cm2, 1,590 mGy, 44.7 minutes, and 800 frames for stroke thrombolysis, 412.3 Gy·cm2, 4,447.8 mGy, 99.3 minutes, and 1,621.3 frames for arteriovenous malformation (AVM) embolization, respectively. For all procedures, the results were comparable to most of those already published. Statistical analysis showed male and presence of procedural complications were significant factors in aneurysmal coiling. Male, number of passages, and procedural combined technique were significant factors in stroke thrombolysis. In AVM embolization, a significantly higher radiation dose was found in the definitive endovascular cure group. CONCLUSION: Various RLs introduced in this study promote the optimization of patient doses in diagnostic and therapeutic interventional neuroradiology procedures. Proposed 3rd quartile DAP (Gy·cm2) values were 101.6 for diagnostic cerebral angiography, 199.9 for aneurysm coiling, 225.1 for stroke thrombolysis, and 412.3 for AVM embolization. Continual evolution of practices and technologies requires regular updates of RLs.

Endovascular Treatment of a Lumbar Spinal Epidural Arteriovenous Fistula with Radiculopathy: A Case Report.

Spinal epidural arteriovenous fistulas (SEDAVFs) are rare spinal vascular malformations that are difficult to diagnose and treat. SEDAVFs can be asymptomatic; however, symptoms can arise from the compression of adjacent nerve roots by dilated vein and perimedullary venous reflux, caused by shunting into the epidural venous plexus. A 31-year-old male presented to our institution with a 2-year history of progressively worsening low-back pain, radiating thigh pain, and sensory changes in his lower extremities. MRI and CT angiography demonstrated dilated epidural vascular lesion compressing the nerve root. The SEDAVF was embolized with multiple coils, which alleviated the nerve root compression from the engorged venous varix and improved the patient's radiculopathy. Our experience from this case shows that endovascular coil embolization using the transarterial approach can be an effective treatment for SEDAVF and an alternative to surgical ligations.

Whirling technique for thyroid fine needle aspiration biopsy: a preliminary study of effectiveness and safety.

PURPOSE: This study was aimed to compare thyroid fine needle aspiration biopsy (FNAB) techniques (conventional vs. whirling) in terms of cell harvesting ability ex vivo, the unsatisfactory rate and complication rate in vivo, and multi-operator performance in a phantom study. METHODS: In the ex vivo study, cell counts per background at ×100 magnification were compared between both techniques. In the in vivo study, 70 patients who underwent whirling FNAB from July 2019 to November 2019 were retrospectively compared to 140 matched patients who underwent conventional FNAB from January 2018 to November 2019 regarding the unsatisfactory rate and complication rate. As a subgroup analysis, thyroid nodules in difficult biopsy situations (nodule diameter <10 mm and location within 3 mm from major anatomical structures) were compared. In the phantom study, eight operators with varying experience recorded levels of dexterity and needle tip visualization, and their preferences for both techniques. RESULTS: In the ex vivo study, cell counts were comparable between both techniques in all thyroid nodule mimickers (80.0% vs. 87.5%, P=0.178). In the in vivo study, the unsatisfactory rate was comparable between the two groups (15.7% vs. 12.9%, P=0.859). In the subgroup analysis, the whirling technique demonstrated a lower unsatisfactory rate (5.9% vs. 24.2%, P=0.045) and a lower complication rate (0% vs. 6.1%, P=0.553). In the phantom study, the whirling technique demonstrated better dexterity and needle tip visualization and was preferred by all operators. CONCLUSION: This newly proposed whirling technique for thyroid FNAB may be effective and safe, especially in difficult biopsy situations.

Carotid Artery Stenting and Intracranial Thrombectomy for Tandem Cervical and Intracranial Artery Occlusions.

BACKGROUND: It remains controversial whether carotid artery stenting (CAS) is needed in cases of tandem cervical internal carotid artery occlusion (cICAO) and intracranial large vessel occlusion (LVO). OBJECTIVE: To investigate the efficacy and safety of CAS in combination with endovascular thrombectomy (CAS-EVT) in cICAO-LVO patients and to compare its outcomes with those of EVT without CAS (EVT-alone). METHODS: We identified all patients who underwent EVT for tandem cICAO-LVO from the prospectively maintained registries of 17 stroke centers. Patients were classified into 2 groups: CAS-EVT and EVT-alone. Clinical characteristics and procedural and clinical outcomes were compared between 2 groups. We tested whether CAS-EVT strategy was independently associated with recanalization success. RESULTS: Of the 955 patients who underwent EVT, 75 patients (7.9%) had cICAO-LVO. Fifty-six patients underwent CAS-EVT (74.6%), and the remaining 19 patients underwent EVT-alone (25.4%). The recanalization (94.6% vs 63.2%, P = .002) and good outcome rates (64.3% vs 26.3%, P = .007) were significantly higher in the CAS-EVT than in the EVT-alone. Mortality was significantly lower in the CAS-EVT (7.1% vs 21.6%, P = .014). There was no significant difference in the rate of symptomatic intracranial hemorrhage between 2 groups (10.7 vs 15.8%; P = .684) and according to the use of glycoprotein IIb/IIIa inhibitor (10.0% vs 12.3%; P = .999) or antiplatelet medications (10.2% vs 18.8%; P = .392). CAS-EVT strategy remained independently associated with recanalization success (odds ratio: 24.844; 95% confidence interval: 1.445-427.187). CONCLUSION: CAS-EVT strategy seemed to be effective and safe in cases of tandem cICAO-LVO. CAS-EVT strategy was associated with recanalization success, resulting in better clinical outcome.

Need for rescue treatment and its implication: stent retriever versus contact aspiration thrombectomy.

BACKGROUD: The need for rescue treatment (RT) may differ depending on first-line modality (stent retriever (SR) or contact aspiration (CA)) in endovascular thrombectomy (EVT). We aimed to investigate whether the type of first-line modality in EVT was associated with the need for RT. METHODS: We identified all patients who underwent EVT for anterior circulation large-vessel occlusion from prospectively maintained registries of 17 stroke centers. Patients were dichotomized into SR-first and CA-first. RT involved switching to the other device, balloon angioplasty, permanent stenting, thrombolytics, glycoprotein IIb/IIIa antagonist, or any combination of these. We compared clinical characteristics, procedural details, and final recanalization rate between the two groups and assessed whether first-line modality type was associated with RT requirement and if this affected clinical outcome. RESULTS: A total of 955 patients underwent EVT using either SR-first (n=526) or CA-first (n=429). No difference occurred in the final recanalization rate between SR-first (82.1%) and CA-first (80.2%). However, recanalization with the first-line modality alone and first-pass recanalization rates were significantly higher in SR-first than in CA-first. CA-first had more device passes and higher RT rate. The RT group had significantly longer puncture-to-recanalization time (93±48 min versus 53±28 min). After adjustment, CA-first remained associated with RT (OR, 1.367; 95% CI, 1.019 to 1.834). RT was negatively associated with good outcome (OR, 0.597; 95% CI, 0.410 to 0.870). CONCLUSION: CA was associated with requiring RT, while recanalization with first-line modality alone and first-pass recanalization rates were higher with SR. RT was negatively associated with good outcome.

Significance of Provocative Perfusion Computed Tomography for Evaluation of Bow Hunter Syndrome.

Bow hunter syndrome (BHS) is a rare vascular phenomenon of vertebrobasilar insufficiency caused by dynamic stenosis of the vertebral artery (VA) by osteophytes, fibrous bands, or disk herniation with neck rotation. We present a rare case of a patient with bilaterally patent VAs on neutral imaging and bilateral dynamic compression of VA with left head rotation. Provocation tests are critical toward understanding dynamic pathophysiology of BHS because normal neutral vascular imaging does not preclude diagnosis of BHS. Although dynamic angiography is the gold standard for diagnosis of BHS, cerebral angiography could be invasive and risky. Provocative test using perfusion computed tomography scan is a simple and noninvasive method to assess BHS on an outpatient basis.

Number of Stent Retriever Passes Associated With Futile Recanalization in Acute Stroke.

Background and Purpose- Stent retriever (SR) thrombectomy has become the mainstay of treatment of acute intracranial large artery occlusion. However, it is still not much known about the optimal limit of SR attempts for favorable outcome. We evaluated whether a specific number of SR passes for futile recanalization can be determined. Methods- Patients who were treated with a SR as the first endovascular modality for their intracranial large artery occlusion in anterior circulation were retrospectively reviewed. The recanalization rate for each SR pass was calculated. The association between the number of SR passes and a patient's functional outcome was analyzed. Results- A total of 467 patients were included. Successful recanalization by SR alone was achieved in 82.2% of patients. Recanalization rates got sequentially lower as the number of passes increased, and the recanalization rate achievable by ≥5 passes of the SR was 5.5%. In a multivariable analysis, functional outcomes were more favorable in patients with 1 to 4 passes of the SR than in patients without recanalization (odds ratio [OR] was 8.06 for 1 pass; OR 7.78 for 2 passes; OR 6.10 for 3 passes; OR 6.57 for 4 passes; all P<0.001). However, the functional outcomes of patients with ≥5 passes were not significantly more favorable than found among patients without recanalization (OR 1.70 with 95% CI, 0.42-6.90 for 5 passes, P=0.455; OR 0.33 with 0.02-5.70, P=0.445 for ≥6 passes). Conclusions- The likelihood of successful recanalization got sequentially lower as the number of SR passes increased. Five or more passes of the SR became futile in terms of the recanalization rate and functional outcomes.

Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Experience.

BACKGROUND AND PURPOSE: Effective rescue treatment has not yet been suggested in patients with mechanical thrombectomy (MT) failure. This study aimed to test whether rescue stenting (RS) improved clinical outcomes in MT-failed patients. METHODS: This is a retrospective analysis of the cohorts of the 16 comprehensive stroke centers between September 2010 and December 2015. We identified the patients who underwent MT but failed to recanalize intracranial internal carotid artery or middle cerebral artery M1 occlusion. Patients were dichotomized into 2 groups: patients with RS and without RS after MT failure. Clinical and laboratory findings and outcomes were compared between the 2 groups. It was tested whether RS is associated with functional outcome. RESULTS: MT failed in 148 (25.0%) of the 591 patients with internal carotid artery or middle cerebral artery M1 occlusion. Of these 148 patients, 48 received RS (RS group) and 100 were left without further treatment (no stenting group). Recanalization was successful in 64.6% (31 of 48 patients) of RS group. Compared with no stenting group, RS group showed a significantly higher rate of good outcome (modified Rankin Scale score, 0-2; 39.6% versus 22.0%; P=0.031) without increasing symptomatic intracranial hemorrhage (16.7% versus 20.0%; P=0.823) or mortality (12.5% versus 19.0%; P=0.360). Of the RS group, patients who had recanalization success had 54.8% of good outcome, which is comparable to that (55.4%) of recanalization success group with MT. RS remained independently associated with good outcome after adjustment of other factors (odds ratio, 3.393; 95% confidence interval, 1.192-9.655; P=0.022). Follow-up vascular imaging was available in the 23 (74.2%) of 31 patients with recanalization success with RS. The stent was patent in 20 (87.0%) of the 23 patients. Glycoprotein IIb/IIIa inhibitor was significantly associated with stent patency but not with symptomatic intracranial hemorrhage. CONCLUSIONS: RS was independently associated with good outcomes without increasing symptomatic intracranial hemorrhage or mortality. RS seemed considered in MT-failed internal carotid artery or middle cerebral artery M1 occlusion.

Collateral status affects the onset-to-reperfusion time window for good outcome.

OBJECTIVE: To characterise the time window in which endovascular thrombectomy (EVT) is associated with good outcome, and to test the differential relationship between functional outcome and onset-to-reperfusion time (ORT), depending on collateral status. METHODS: This was a retrospective analysis of clinical and imaging data of 554 consecutive patients, who had recanalisation success by EVT for anterior circulation large artery occlusion, from the prospectively maintained registries of 16 comprehensive stroke centres between September 2010 and December 2015. The patients were dichotomised into good and poor collateral groups, based on CT angiography. We tested whether the likelihood of good outcome (modified Rankin Scale, 0-2) by ORT was different between two groups. RESULTS: ORT was 298 min±113 min (range, 81-665 min), and 84.5% of patients had good collaterals. Age, diabetes mellitus, previous infarction, National Institutes of Health Stroke Scale, good collaterals (OR 40.766; 95% CI 10.668 to 155.78; p<0.001) and ORT (OR 0.926 every 30 min delay; 95% CI 0.862 to 0.995; p=0.037) were independently associated with good outcome. The drop in likelihood of good outcome associated with longer ORT was significantly faster in poor collateral group (OR 0.305 for every 30 min; 95% CI 0.113 to 0.822) than in good collateral group (OR 0.926 for every 30 min; 95% CI 0.875 to 0.980). CONCLUSIONS: Earlier successful recanalisation was strongly associated with good outcome in poor collateral group; however, this association was weak during the tested time window in good collateral group. This suggests that the ORT window for good outcome can be adjusted according to collateral status.

Complications of endovascular treatment for intracranial aneurysms: Management and prevention.

Endovascular coiling for intracranial aneurysms has become an accepted treatment with good clinical results and provides adequate protection against rebleeding and rupture of aneurysms. However, despite the experience, preparation, or skill of the physician, complications during endovascular treatment still occur. The main complications of endovascular coiling are: procedural aneurysmal perforations by the microcatheter, micro-guidewire, or coil, and thromboembolic events. Such situations are unexpected, complex, and can have devastating consequences. In this article, we present a comprehensive review of the two most common complications, aneurysmal perforation and thromboembolism during endovascular coiling, and how we can prevent or overcome these complications to achieve a satisfactory outcome. In addition, as the flow diverter has been become an important tool for management of large, wide necked, and other anatomically challenging aneurysms, we also describe complications stemming from the use of the tool, which remains a novel treatment option for complex aneurysms.

Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms: A Multicenter Study.

PURPOSE: To assess patient radiation doses during cerebral angiography and embolization of intracranial aneurysms across multi-centers and propose a diagnostic reference level (DRL). MATERIALS AND METHODS: We studied a sample of 490 diagnostic and 371 therapeutic procedures for intracranial aneurysms, which were performed at 23 hospitals in Korea in 2015. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time and total angiographic image frames were obtained and analyzed. RESULTS: Total mean DAP, CAK, fluoroscopy time, and total angiographic image frames were 106.2 ± 66.4 Gy-cm(2), 697.1 ± 473.7 mGy, 9.7 ± 6.5 minutes, 241.5 ± 116.6 frames for diagnostic procedures, 218.8 ± 164.3 Gy-cm(2), 3365.7 ± 2205.8 mGy, 51.5 ± 31.1 minutes, 443.5 ± 270.7 frames for therapeutic procedures, respectively. For diagnostic procedure, the third quartiles for DRLs were 144.2 Gy-cm(2) for DAP, 921.1 mGy for CAK, 12.2 minutes for fluoroscopy times and 286.5 for number of image frames, respectively. For therapeutic procedures, the third quartiles for DRLs were 271.0 Gy-cm(2) for DAP, 4471.3 mGy for CAK, 64.7 minutes for fluoroscopy times and 567.3 for number of image frames, respectively. On average, rotational angiography was used 1.5 ± 0.7 times/session (range, 0-4; n=490) for diagnostic procedures and 1.6 ± 1.2 times/session (range, 0-4; n=368) for therapeutic procedures, respectively. CONCLUSION: Radiation dose as measured by DAP, fluoroscopy time and image frames were lower in our patients compared to another study regarding cerebral angiography, and DAP was lower with fewer angiographic image frames for therapeutic procedures. Proposed DRLs can be used for quality assurance and patient safety in diagnostic and therapeutic procedures.

Hemangioma of the Maxillary Sinus Presenting as a Mass: CT and MR Features.

Hemangiomas of the sinonasal tract are rare, and because these lesions lack the typical signs or symptoms, they can be confused with other malignant conditions. We report a case of cavernous hemangioma of the maxillary sinus in a 68-year-old man that was completely resected by endoscopic sinus surgery. Although computed tomography (CT) and magnetic resonance imaging (MRI) showed several enhancing areas within the tumor, the substantial bone erosion and remodeling made it difficult to differentiate this cavernous hemangioma from other expansile maxillary sinus lesions. We present the CT and MR findings of this lesion and discuss the differential diagnoses and potential therapeutic approaches.

Multiple overlapping stent-assisted coiling of complex aneurysms: a single-center experience.

OBJECTIVES: Coil embolization of wide-necked and fusiform aneurysms is challenging and is frequently associated with recanalization despite assistance of any additional device. The purpose of this study was to evaluate the feasibility and mid-term outcomes of complex aneurysms after multiple overlapping stent-assisted coiling (OSAC). METHODS: We retrospectively evaluated 26 wide-necked and fusiform atherosclerotic or dissecting aneurysms that were treated with multiple OSAC. Eight aneurysms (30·8%) presented with subarachnoid hemorrhage and one (3·9%) with intracranial hemorrhage. RESULTS: Complete embolization was achieved in 15 of the 26 aneurysms (57·7%), while remnant neck was identified in nine (34·6%) and remnant aneurysm was noted in two (7·7%). Immediate procedure-related complications were observed in five patients (19·2%) including two with asymptomatic in-stent thrombosis, one with transient right-sided weakness, one with decreased mentality, and one with aphasia and quadriplegia. A procedure-related permanent neurologic deficit (modified Rankin scale scores of 1 and 5) was noted in two patients (7·7%). Angiographic follow-up (mean duration 23·9 months) after OSAC was carried out in 18 patients (69·2%): 11 (61·1%) were stable, 3 (16·7%) improved, 3 (16·7%) had minor compaction, and 1 had major recanalization (5·5%). One recurred aneurysm after OSAC and two recanalized aneurysms after single stenting were re-treated using additional stent-assisted coiling, and there was no recanalization in these three aneurysms during the 25·7 months after re-treatment. CONCLUSIONS: Multiple OSAC is feasible and effective for complex aneurysms and recurrent aneurysms after stent-assisted coiling.

Patient radiation dose in diagnostic and interventional procedures for intracranial aneurysms: experience at a single center.

OBJECTIVE: To assess patient radiation doses during cerebral angiography and embolization of intracranial aneurysms in a large sample size from a single center. MATERIALS AND METHODS: We studied a sample of 439 diagnostic and 149 therapeutic procedures for intracranial aneurysms in 480 patients (331 females, 149 males; median age, 57 years; range, 21-88 years), which were performed in 2012 with a biplane unit. Parameters including fluoroscopic time, dose-area product (DAP), and total angiographic image frames were obtained and analyzed. RESULTS: Mean fluoroscopic time, total mean DAP, and total image frames were 12.6 minutes, 136.6 ± 44.8 Gy-cm(2), and 251 ± 49 frames for diagnostic procedures, 52.9 minutes, 226.0 ± 129.2 Gy-cm(2), and 241 frames for therapeutic procedures, and 52.2 minutes, 334.5 ± 184.6 Gy-cm(2), and 408 frames for when both procedures were performed during the same session. The third quartiles for diagnostic reference levels (DRLs) were 14.0, 61.1, and 66.1 minutes for fluoroscopy time, 154.2, 272.8, and 393.8 Gy-cm(2) for DAP, and 272, 276, and 535 for numbers of image frames in diagnostic, therapeutic, and both procedures in the same session, respectively. The proportions of fluoroscopy in DAP for the procedures were 11.4%, 50.5%, and 36.1%, respectively, for the three groups. The mean DAP for each 3-dimensional rotational angiographic acquisition was 19.2 ± 3.2 Gy-cm(2). On average, rotational angiography was used 1.4 ± 0.6 times/session (range, 1-4; n = 580). CONCLUSION: Radiation dose in our study as measured by DAP, fluoroscopy time and image frames did not differ significantly from other reported DRL studies for cerebral angiography, and DAP was lower with fewer angiographic image frames for embolization. A national registry of radiation-dose data is a necessary next step to refine the dose reference level.

Reconstructive treatment of ruptured blood blister-like aneurysms with stent and coil.

BACKGROUND: Controversy remains about the optimal treatment for blood blister--like aneurysms (BBAs). OBJECTIVE: To evaluate clinical and angiographic outcomes after reconstructive treatment for BBA with stent and coil. METHODS: Thirty-four patients (6 men, 28 women; mean age, 47.3 years) with ruptured BBAs underwent reconstructive treatment with stent and coil. Posttreatment courses and outcomes were retrospectively evaluated. RESULTS: Initial treatments were ≥ 2 overlapping stents with or without coiling (n = 28) and single stent with coiling (n = 6). Three BBAs rebled on days 9, 11, and 15 after treatment, resulting in 1 death. Except for 3 patients who died early, 31 patients were followed up for 7 to 80 months (median, 32 months). One patient recovered completely but died of complications of systemic lupus erythematosus at 25 months. Of the remaining 30 patients, 25 had favorable outcomes (modified Rankin scale, 0-2) and 5 had unfavorable outcomes. Angiographic follow-up was available in the 32 BBAs. Eight (25.0%) recurred, all within 5 weeks. In the multiple stents group (n = 26), 22 BBAs showed improvement or complete healing, but 4 (15.4%, 2 rebleedings) had recurrence. In the single stent with coiling group (n = 6), 2 BBAs were stable but 4 (66.7%, 1 rebleeding) had recurrence. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence (P < .05). CONCLUSION: Reconstructive treatment with stent and coil appears a viable option for BBAs. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence. Follow-up angiography should be considered mandatory soon after treatment. ABBREVIATIONS: BBA, blood blister--like aneurysmICA, internal carotid arterymRS, modified Rankin ScaleSAH, subarachnoid hemorrhage.

Transvenous Embolization of Cavernous and Paracavernous Dural Arteriovenous Fistula through the Facial Vein: Report of 12 Cases.

PURPOSE: The aim of this study was to evaluate the feasibility and safety of the transfacial venous embolization of cavernous or paracavernous dural arteriovenous fistula (DAVF) in which approach via inferior petrosal sinus (IPS) was not feasible. MATERIALS AND METHODS: We identified the cases of transfacial venous embolization of cavernous sinus (CS) or adjacent dural sinuses from the neurointerventional database of three hospitals. The causes and clinical and angiographic outcomes of transfacial venous embolization were retrospectively evaluated. RESULTS: Twelve patients with CS (n = 11) or lesser wing of sphenoid sinus (LWSS, n = 1) DAVF were attempted to treat by transvenous embolization via ipsilateral (n = 10) or contralateral (n = 2) facial vein. Trans-IPS access to the target lesion was impossible due to chronic occlusion (n = 11) or acute angulation adjacent the target lesion (n = 1). In all twelve cases, it was possible to navigate through facial vein, angular vein, superior ophthalmic vein, and then CS. It was also possible to further navigation to contralateral CS through intercavernous sinus in two cases, and laterally into LWSS in one case. Post-treatment control angiography revealed complete occlusion of the DAVF in eleven cases and partial occlusion in one patient, resulting in complete resolution of presenting symptom in eight and gradually clinical improvement in four patients. There was no treatment-related complication during or after the procedure. CONCLUSION: In the cavernous or paracavernous DAVF in which trans-IPS approach is not feasible, the facial vein seems to be safe and effective alternative route for transvenous embolization.

Coil-protected embolization technique for a branch-incorporated aneurysm.

OBJECTIVE: A small branch-incorporated aneurysm is an aneurysm with a small branch incorporated into the sac or the neck. It is one of the most difficult aneurysms to treat with coil embolization. The aim of this study was to evaluate the safety and effectiveness of the coil-protected embolization technique for small-branch incorporated aneurysm. MATERIALS AND METHODS: Fourteen aneurysms (2 ruptured and 12 unruptured) in 12 patients (mean age, 56 years, range, 40-73 years; 6 men and 6 women) were treated with the coil-protected embolization technique during the period between February 2007 and October 2011. Clinical and angiographic outcomes were retrospectively evaluated. RESULTS: All aneurysms were successfully treated without any complications during the procedure. Immediate post-treatment angiographies demonstrated complete or near complete occlusion in 12 and incomplete occlusion in 2 patients. Two patients had a delayed small embolic infarction in the relevant posterior circulation territory and middle cerebral artery territory 10 days and 14 days later, respectively, but both recovered completely or almost completely (modified Rankin scale score [mRS score], 0 and 1, respectively). During the clinical follow-up period (mean, 21 months; range: 2-58 months), all patients reported an mRS score of 0 (n = 10) or 1 (n = 2). Vascular imaging follow-up (catheter angiography: n = 3 and MR angiography: n = 8) was available in 11 aneurysms at 6-12 months. All 11 aneurysms showed complete occlusion except for 1 minor neck recurrence that did not require further treatment. CONCLUSION: In this series of cases, the coil-protected embolization technique seems to be feasible and effective in the treatment of small-branch incorporated aneurysms.