Treatment Strategy of Unruptured Intracranial Aneurysms in Octogenarian Patients: A Single-Institution Experience.

AIM: To share our clinical insights into octogenarian patients with unruptured intracranial aneurysms (UIAs) and evaluate the treatment strategies for this demographic. MATERIAL AND METHODS: A retrospective analysis was conducted on data from 134 patients with a follow-up exceeding 6 months, all enrolled in this study. We assessed the incidence rates (IRs) of aneurysm growth and rupture, along with potential predictors of aneurysm growth. RESULTS: Among the 134 patients, 99 (73.9%) underwent conservative management, 25 (18.7%) received coiling, and 10 (7.5%) underwent clipping. The mean age of the cohort was 81.8 years. The middle cerebral artery was the most common location for aneurysms. The mean aneurysm size was 4.9 mm, with sizes significantly larger in the treatment groups (coiling and clipping) compared to the observation group (4.4 mm in the observation group; 5.9 and 7.4 mm in the coiling and clipping groups, respectively). The proportion of aneurysms with a daughter sac was higher in the treatment groups compared to the observation group (6.1% vs. 44% [coiling] and 50% [clipping]). The IR of aneurysm growth was 5.9 per 100 person-years, and that of aneurysm rupture was 0.8 per 100 person-years. No factors were statistically significant for aneurysm growth. CONCLUSION: Age alone, especially in individuals over 80 years old, may not be a contraindication for UIA treatment. We recommend considering treatment in octogenarians with high-risk aneurysm features, such as a large aneurysm and the presence of a daughter sac, as the complication rates are low.

Shunt-dependent hydrocephalus and shunt failure rate in patients with aneurysmal subarachnoid hemorrhage in Korea.

OBJECTIVE: Shunt-dependent hydrocephalus is a major complication of aneurysmal subarachnoid hemorrhage (SAH). Despite this, the factors influencing shunt dependency and shunt failure remain unclear. Therefore, the aim of this study was to estimate shunt dependency and failure rates and determine the contributing factors in patients with aneurysmal SAH using the Korean National Health Insurance database over a 13-year period. METHODS: Patients with aneurysmal SAH aged > 18 years who underwent surgical procedures were included. Using the shunt surgery prescription data, the shunt-dependent hydrocephalus rate was evaluated according to sex, age, aneurysm location, and year of admission. Among patients who underwent shunt surgery, the shunt failure rate was estimated using surgical prescription data. RESULTS: A total of 57,030 patients with SAH who underwent aneurysm surgery were included. The overall raw rate of shunt-dependent hydrocephalus was 15.0% (8530/57,030). Age (HR 1.04, 95% CI 1.04-1.04; p < 0.001) and endovascular coiling (vs surgical clipping, HR 0.71, 95% CI 0.67-0.74; p < 0.001) were related to shunt-dependent hydrocephalus in the multivariate logistic regression analysis. Posterior circulation and anterior communicating aneurysms showed a high risk of shunt dependency. Among 8530 patients who underwent shunt surgery, the shunt failure rate was 11.3% (961/8530). Female sex (HR 1.18, 95% CI 1.01-1.39; p = 0.0324), age (HR 0.99, 95% CI 0.98-0.99; p < 0.001), early shunt placement (HR 1.25, 95% CI 1.08-1.47; p = 0.004) and lumboperitoneal shunt placement (HR 2.19, 95% CI 1.65-2.91; p < 0.001) were the risk factors for shunt failure in the multivariate logistic regression analysis. CONCLUSIONS: The rate of shunt-dependent hydrocephalus after aneurysmal SAH was 15.0% in this study using a medical claims database in Korea. The shunt surgery rate was highest in patients in their 60s and 70s. Shunt failure occurred in 11.3% of the patients, and a lumboperitoneal shunt was most related to the need for revision surgery.

Real-World Impact of Modern Reperfusion Therapy for Acute Ischemic Stroke : A Nationwide Population-Based Data Study in Korea.

OBJECTIVE: The treatment paradigm for acute ischemic stroke has undergone several major changes in the past decade, contributing to improved patient prognosis in clinical practice. However, the extent to which these changes have affected patient prognosis in the real-world is yet to be clarified. This study aimed to evaluate the real-world impact of modern reperfusion therapy for acute ischemic stroke using data from the National Health Insurance Service in Korea. METHODS: This study included patients aged 18-80 years who were admitted via the emergency room with an I63 code between 2011 and 2020. The rates of intravenous thrombolysis use and endovascular treatment according to the year of admission were investigated. Furthermore, the rates of decompressive craniectomy and 3-month mortality were also analyzed. The 10-year observational period was divided into three periods based on the 2015 guideline change as follows : prior, 2011-2014; transitional, 2015-2016; and modern, 2017-2020. RESULTS: A total of 307117 patients (mean age, 65.7±10.9 years) were included, and most patients were male (59.7%). The rate of endovascular treatment gradually increased during the study period from 0.71% in the prior period to 1.32% in the transitional period and finally to 1.85% in the modern period. Meanwhile, the 3-month mortality rate gradually decreased from 4.78% in the prior period to 4.03% in the transitional period and to 3.71% in the modern period. CONCLUSION: In Korea, the mortality rate decreased as the rate of modern reperfusion therapy increased in patients with acute ischemic stroke. Overall, technical and scientific advances in reperfusion therapy have improved the outcome of patients with acute ischemic stroke in Korea.

Flow diversion via telescoping stent with Low-profile Visualized Intraluminal Support Junior for treatment of ruptured dissecting aneurysm located at proximal posterior inferior cerebellar artery.

Dissecting aneurysm involving the posterior inferior cerebellar artery (PICA) are challenging because of its nature and anatomic relationship to medulla and lower cranial nerve. We introduce a case of ruptured dissecting aneurysm located at the proximal PICA treated with telescoping stents for flow diversion and dissection healing. A 49 years old female visited to the emergency room for ruptured dissecting aneurysm at right proximal PICA. Telescoping stent was deployed along the right vertebral artery to PICA covering the dissecting aneurysm bleb using two Low-profile Visualized Intraluminal Support Jr (LVIS Jr) stents. Three months follow up angiography revealed a disappearance of aneurysm bleb and healing of dissection by parent artery remodeling. Telescoping stent with LVIS Jr may be an effective treatment for dissecting aneurysm with small diameter (<2 mm) parent artery. Convenient navigation and targeted telescoping stent for minimizing metal coverage at perforating arteries are an advantage for this method.

Misdiagnosis of Spontaneous Intracranial Hypotension Presenting as Acute Mental Deterioration Caused by Unilateral Acute Subdural Hematoma: Case Report.

Spontaneous intracranial hypotension (SIH) is usually a benign disease which mostly present as orthostatic headache and resolves by conservative treatment or epidural blood patch. However, in severe cases large subdural hematoma or brain caudal herniation can progress to brain herniation and neurologic complications. We introduce a rare case of SIH which presented as acute mental deterioration with unilateral acute subdural hematoma. A 60 years old female visited to emergency room for stuporous mental change and unilateral acute subdural hematoma. Decompressive craniectomy and hematoma removal was performed to release brain herniation and increased intracranial pressure. There was temporary improvement of consciousness, but sustained leakage of cerebrospinal fluid (CSF) and caudal brain herniation worsened patient's condition. After recognizing that CSF leakage and hypovolemia was the underlying disease, emergent epidural blood patch and early cranioplasty was performed. After treatment CSF volume was normalized and patient recovered completely without neurologic deficits. Acute mental deterioration with unilateral subdural hematoma is a rare presentation for SIH. Treatment strategy for subdural hematoma with concomitant SIH patients, should be planned carefully with concerns to CSF hypovolemia and intracranial pressure.

High-degree centrum semiovale-perivascular spaces are associated with development of subdural fluid in mild traumatic brain injury.

BACKGROUND: Severe centrum semiovale perivascular spaces (CSO-PVSs) are associated with the onset of brain atrophy and dementia. This study explored the relationship between severity of CSO-PVS and development of subdural fluid (SDF) in patients with mild traumatic brain injury (TBI), with the aim of investigating independent radiological risk factors for development of SDF. METHODS: The study cohort comprised 222 patients with a mean age of 51 years (64.0% men) who presented with mild TBI from January 2013 to November 2016. In this study, mild TBI was defined as a Glasgow Coma Scale (GCS) of ≥ 13, Post-Traumatic Amnesia (PTA) of <1 day, and Loss of Consciousness (LOC) of <30 minutes. The severity of CSO-PVS was categorized as low or high-degree. RESULTS: Among the 222 enrolled patients, 38 (17.1%) and 90 (40.5%) had high-degree PVS in the basal ganglia (BG) and centrum semiovale, respectively. Compared with patients who did not develop SDF, the mean age of patients who developed SDF was significantly higher (47.41 years versus 60.33 years, P < 0.0001). The incidence of de novo SDF was significantly higher in men than in women (77.8% versus 59.5%, P = 0.0151). Patients who showed SDF on brain computed tomography at admission more frequently developed de novo SDF (68.5% versus 38.1%, P < 0.0001). In multivariate logistic regression analysis of risk factors, high-degree CSO-PVS, male sex, initial SDF on admission, and old age were independently associated with development of de novo SDF after mild TBI. In Cox proportional hazards models of risk factors for SDF-development free survival rate, high-degree CSO-PVS, old age, and initial subdural hemorrhage showed statistically significant differences. CONCLUSIONS: Our study might help neurosurgeons determine the frequency of brain CT or the duration of follow-up for patients who present with mild TBI with high-degree CSO-PVS.

Relationship between ophthalmic artery flow direction and visual deterioration after carotid angioplasty and stenting.

OBJECTIVE: Visual deterioration is one of the disabling complications that can occur after carotid angioplasty and stenting (CAS). The purpose of this study was to evaluate the risk factors for newly developed visual symptoms after CAS, focusing on ophthalmic artery (OA) flow pattern and etiology of visual loss. METHODS: A retrospective review of 127 patients with 138 internal carotid artery (ICA) stenosis lesions that were treated with CAS from February 2009 to October 2017 in a single institution was performed. The flow pattern of the OA was evaluated with digital subtraction angiography and classified into 3 types: type I, antegrade OA flow before and after CAS; type II, antegrade OA flow reversal after CAS; and type III, retained nonantegrade OA flow after CAS. RESULTS: The degree of ipsilateral ICA stenosis was significantly higher in the nonantegrade group than that in the antegrade group (81.73% ± 9.87% vs 75.74% ± 10.27%, p = 0.001). Independent risk factors for newly developed visual symptoms after CAS were visual symptoms before CAS (OR 65.29, 95% CI 5.14-827.2; p = 0.001) and type III OA flow pattern (OR 55.98, 95% CI 2.88-1088.0; p = 0.008). The post-CAS visual symptoms in 10 patients were related to acute elevation of intraocular pressure in 6 patients and retinal artery occlusion in 3 patients. CONCLUSIONS: Maintained retrograde or undetected OA flow after CAS and initial visual symptoms before CAS were related to post-CAS visual symptoms. Thus, careful attention is needed for these patients during the perioperative period, and immediate evaluation and management are required for patients with post-CAS visual loss.

Correction to: Cerebrolysin for the Treatment of Aneurysmal Subarachnoid Hemorrhage in Adults: A Retrospective Chart Review.

Unfortunately the funding information is incorrect in the published article.

Risk factors for recurrence and retreatment after endovascular treatment of intracranial saccular aneurysm larger than 8 mm.

BACKGROUND: Large intracranial aneurysm is challenging for both surgical and endovascular treatment. High recurrence and retreatment rates are still limitations for endovascular treatment. Analysing risk factors of recurrence after endovascular treatment can be useful for planning future treatment strategies. METHOD: We retrospectively reviewed patients with intracranial saccular aneurysm (≥ 8 mm) who underwent endovascular treatment from 2008 to 2017 at our institution. The demographic features, clinical information and angiographic results were analysed to reveal the risk factors for recurrence and retreatment. Subgroup analysis was performed according to packing density (PD) and stent insertion status. RESULTS: The total recurrence and retreatment rates were 25.7% (44/171) and 10.5% (18/171), respectively. Independent risk factors for recurrence after endovascular treatment were larger aneurysm size (OR 1.32; 95% CI 1.17-1.51; p < 0.001), ruptured status (OR 3.91; 95%CI 1.44-10.90; p = 0.008), initial incomplete occlusion (OR 2.72; 95%CI 1.18-6.41; p = 0.020), and low dome-to-neck ratio (OR 0.61; 95%CI 0.36-0.97; p = 0.047). The recurrence rate for the no-stent with low PD (< 17.5%) group was 50% (14/28); 37.5% (6/16) for stent-assisted coil (SAC) with low PD group, 22.0% (20/91) for no-stent with high PD group and 11.1% (4/36) for SAC with high PD group. CONCLUSION: The independent risk factors for recurrence after endovascular treatment in large (≥ 8 mm) intracranial saccular aneurysm were larger aneurysm size, ruptured status, low dome-to-neck ratio and initial incomplete occlusion state. SAC is a useful method for lowering recurrence after endovascular treatment for relatively large (≥ 8 mm) cerebral aneurysm.

Cerebrolysin for the Treatment of Aneurysmal Subarachnoid Hemorrhage in Adults: A Retrospective Chart Review.

INTRODUCTION: Cerebrolysin is a neuroprotective drug used in the treatment of acute ischemic stroke. To our knowledge, this drug has never been evaluated in patients with aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to evaluate the effect of Cerebrolysin in patients with aneurysmal SAH. METHODS: Aneurysmal SAH patients who had their aneurysm obliterated at our institution from 2007 to 2016 were retrospectively studied. Patients received Cerebrolysin treatment or standard care only (control group). Subgroup analyses were performed according to Hunt and Hess grade (good grade ≤ 2, N = 216; poor grade ≥ 3, N = 246) and treatment procedure (clip or coil). RESULTS: In good-grade patients (N = 216), clinical outcomes and mortality did not differ significantly between the control and Cerebrolysin groups. In poor-grade patients (N = 246), the mortality rate was significantly lower in the Cerebrolysin group (8.7%) than in the control group (25.4%, p = 0.006). In patients who received microsurgical clipping (N = 328), the mortality rate was significantly lower in the Cerebrolysin group (7.3%) than in the control group (18.5%, p = 0.016). CONCLUSION: Cerebrolysin injection during the acute period of SAH appeared to reduce the mortality rate, especially in poor-grade patients. This study suggests the potential of Cerebrolysin for treating aneurysmal SAH. Further studies are needed to confirm our results.

Predicting factors for shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) is a major complication that leads to a medical burden and poor clinical outcomes. The aim of this study was to evaluate the predictive factors of shunt-dependent hydrocephalus focusing on postoperative fever and infection. METHOD: A total of 418 patients were included in this study and the patient demographic features, radiologic findings, days of fever burden, and infection were compared between the shunt (n = 72) and no shunt group (n = 346). Days of fever burden was defined as the total number of days with the highest body temperature ≥ 38.0 °C each day from day 1 to day 14. Pneumonia, urinary tract infection (UTI), meningitis, and bacteremia were recorded in all patients. RESULTS: The independent predictive factors for shunt-dependent hydrocephalus were older age ≥ 65, microsurgical clipping, placement of extraventricular drainage (EVD), days of fever burden, and infection. The incidence of shunt dependency was 2.4% in the no fever burden patients (n = 123), 14.9% in the 1-3 days of fever burden patients (n = 161), 27.0% in the 4-6 days of fever burden patients (n = 74), and 41.7% in the ≥ 7 days of fever burden patients with statistical significance among groups (p < 0.001). CONCLUSION: The rate of shunt dependency increased proportionally as the days of fever burden increased. Older age (≥ 65), microsurgical clipping, placement of EVD, days of fever burden, and infection were independent predictive factors for shunt dependency. Proper postoperative care for maintaining normal body temperature and preventing infectious disease can help reduce the rate of shunt dependency and improve clinical outcomes.

Intraprocedural Rupture During Endovascular Treatment of Intracranial Aneurysm: Clinical Results and Literature Review.

OBJECTIVE: Intraprocedural rupture (IPR) during endovascular treatment of cerebral aneurysm is the most feared complication, with high morbidity and mortality. The aim of this study was to estimate the incidence and risk factors of IPR during endovascular treatment of ruptured and unruptured cerebral aneurysms. METHODS: A total of 235 intracranial aneurysms (80 ruptured and 155 unruptured) in 219 patients who received endovascular treatment in our institution between January 2010 and December 2016 were enrolled in our study. Demographic and radiologic data were analyzed to evaluate risk factors of IPR. We conducted a literature review to estimate the incidence of IPR according to rupture status and aneurysm location. RESULTS: Ten patients (6 ruptured, 4 unruptured) experienced IPR during endovascular treatment. The IPR incidence was 7.5% in ruptured and 2.5% in unruptured aneurysms. Aneurysm size (smaller than 3.58 mm) and anterior communicating artery aneurysm were independent risk factors for IPR. According to the literature review, the overall IPR incidence was 4.47% (393/8791) in ruptured and 1.43% (145/10,131) in unruptured aneurysms. CONCLUSIONS: Independent risk factors for IPR during endovascular treatment of intracranial aneurysm were aneurysm size and anterior communicating artery aneurysm. Ruptured aneurysms showed a higher tendency toward IPR than did unruptured aneurysms.

Predictive Factors of Fever After Aneurysmal Subarachnoid Hemorrhage and Its Impact on Delayed Cerebral Ischemia and Clinical Outcomes.

OBJECTIVE: Fever is relatively common and worsens neurologic injury after aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to display the time course of body temperature, identify predictive factors of fever after SAH, and evaluate its impact on delayed cerebral ischemia (DCI) and clinical outcomes. METHODS: Four hundred twelve patients with SAH and ruptured aneurysms who were treated at our institution between January 2007 and December 2016 were analyzed retrospectively. The febrile group was defined as patients having a maximal temperature ≥38.0°C for 2 consecutive days or for more than 3 days within 2 weeks after SAH, and the remaining patients comprised the afebrile group. The impact of fever on DCI and clinical outcomes was assessed. RESULTS: Anterior communicating artery aneurysm, Hunt and Hess grade, SAH sum score, intraventricular hemorrhage sum score, and body mass index were independent predictive factors for fever after SAH. A larger SAH and fever were independent risk factors for DCI. A worse Hunt and Hess grade, concomitant intracerebral hemorrhage, DCI, old age, and fever were independent risk factors for unfavorable outcomes. CONCLUSIONS: Predictors of fever after SAH were a worse clinical status at admission, larger SAH and intraventricular hemorrhage, anterior communicating artery aneurysm, and greater body mass index. Fever itself was an independent risk factor for DCI and unfavorable outcomes after aneurysmal SAH.

Spontaneous anterior cerebral artery dissection presenting with simultaneous subarachnoid hemorrhage and cerebral infarction in a patient with multiple extracranial arterial dissections.

Simultaneous subarachnoid hemorrhage and infarction is a quite rare presentation in a patient with a spontaneous dissecting aneurysm of the anterior cerebral artery. Identifying relevant radiographic features and serial angiographic surveillance as well as mode of clinical manifestation, either hemorrhage or infarction, could sufficiently determine appropriate treatment. Enlargement of ruptured aneurysm and progressing arterial stenosis around the aneurysm indicates impending risk of subsequent stroke. In this setting, prompt treatment with stent-assisted endovascular embolization can be a reliable alternative to direct surgery. When multiple arterial dissections are coexistent, management strategy often became complicated. However, satisfactory clinical results can be obtained by acknowledging responsible arterial site with careful radiographic inspection and antiplatelet medication.

The relationship between metabolic syndrome (MetS) and spontaneous intracerebral hemorrhage (ICH).

Metabolic syndrome (MetS), well-known risk factor for cardiovascular diseases and ischemic stroke, would be associated with an increased incidence of spontaneous non-lesional intracerebral hemorrhage (ICH) because of some pathophysiologic overlaps between stroke subtypes. The purpose of this study is to identify the associations between MetS components, cerebral infarctions and ICH volume. In this review, demographic and computed tomographic data describing five elements constituting MetS as well as hematoma volume were assessed in 829 spontaneous ICH patients over 10 consecutive years. The same data were also assessed from a control group. The incidence and average numbers of MetS components differed significantly between ICH and control group (p = 0.002, <0.001). When ICH patients were divided into two groups based on whether they had MetS, the average number of MetS components was significantly different (p < 0.001). When the ICH group was divided into two groups based on whether the ICH was accompanied by cerebral infarction, the cerebral infarction group had significantly higher blood pressure, fasting glucose levels and triglyceride levels. When the ICH group was divided based on hematoma volume, there were no significant differences between groups. ICH patients presented more components of MetS than the control group, but detailed relationship between MetS and spontaneous ICH have yet to be completely understood. This study confirmed the association between ICH patients with cerebral infarction and individual MetS components, and therefore the authors strongly suggest controlling hypertension, and maintaining appropriate levels of blood sugar and triglyceride when treating high-risk patients.