Middle Meningeal Artery Embolization for Chronic Subdural Hematoma.

Purpose To evaluate the effect of middle meningeal artery (MMA) embolization on chronic subdural hematoma (CSDH) and compare the treatment outcomes of MMA embolization and conventional treatment. Materials and Methods All consecutive patients 20 years or older with CSDH were assessed for eligibility. CSDHs with a focal location, a thickness of 10 mm or less, no mass effect, or underlying conditions were excluded. Seventy-two prospectively enrolled patients with CSDH underwent MMA embolization (embolization group; as the sole treatment in 27 [37.5%] asymptomatic patients and with additional hematoma removal for symptom relief in 45 [62.5%] symptomatic patients). For comparison, 469 patients who underwent conventional treatment were included as a historical control group (conventional treatment group; close, nonsurgical follow-up in 67 [14.3%] and hematoma removal in 402 [85.7%] patients). Primary outcome was treatment failure defined as a composite of incomplete hematoma resolution (remaining or reaccumulated hematoma with thickness > 10 mm) or surgical rescue (hematoma removal for relief of symptoms that developed with continuous growth of initial or reaccumulated hematoma). Secondary outcomes included surgical rescue as a component of the primary outcome and treatment-related complication for safety measure. Six-month outcomes were compared between the study groups with logistic regression analysis. Results Spontaneous hematoma resolution was achieved in all of 27 asymptomatic patients undergoing embolization without direct hematoma removal. Hematoma reaccumulation occurred in one (2.2%) of 45 symptomatic patients receiving embolization with additional hematoma removal. Treatment failure rate in the embolization group was lower than in the conventional treatment group (one of 72 patients [1.4%] vs 129 of 469 patients [27.5%], respectively; adjusted odds ratio [OR], 0.056; 95% confidence interval [CI]: 0.011, 0.286; P = .001). Surgical rescue was less frequent in the embolization group (one of 72 patients [1.4%] vs 88 of 469 patients [18.8%]; adjusted OR, 0.094; 95% CI: 0.018, 0.488; P = .005). Treatment-related complication rate was not different between the two groups (0 of 72 patients vs 20 of 469 patients [4.3%]; adjusted OR, 0.145; 95% CI: 0.009, 2.469; P = .182). Conclusion MMA embolization has a positive therapeutic effect on CSDH and is more effective than conventional treatment. © RSNA, 2017.

Risk factor analysis of recanalization and retreatment for patients with endovascular treatment of internal carotid artery bifurcation aneurysms.

PURPOSE: Only a few reports of internal carotid artery (ICA) bifurcation aneurysms using the endovascular technique have been published in the current literature. The purpose of this study was to assess how multiple risk factors including angioarchitectural features of ICA bifurcation characteristics may have influenced aneurysmal rupture, recanalization, and retreatment. METHODS: Fifty-one patients with 52 ICA bifurcation aneurysms treated with endovascular coiling between July 2003 and July 2015 were retrospectively analyzed. The patients' clinical records, endovascular reports, and clinical and angiographic outcomes were reviewed. We also evaluated risk factors for recanalization and retreatment, including the angioarchitectural anatomy. RESULTS: The clinical outcomes were observed to be satisfactory in 49 patients (96.0%) and unfavorable in 2 patients (4.0%). The risk factor for aneurysmal rupture was young age (P = 0.024). Symptomatic complications due to thromboembolism occurred in 1.9% of cases; no patients suffered a fatal complication. Eleven of 52 ICA bifurcation aneurysms (21.2%) were recanalized within an average of 54.3 ± 33.5 months of follow-up. Among the aneurysms, 4 (7.7%) underwent recoiling. Multivariate analysis showed that ruptured aneurysms (P = 0.006) and a lower packing density (P = 0.048) were risk factors for recanalization. A lower packing density was the only risk factor for retreatment (P = 0.019). CONCLUSION: Endovascular treatment of ICA bifurcation aneurysms is considered safe and acceptable. This study showed that the ICA bifurcation aneurysms ruptured more frequently at a younger age. A higher packing density has been shown to reduce major recanalization and retreatment.

P2Y12 Reaction Units Threshold for Implementing Modified Antiplatelet Preparation in Coil Embolization of Unruptured Aneurysms: A Prospective Validation Study.

Purpose To identify and apply an optimized P2Y12 reaction units (PRU) threshold for implementing modified antiplatelet preparation to prevent thromboembolic events in patients nonresponsive to clopidogrel (clopidogrel nonresponders) undergoing coil embolization of unruptured aneurysms and to evaluate the clinical validity. Materials and Methods The optimal PRU threshold for prediction of thromboembolic events was determined with the Youden index in post hoc analysis of a previous, prospectively enrolled cohort of 165 patients in whom the antiplatelet regimen was not modified. This optimal PRU threshold was used to define clopidogrel nonresponders in a prospective validation study of 244 patients. Standard preparation (aspirin, clopidogrel) was maintained for 126 patients responsive to clopidogrel (clopidogrel responders, 51.6%), and modified preparation (aspirin, prasugrel) was prescribed prior to embolization for 118 clopidogrel nonresponders (48.4%). Fifty-seven clopidogrel nonresponders from the previous cohort who did not receive the modified preparation were included as a historical control group. Thromboembolic and bleeding events were compared among groups by using logistic regression analysis. Results Post hoc analysis from the previous cohort yielded PRU of at least 220 as the optimal threshold for modified preparation selection. The thromboembolic event rate of the clopidogrel responders (one of 126 [0.8%]) was lower than that of the historical control group that received standard preparation (seven of 57 patients [12.3%]; adjusted risk difference [RD], -10.1%; 95% confidence interval [CI]: -18.5, -1.7; P = .015) and was similar to that of clopidogrel nonresponders who received modified preparation (one of 118 [0.8%]; adjusted RD, -0.5%; 95% CI: -3.1, 2.1; P = .001 for noninferiority; P = .699 for superiority). Bleeding event rates did not differ among groups (four of 126 clopidogrel responders [3.2%] vs four of 57 clopidogrel nonresponders that received standard preparation [7.0%] [adjusted RD, -4.5%; 95% CI: -11.1, 3.4; P = .228] vs five of 118 clopidogrel nonresponders that received modified preparation [4.2%] [adjusted RD, -0.6%; 95% CI: -5.8, 4.2; P = .813]). Conclusion Patients undergoing coil embolization of unruptured aneurysms, regardless of clopidogrel responsiveness, had low thromboembolic risk when using PRU of at least 220 as the threshold for implementing modified antiplatelet preparation with prasugrel. © RSNA, 2016 Online supplemental material is available for this article.

Major recanalization occurs more often in young patients after unruptured aneurysm coil embolization.

BACKGROUND: The recanalization rate after coil embolization of unruptured aneurysms was compared between young and old age groups. METHODS: From May 2003 to December 2010, 636 patients with 715 saccular unruptured intracranial aneurysms (UIA) underwent endovascular coiling and were followed for at least 6 months. For comparative analysis, patients were categorized into two groups according to age 40: 42 patients with 46 aneurysms who were 40 years or younger (young age group) and 594 patients with 669 aneurysms who were older than 40 years (old age group). Angiographic and clinical outcomes including recanalization rates were compared. RESULTS: Angiographically, class 1 or 2 occlusion according to the Raymond-Roy Occlusion Classification system was achieved in 89.2 % of the patients (91.3 % in the young age group and 89.1 % in the old age group, p = 0.74). Procedure-related complication rate was 2.2 % and 3.4 % in the young and the old age group (p = 0.16), respectively. The mean follow-up duration was 30.51 ± 18.59 months. Major recanalization occurred in seven aneurysms (15.2 %) in the young age group and in 44 aneurysms (6.6 %) in the old age group (p = 0.03). Retreatment was performed in seven patients (15.2 %) in the young age group and in 35 patients (5.2 %) in the old age group (p = 0.01). CONCLUSIONS: The present study showed that the technical feasibility and safety of endovascular coiling for UIA did not differ between the two age groups. However, the major recanalization rate was higher in the young age group.

Early carotid artery stenting for symptomatic carotid artery stenosis.

BACKGROUND: The aim of present study was to assess safety and efficacy of early carotid artery stent (CAS) in patients with symptomatic carotid artery stenosis compared with delayed CAS. METHODS: This retrospective study was approved by the institutional review board, and the requirement to obtain written informed consent was waived. Outcomes of 206 patients with symptomatic carotid stenosis who were treated by CAS were analyzed. According to CAS timing from last symptom, patients were divided into early (within 2 weeks, 74 [35.0 %]) and delayed (after 2 weeks, 112 [64.1 %]) group by CAS timing from the last symptom. Procedural complication and early (≤30 days of CAS) event (ipsilateral stroke or any death) for safety, and late (31 days to 1 year of CAS) event for efficacy of CAS preventing further stroke were evaluated. The two groups were compared using Cox proportional hazard analysis. RESULTS: No difference was found in procedural complication between the groups (early 2 [2.7 %] vs. delayed group 7 [5.3 %], hazard ratio [HR] 0.61, 95 % confidence interval [CI] 0.123-2.979, p = 0.537). In the early group, however, early event developed more frequently than in the late group (9 [12.2 %] vs. 1 [0.8 %], HR 16.05, 95 % CI 1.991-129.438, p = 0.009). The late event rate showed no difference between the two groups (4 [5.4 %] vs. 4 [3.0 %], HR 2.09, 95 % CI 0.484-8.989, p = 0.324). CONCLUSIONS: Early CAS is not safe during periprocedural period, compared with late CAS. In CAS for symptomatic carotid stenosis, delayed CAS should be considered.

Morphology and related hemodynamics of the internal carotid arteries of moyamoya patients.

BACKGROUND: Morphological studies investigating the intracranial-extradural internal carotid artery with moyamoya disease have not been reported. We designed this case-control study to investigate the morphological differences of the internal carotid artery with moyamoya disease, and to clarify the contributions of these differences to the resultant fluid dynamics. METHODS: Patients with moyamoya disease and normal controls were assigned to each group. The vascular tortuosity of internal carotid artery was measured with three-dimensional rendering using magnetic resonance angiography. By computational fluid dynamics, hemodynamic characteristics were simulated and compared between two groups. RESULTS: Distances were measured from the carotid canal to the siphon. A shorter actual distance was observed in the moyamoya group (p = 0.0170). Vascular tortuosity was significantly low in moyamoya patients showing lower curvature angles in the petrous and intra-cavernous segments (p = 0.0012). Less blood flowed (p < 0.0001) through the narrower internal carotid artery (p < 0.0001) in the moyamoya group at the carotid canal level. The blood flow velocities were not significantly different (p = 0.2332). Faster blood flow and higher wall shear stress in the internal carotid artery bifurcation were verified with computational fluid dynamics. CONCLUSIONS: Significant morphological differences were confirmed to exist in the intracranial-extradural internal carotid artery of moyamoya patients. These differences might influence the hemodynamics around the bifurcation of the internal carotid artery.

Delayed ischemic stroke after stent-assisted coil placement in cerebral aneurysm: characteristics and optimal duration of preventative dual antiplatelet therapy.

PURPOSE: To evaluate characteristics of delayed ischemic stroke after stent-assisted coil placement in cerebral aneurysms and to determine the optimal duration of dual antiplatelet therapy for its prevention. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board, and the requirement to obtain written informed consent was waived. Of 1579 patients with 1661 aneurysms, 395 patients (25.0%) with 403 aneurysms (24.3%) treated with stent-assisted coil placement were included and assigned to groups stratified as early (126 patients [31.9%]; 3 months of coil placement), midterm (160 patients [40.5%]; 6 months), or late (109 patients [27.6%]; ≥ 9 months), according to the time points of switching dual antiplatelet therapy to monotherapy from coil placement. Cumulative rates of delayed ischemic stroke in each group were calculated by using Kaplan-Meier estimates that were compared with log-rank tests. Risk factors of delayed ischemic stroke were identified by using Cox proportional hazard analysis. RESULTS: Delayed ischemic stroke occurred in 3.5% of all cases (embolism, 3.0%; thrombotic occlusion, 0.5%) within 2 months following the switch. Late switch yielded no delayed ischemic stroke, unlike early (seven of 126 patients [5.6%]; P = .013) or midterm (seven of 160 patients [4.4%]; P = .028) switch. Incomplete occlusion (hazard ratio, 6.68 [95% confidence interval: 1.490, 29.900]) was identified as a risk factor. CONCLUSION: Delayed ischemic stroke after stent-assisted coil placement is caused by embolism from or thrombotic occlusion of stent-containing vessels after switching from dual antiplatelet therapy to monotherapy. The stent-containing vessel with incomplete aneurysm occlusion presents as a long-term thromboembolic source. Therefore, dual antiplatelet therapy for more than 9 months and late switch to monotherapy are recommended for its prevention.

Endovascular internal carotid artery trapping for ruptured blood blister-like aneurysms: long-term results from a single centre.

INTRODUCTION: Endovascular internal carotid artery (ICA) trapping was performed to treat ruptured blood blister-like aneurysms (BBAs). The aim of this study was to evaluate the procedural risks and long-term follow-up results. METHODS: The records of 11 consecutive patients with BBAs who underwent endovascular ICA trapping between 2005 and 2010 were reviewed. Clinical outcomes were assessed with modified Rankin Scale (mRS) scores. RESULTS: Endovascular ICA trapping was performed in 11 patients as either the primary treatment (7 patients) or the secondary treatment (4 patients) after the patient underwent other treatments. Three patients underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass when balloon test occlusion (BTO) revealed inadequate collateral circulation. In the primary ICA trapping group (seven patients), six patients had good outcomes (mRS 0 in five, mRS 1 in one), and one patient had a poor outcome (mRS 6: dead). In the secondary ICA trapping group (four patients), two patients had good outcomes (mRS 0), and two patients had poor outcomes (mRS 4, 5). All ten of the surviving patients were clinically stable during the follow-up period (mean 39 months). A radiological follow-up of nine patients (mean 22 months) demonstrated stable occlusion, with the exception of one reopening of the ICA because of coil migration. Perfusion studies of nine patients (mean: 23 months) demonstrated no perfusion decrease. CONCLUSION: Endovascular ICA trapping is an effective and durable treatment for BBAs.

Coil embolization of intracranial saccular aneurysms using the Low-profile Visualized Intraluminal Support (LVIS™) device.

INTRODUCTION: The novel Low-profile Visualized Intraluminal Support (LVIS™, LVIS and LVIS Jr.) device was recently introduced for stent-supported coil embolization of intracranial aneurysms. Periprocedural and midterm follow-up results for its use in stent-supported coil embolization of unruptured aneurysms are presented herein. METHODS: In this prospective multicenter study, clinical and radiologic outcomes were analyzed for 55 patients with saccular aneurysms undergoing LVIS-assisted coil embolization between October 2012 and February 2013. Magnetic resonance angiography or digital subtraction angiography was performed to evaluate midterm follow-up results. RESULTS: The standard LVIS device, deployed in 27 patients, was more often used in internal carotid artery (ICA) aneurysms (n=19), whereas the LVIS Jr. (a lower profile stent, n=28) was generally reserved for anterior communicating artery (n=14) and middle cerebral artery (n=8) aneurysms. With LVIS-assisted coil embolization, successful occlusion was achieved in 45 aneurysms (81.8 %). Although no instances of navigation failure or stent malposition occurred, segmentally incomplete stent expansion was seen in five patients where the higher profile LVIS was applied to ICA including carotid siphon. Procedural morbidity was low (2/55, 3.6 %), limited to symptomatic thromboembolism. In the imaging of lesions (54/55, 98.2 %) at 6-month follow-up, only a single instances of major recanalization (1.9 %) occurred. Follow-up angiography of 30 aneurysms (54.5 %) demonstrated in-stent stenosis in 26 (86.7 %), with no instances of stent migration. Only one patient suffered late delayed infarction (modified Rankin Scale 1). CONCLUSION: The LVIS device performed acceptably in stent-assisted coil embolization of non-ruptured aneurysms due to easy navigation and precise placement, although segmentally incomplete stent expansion and delayed in-stent stenosis were issues.

Simple coiling using single or multiple catheters without balloons or stents in middle cerebral artery bifurcation aneurysms.

INTRODUCTION: We evaluated the outcomes of middle cerebral artery bifurcation (MCAB) aneurysms treated with simple coiling using single or multiple catheters without stents or balloons. METHODS: This study included 100 patients with 103 MCAB aneurysms who underwent a simple coiling procedure without the adjuvant use of stents or balloons. The angiographic clinical outcomes and recurrence of these aneurysms were evaluated. RESULTS: Of the 103 aneurysms, 102 (99.0 %) aneurysms were successfully treated with simple coiling. One patient died from the consequences of a procedural aneurysm rupture. The treatment-associated permanent morbidity and mortality rates were 0 and 1.0 %, respectively. Post-coiling angiograms showed 28 complete occlusions (27.2 %), 60 neck remnants (58.3 %), and 14 partial occlusions (13.6 %). A follow-up angiography (median duration, 30 months; range, 3-73 months) was performed in 80 lesions. Recanalisation was found in 28 lesions (35.0 %), of which 6 were complete occlusions, 18 were neck remnants, and 4 were partial occlusions, as determined by post-coiling angiograms. Among these lesions, 14 major recurrences were retreated with coiling (n = 12) and clipping (n = 2) without complications. Age (odds ratio [OR], 0.93; 95 % confidence interval [CI], -0.11 to -0.01; p = 0.03), the presence of a rupture (OR, 3.89; 95 % CI, 0.12 to 2.60; p = 0.03), and a wide aneurysm neck (OR, 6.40; 95 % CI, 0.57 to 3.14; p = 0.005) were significantly associated with the aneurysm recurrence, as determined by multivariable analyses. CONCLUSION: Our study suggests that simple coiling of MCAB aneurysms is feasible and safe; however, it has limitations in durability, particularly in ruptured or wide-necked aneurysms and in young patients.

Surgical flow disconnection of cerebral pial dual-channel arteriovenous fistula with a large varix: the role of anti-platelet agent or anti-coagulation therapy.

INTRODUCTION: Intracranial pial arteriovenous fistula (AVF) is a rare cerebrovascular lesion, and the literature is sparse. Most authors insist that simple disconnection of arteriovenous shunting is enough to treat intracral single-channel pial AVF in most cases, either by microsurgery or endovascular embolization without resection of entire vascular malformation. DISCUSSION: We report an insidious onset of peri-lesional edema formation after abrupt disconnection of AVF shunting with surgical arterial ligation. Treatment entailed anti-platelet and anti-coagulation agent to slow down thrombus formation in intracranial dual-channel pial AVF. We suggest that slowing down thrombus formation in the large varix with anti-platelet and/or anti-coagulation agents seems to be necessary in case of abrupt disconnection of shunting in intracranial single- or dual-channel pial AVF to prevent postoperative cerebral edema or infarction.

Intrawound Vancomycin Powder Application for Preventing Surgical Site Infection Following Cranioplasty.

OBJECTIVE: Surgical site infection is the most detrimental complication following cranioplasty. In other surgical fields, intrawound vancomycin powder application has been introduced to prevent surgical site infection and is widely used based on results in multiple studies. This study evaluated the effect of intrawound vancomycin powder in cranioplasty compared with the conventional method without topical antibiotics. METHODS: This retrospective study included 580 patients with skull defects who underwent cranioplasty between August 1, 1998 and December 31, 2021. The conventional method was used in 475 (81.9%; conventional group) and vancomycin powder (1 g) was applied on the dura mater and bone flap in 105 patients (18.1%; vancomycin powder group). Surgical site infection was defined as infection of the incision, organ, or space that occurred after cranioplasty. Surgical site infection within 1-year surveillance period was compared between the conventional and vancomycin powder groups with logistic regression analysis. Penalized likelihood estimation method was used in logistic regression to deal with zero events. All local and systemic adverse events associated with topical vancomycin application were also evaluated. RESULTS: Surgical site infection occurred in 31 patients (5.3%) and all were observed in the conventional group. The median time between cranioplasty and detection of surgical site infection was 13 days (range, 4-333). Staphylococci were the most common organisms and identified in 25 (80.6%) of 31 cases with surgical site infections. The surgical site infection rate in the vancomycin powder group (0/105, 0.0%) was significantly lower than that in the conventional group (31/475, 6.5%; crude odds ratio [OR], 0.067; 95% confidence interval [CI], 0.006-0.762; adjusted OR, 0.068; 95% CI, 0.006-0.731; p=0.026). No adverse events associated with intrawound vancomycin powder were observed during the follow-up. CONCLUSION: Intrawound vancomycin powder effectively prevented surgical site infections following cranioplasty without local or systemic adverse events. Our results suggest that intrawound vancomycin powder is an effective and safe strategy for patients undergoing cranioplasty.

Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms: a nationwide registry study.

BACKGROUND: Antiplatelet therapy, where regimens are tailored based on platelet function testing, has been introduced into neurointerventional surgery. This nationwide registry study evaluated the effect and safety of tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms compared with conventional therapy using a standard regimen. METHODS: This study enrolled 1686 patients in 44 participating centers who received stent assisted coiling for unruptured aneurysms between January 1, 2019 and December 31, 2019. The standard regimen (aspirin and clopidogrel) was used for all patients in the conventional group (924, 19 centers). The regimen was selected based on platelet function testing (standard regimen for clopidogrel responders; adding cilostazol or replacing clopidogrel with other thienopyridines (ticlopidine, prasugrel, or ticagrelor) for clopidogrel non-responders) in the tailored group (762, 25 centers). The primary outcome was thromboembolic events. Secondary outcomes were bleeding and poor outcomes (increase in modified Rankin Scale score). Outcomes within 30 days after coiling were compared using logistic regression analysis. RESULTS: The thromboembolic event rate was lower in the tailored group than in the conventional group (30/762 (3.9%) vs 63/924 (6.8%), adjusted OR 0.560, 95% CI 0.359 to 0.875, P=0.001). The bleeding event rate was not different between the study groups (62/762 (8.1%) vs 73/924 (7.9%), adjusted OR 0.790, 95% CI 0.469 to 1.331, P=0.376). Poor outcomes were less frequent in the tailored group (12/762 (1.6%) vs 34 (3.7%), adjusted OR 0.252, 95% CI 0.112 to 0.568, P=0.001). CONCLUSION: Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms reduced thromboembolic events and poor outcomes without increasing bleeding.

Safety and Efficacy of Flow Diverter Therapy for Unruptured Intracranial Aneurysm Compared to Traditional Endovascular Strategy : A Multi-Center, Randomized, Open-Label Trial.

OBJECTIVE: Endovascular treatment of large, wide-necked intracranial aneurysms by coil embolization is often complicated by low rates of complete occlusion and high rates of recurrence. A flow diverter device has been shown to be safe and effective for the treatment of not only large and giant unruptured aneurysms, but small and medium aneurysms. However, in Korea, its use has only recently been approved for aneurysms <10 mm. This study aims to compare the safety and efficacy of flow diversion and coil embolization for the treatment of unruptured aneurysms ≥7 mm. METHODS: The participants will include patients aged between 19 and 75 years to be treated for unruptured cerebral aneurysms ≥7 mm for the first time or for recurrent aneurysms after initial endovascular coil embolization. Participants assigned to a flow diversion cohort will be treated using any of the following devices : Pipeline Flex Embolization Device with Shield Technology (Medtronic, Minneapolis, MN, USA), Surpass Evolve (Stryker Neurovascular, Fremont, CA, USA), and FRED or FRED Jr. (MicroVention, Tustin, CA, USA). Participants assigned to a coil embolization cohort will undergo traditional endovascular coiling. The primary endpoint will be complete occlusion confirmed by cerebral angiography at 12 months after treatment. Secondary safety outcomes will evaluate periprocedural and post-procedural complications for up to 12 months. RESULTS: The trial will begin enrollment in 2022, and clinical data will be available after enrollment and follow-up. CONCLUSION: This article describes the aim and design of a multi-center, randomized, open-label trial to compare the safety and efficacy of flow diversion versus traditional endovascular treatment for unruptured cerebral aneurysms ≥7 mm.

Imaging Features and Pathological Correlation in Mixed Microcystic and Angiomatous Meningioma: A Case Report.

Meningiomas are the most common intracranial tumors. However, microcystic and angiomatous meningiomas are very rare subtypes that present unusual imaging findings. Hence, radiological diagnosis of these tumors can be challenging. We herein describe a case of mixed angiomatous and microcystic meningioma in an 81-year-old male. MRI revealed an extra-axial mass with high T2 signal intensity, measuring 1.5 cm in diameter, with multiple tiny intralesional cysts and entrapped peritumoral cyst formation. After tumor resection, a histopathological diagnosis of mixed angiomatous and microcystic meningioma was made.

Genome-wide polygenic risk impact on intracranial aneurysms and acute ischemic stroke.

Polygenic risk scores (PRSs) have an important relevance to approaches for clinical usage in intracranial aneurysm (IA) patients. Hence, we aimed to develop IA-predicting PRS models including the genetic basis shared with acute ischemic stroke (AIS) in Korean populations. We applied a weighted PRS (wPRS) model based on a previous genome-wide association study (GWAS) of 250 IA patients in a hospital-based multicenter cohort, 222 AIS patients in a validation study, and 296 shared controls. Risk predictability was analyzed by the area under the receiver operating characteristic curve (AUROC). The best-fitting risk models based on wPRSs were stratified into tertiles representing the lowest, middle, and highest risk groups. The weighted PRS, which included 29 GWASs (p < 5×10-8) and two reported genetic variants (p < 0.01), showed a high predictability in IA patients (AUROC = 0.949, 95% CI: 0.933-0.966). This wPRS was significantly validated in AIS patients (AUROC = 0.842, 95% CI: 0.808-0.876; p < 0.001). Two-stage risk models stratified into tertiles showed an increased risk for IA (OR = 691.25, 95% CI: 241.77-1976.35; p = 3.1×10-34; sensitivity/specificity = 0.728/0.963), which was replicated in AIS development (OR = 39.76, 95% CI: 16.91-93.49; p = 3.1×10-17; sensitivity/specificity = 0.284/0.963). A higher wPRS for IA may be associated with an increased risk of AIS in the Korean population. These findings suggest that IA and AIS may have a shared genetic architecture and should be studied further to generate a precision medicine model for use in personalized diagnosis and treatment.

Fine-mapping of intracranial aneurysm susceptibility based on a genome-wide association study.

In addition to conventional genome-wide association studies (GWAS), a fine-mapping analysis is increasingly used to identify the genetic function of variants associated with disease susceptibilities. Here, we used a fine-mapping approach to evaluate candidate variants based on a previous GWAS involving patients with intracranial aneurysm (IA). A fine-mapping analysis was conducted based on the chromosomal data provided by a GWAS of 250 patients diagnosed with IA and 296 controls using posterior inclusion probability (PIP) and log10 transformed Bayes factor (log10BF). The narrow sense of heritability (h2) explained by each candidate variant was estimated. Subsequent gene expression and functional network analyses of candidate genes were used to calculate transcripts per million (TPM) values. Twenty single-nucleotide polymorphisms (SNPs) surpassed a genome-wide significance threshold for creditable evidence (log10BF > 6.1). Among them, four SNPs, rs75822236 (GBA; log10BF = 15.06), rs112859779 (TCF24; log10BF = 12.12), rs79134766 (OLFML2A; log10BF = 14.92), and rs371331393 (ARHGAP32; log10BF = 20.88) showed a completed PIP value in each chromosomal region, suggesting a higher probability of functional candidate variants associated with IA. On the contrary, these associations were not shown clearly under different replication sets. Our fine-mapping analysis suggested that four functional candidate variants of GBA, TCF24, OLFML2A, and ARHGAP32 were linked to IA susceptibility and pathogenesis. However, this approach could not completely replace replication sets based on large-scale data. Thus, caution is required when interpreting results of fine-mapping analysis.

Partial recovery after intraarterial pharmacomechanical thrombolysis in ophthalmic artery occlusion following nasal autologous fat injection.

Although autologous fat injection into the face is a widely used procedure in aesthetic surgery, heed must be taken because it may cause severe complications related to inadvertent arterial embolization, including stroke and vision loss. Vision loss may originate from ophthalmic artery occlusion, and no therapeutic options have yet been reported for this condition. Herein, the authors report a case of ophthalmic artery occlusion following nasal autologous fat injection. Partial recovery of choroidal and retinal perfusion, ocular motility, and corneal clarity was achieved after intraarterial pharmacomechanical thrombolysis.

Procedural predictors of delayed cerebral infarction after intra-arterial vasodilator infusion for vasospasm following aneurysmal subarachnoid hemorrhage.

PURPOSE: The goals of this study were to identify predictors of delayed cerebral infarction in aneurysmal SAH after intra-arterial (IA) vasodilator infusion and to select proper parameters for treatment success. METHODS: Forty-three patients qualified for review. Cerebral infarction was determined by DWI within 1 week of angiographic vasospasm. RESULTS: Infarction developed in 18 of the 43 patients (41.9%) after IA vasodilator infusion and was associated with a high degree of proximal vessel residual narrowing and angiographic cerebral circulation time (CCT) prolongation at the end of IA vasodilator infusion (p < 0.001). A high degree of proximal residual narrowing (p = 0.018; odds ratio = 1.071; 95% confidence interval [CI] 1.012-1.123) and CCT prolongation at the end of the procedure (p = 0.007; odds ratio = 2.203; 95% CI 1.254-4.232) were found to be predictors of infarction by multivariate analysis. Furthermore, receiver operating characteristic (ROC) curves showed that both variables predicted the development of infarction (proximal vessel residual narrowing, area under the ROC curve [AUC], 0.828; CCT, AUC, 0.866). When proximal vessel narrowing of >30% or a CCT of >7 s by final angiography during IA vasodilator infusion were used as a threshold, the negative predictive value for infarction was 88.9% (95% CI 65.3-98.6%), and when narrowing was >30% and CCT was >7 s, the probability of subsequent cerebral infarction was 100% (95% CI 71.7-100%). CONCLUSIONS: Angiographic CCT and residual narrowing at the end of IA vasodilator infusion were found to predict the subsequent occurrence of cerebral infarction. The authors suggest that residual narrowing of 30% and a CCT of 7 s could be used as a minimum indicator of IA vasodilator infusion endpoints.

Intra-arterial thrombolysis for central retinal artery occlusion: two cases report.

Central retinal artery occlusion (CRAO) causes severe visual loss in affected eye and vision does not recover in more than 90% of the patients. It is believed that it occurs by occlusion of the central retinal artery with small emboli from atherosclerotic plaque of internal cerebral artery. Retina is a part of the brain, thus basically CRAO is corresponding to acute occlusion of intracerebral artery and retinal ischemia is to cerebral stroke. Therefore, intra-arterial thrombolysis (IAT) has been considered as a treatment method in CRAO. Recently, we treated 2 patients diagnosed as CRAO and could achieve complete recanalization on fundus fluorescein angiogram with IAT. Of them, one recovered visual acuity to 20/25. We report our 2 CRAO cases treated with IAT and discuss technical aspects for IAT and management of patient. To the best of our knowledge, this is the first Korean report of IAT for CRAO.