Additional rescue stenting with Neuroform Atlas stents during stent-assisted coiling of saccular aneurysms.

OBJECTIVE: Overlapping stenting is sometimes attempted during endovascular treatment of cerebral aneurysm as a rescue for coil herniation, stent mal-positioning, or in-stent thrombosis. We retrospectively evaluated the efficacy and safety of additional rescue stenting (ARS) in telescoping fashion with Neuroform Atlas stent (NAS) during stent-assisted coiling of saccular aneurysms. METHODS: We collected clinical and radiological data of patients with saccular aneurysms treated with ARS using NASs between March 2018 and December 2021. Y or X-stent-assisted coiling technique was excluded. RESULTS: Eighteen unruptured and 5 ruptured aneurysms in 23 patients were treated with ARS using NASs. Sizes of aneurysms ranged from 2.0 mm to 10.0 mm (mean: 5.0 mm). Immediate angiographic results were complete occlusion in 11 aneurysms, residual neck in 4 aneurysms, and residual sac in 8 aneurysms. Peri-operative morbidity was 4.3 %. Nineteen of 23 patients underwent follow-up conventional angiography (mean, 9.9 months). Results showed progressive occlusion in 10 (52.6 %) cases and asymptomatic in-stent stenosis in 3 (15.8 %) cases. At the end of the observation period (mean, 17.4 months), all 18 patients without subarachnoid hemorrhage had excellent clinical outcomes (mRS of 0), except one (mRS of 1). Of five patients with subarachnoid hemorrhage, four had a favorable outcome (mRS of 0-1), while the other one was dependent (mRS of 4). CONCLUSION: In this report on 23 patients, ARS with NASs for treating saccular aneurysms showed good technical safety with favorable clinical and angiographic outcomes. However, delayed in-stent stenosis was not uncommon. Thus, regular imaging follow-up is required.

Kissing Aneurysms at Fenestrated Proximal Basilar Artery: Double-barrel Stent-assisted Coiling Using Dual Closed-cell Stents.

Kissing aneurysms associated with a proximal basilar artery fenestration are an exceedingly rare and unique therapeutic challenge due to anatomical complexity. This report describes double-barrel stent-assisted technique with dual closed-cell stents for the successful endovascular coiling of kissing aneurysms from a proximal basilar artery fenestration.

Neurological Deterioration after Decompressive Suboccipital Craniectomy in a Patient with a Brainstem-compressing Thrombosed Giant Aneurysm of the Vertebral Artery.

We experienced a case of neurological deterioration after decompressive suboccipital craniectomy (DSC) in a patient with a brainstem-compressing thrombosed giant aneurysm of the vertebral artery (VA). A 60-year-old male harboring a thrombosed giant aneurysm (about 4 cm) of the right vertebral artery presented with quadriparesis. We treated the aneurysm by endovascular coil trapping of the right VA and expected the aneurysm to shrink slowly. After 7 days, however, he suffered aggravated symptoms as his aneurysm increased in size due to internal thrombosis. The medulla compression was aggravated, and so we performed DSC with C1 laminectomy. After the third post-operative day, unfortunately, his neurologic symptoms were more aggravated than in the pre-DSC state. Despite of conservative treatment, neurological symptoms did not improve, and microsurgical aneurysmectomy was performed for the medulla decompression. Unfortunately, the post-operative recovery was not as good as anticipated. DSC should not be used to release the brainstem when treating a brainstem-compressing thrombosed giant aneurysm of the VA.

Borderline basal ganglia hemorrhage volume: patient selection for good clinical outcome after stereotactic catheter drainage.

OBJECTIVE The purpose of this study was to determine predisposing factors for good clinical outcome in patients with spontaneous basal ganglia hemorrhage with borderline volumes (defined as a hematoma volume between 20 and 50 cm3) who had undergone treatment by stereotactic catheter drainage. METHODS From the 298 patients whose information had been prospectively collected in the institutional database between January 2010 and December 2013, 93 patients were included in this retrospective study and divided into 2 groups: best medical treatment alone (Group A, n = 44) and best medical treatment plus catheterization (Group B, n = 49). All patients met the following criteria: 1) a diagnosis of spontaneous basal ganglia hemorrhage, and 2) a borderline hematoma volume (20 to 50 cm3). Postoperative modified Rankin Scale (mRS) scores and recovery of motor weakness were compared between the 2 groups, and predisposing factors for good clinical outcome were evaluated. RESULTS Patients in Group B showed earlier recovery of motor weakness and improved mRS scores than patients in Group A. The final mRS score at 12 months was better in Group B than in Group A (p = 0.006). Predisposing factors for a good clinical outcome were a hematoma volume < 30 cm3 (OR 6.158, 95% CI 1.221-31.053, p = 0.028), an initial Glasgow Coma Scale (GCS) score ≥ 13 (OR 6.331, 95% CI 1.129-35.507, p = 0.036), the absence of internal capsule involvement (OR 4.680, 95% CI 1.152-19.010, p = 0.031), and catheterization (OR 13.376, 95% CI 2.423-73.842, p = 0.003) based on logistic regression analysis. CONCLUSIONS Good clinical outcome can be expected after stereotactic catheter drainage in patients with a hematoma volume between 20 and 30 cm3, an initial GCS score ≥ 13, and the absence of internal capsule involvement. Among these patients, stereotactic catheter drainage may have a beneficial effect on early recovery of motor weakness and functional outcome, indicating that lateral-type basal ganglia hematoma compression not involving the internal capsule may be better treated using stereotactic catheter drainage than treated medically.

Deep Intracerebral Hemorrhage Caused by Rupture of Distal Lenticulostriate Artery Aneurysm : A Report of Two Cases and a Literature Review.

Intracerebral hemorrhage (ICH) is common among various types of storkes; however, it is rare in young patients and patients who do not have any risk factors. In such cases, ICH is generally caused by vascular malformations, tumors, vasculitis, or drug abuse. Basal ganglia ICH is rarely related with distal lenticulostriate artery (LSA) aneurysm. Since the 1960s, a total of 29 distal LSA aneurysm cases causing ICH have been reported in the English literature. Despite of the small number of cases, various treatment methods have been attempted : surgical clipping, endovascular treatment, conservative treatment, superficial temporal artery-middle cerebral artery anastomosis, and gamma-knife radiosurgery. Here, we report two additional cases and review the literature. Thereupon, we discerned that young patients with deep ICH are in need of conventional cerebral angiography. Moreover, initial conservative treatment with follow-up cerebral angiography might be a good treatment option except for cases with a large amount of hematoma that necessitates emergency evacuation. If the LSA aneurysm still persists or enlarges on follow-up angiography, it should be treated surgically or endovascularly.

Clinico-radiological Characteristics of Spontaneous Basal Ganglia Hemorrhage, According to Regional Classification.

OBJECTIVE: The clinico-radiologic features of the spontaneous basal ganglia hemorrhage (BGH) may often differ one from another, according to its regional location. Therefore, we attempted to classify the BGH into regional subgroups, and to extrapolate the distinct characteristics of each group of BGH. MATERIALS AND METHODS: A total of 103 BGHs were analyzed by retrospective review of medical records. BGH was classified according to four subgroups; anterior BGH; posterior BGH; lateral BGH; massive BGH. RESULTS: The most common BGH was the posterior BGH (56, 54.4%), followed by the lateral BGH (26, 25.2%), the massive BGH (12, 11.7%), and the anterior BGH (9, 8.7%). The shape of hemorrhage tended to be round in anterior, irregular in posterior, and ovoid in lateral BGH. A layered density of hematoma on initial computed tomography showed correlation with hematoma expansion (p = 0.016), which was observed more often in the postero-lateral group of BGH than in the anterior BGH group. Relatively better recovery from the initial insult was observed in the lateral BGH group than in the other regional BGH groups. The proportion of poor outcome (modified Rankin scale 4, 5, 6) was 100% in the massive, 41.1% in the posterior, 34.6% in the lateral, and 0% in the anterior BGH group. CONCLUSION: We observed that BGH can be grouped according to its regional location and each group may have distinct characteristics. Thus, a more sophisticated clinical strategy tailored to each group of BGHs can be implemented.

Intradural retroclival chordoma.

A 43-year-old woman presented with dizziness, ataxia and right hearing difficulty. Her magnetic resonance images demonstrated an inhomogeneously contrast-enhanced large tumor growing into right cavernous sinus and Meckel's cave located totally within intradural retroclival region. She underwent retromastoid suboccipital craniotomy to resect the tumor mass and adjuvant gamma knife radiosurgery for remnant tumor at 1 month after operation. Adjuvant radiosurgery after surgical excision seems to be effective for the treatment of intradural extraosseous chordomas.