ABSTRACT
With the advent of high-resolution imaging and advancements in computational fluid dynamics(CFD)and computational structural mechanics(CSM)analyses, clinical simulation of endovascular intervention has gradually become feasible. Virtual stents have become indispensable for coil embolization. For braided stents, such as those with low-profile visualized intraluminal support and flow diverters, predicting postplacement elongation and contraction is challenging; however, software development has enabled more precise treatment planning. Additionally, simulations utilizing three-dimensional(3D)printer models can enable realistic simulations of procedures such as intracranial stents and Woven EndoBridge placement. This approach is beneficial for shunt disorders such as arteriovenous malformations and dural arteriovenous fistulas, offering 3D visualization of shunt access routes and intuitive treatment strategy planning, even for beginners. Furthermore, it can be applied to procedures such as open surgical clipping and nidus resection, aiding in the selection of suitable clips and considerations for ideal resection based on nidus curvature. Simulations using CFD, CSM, and 3D printers are crucial for training surgeons and handling new devices. Harnessing medicine-engineering synergy is essential, and regulatory approval(insurance coverage)and appropriate commercialization of simulations are paramount for the future.
Subject(s)
Embolization, Therapeutic , Endovascular Procedures , Intracranial Aneurysm , Humans , Intracranial Aneurysm/surgery , Blood Vessel Prosthesis , Stents , Software , Embolization, Therapeutic/methods , Treatment OutcomeABSTRACT
OBJECTIVES: Methods for assessing platelet function in patients with neurovascular disease remain controversial and poorly studied. This study aimed to assess associations between thromboelastography 6s (TEG6s) measurements and postoperative ischemic complications in patients with unruptured intracranial aneurysms (UIAs) treated by coil embolization. METHODS: Eighty-four patients with UIAs taking a combined aspirin and clopidogrel protocol were retrospectively reviewed from January 2021 to May 2022. Blood samples were obtained for TEG6s to assess platelet function on the day of coil embolization. To identify acute ischemic complications, diffusion-weighted imaging (DWI) was performed within 24 h after coil embolization. Multivariate logistic regression analysis was conducted to identify potential risk factors for postoperative positive DWI (DWI (+)) lesions. RESULTS: Forty-three of the 84 patients (51%) with DWI (+) lesions were identified. Compared with patients without DWI (+) lesions, Adenosine diphosphate (ADP)-induced platelet-fibrin clot strength (MAADP) was significantly higher (53.6 mm [Interquartile range (IQR): 48.3-58.3 mm] vs 46.7 mm [IQR: 36.8-52.2 mm]; p=0.001) and ADP inhibition rate (ADP%) was significantly lower (19% [IQR: 11-31%] vs 31% [IQR: 21-44%]; p=0.001) in DWI (+) patients. Multivariate analysis identified MAADP, ADP%, and procedure time as significant independent predictors of subsequent DWI (+) lesions (odds ratios: 1.07, 0.96, and 1.02, respectively). Based on receiver operating characteristic curve analysis, MAADP >50.9 mm and ADP% <28.8% were associated with postoperative DWI (+) lesions in patients undergoing coil embolization for UIAs. CONCLUSIONS: MAADP and ADP% as assessed by TEG6s can offer reliable parameters to predict postoperative ischemic complications after coil embolization of UIAs. Lower MAADP values and higher ADP% may decrease the risk of postoperative ischemic complications.
Subject(s)
Embolization, Therapeutic , Intracranial Aneurysm , Humans , Retrospective Studies , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/therapy , Intracranial Aneurysm/complications , Thrombelastography , Aspirin/adverse effects , Adenosine Diphosphate/pharmacology , Embolization, Therapeutic/adverse effects , Platelet Aggregation Inhibitors/adverse effects , Treatment OutcomeABSTRACT
Since most unruptured intracranial aneurysms(UIA)are asymptomatic, it is important to determine treatment indications. The purpose of UIA treatment is to prevent rupture and relieve the patient's mental burden. Therefore, building a good relationship between doctors and patients is a major premise for one of the indications for surgical treatments. In addition, long-term follow-up of patients is necessary because endovascular treatment has the possibility of recurrence and retreatment. Since endovascular treatment is "possible" and "suitable" is different, it is necessary to determine the treatment policy from a radical point of view.
Subject(s)
Aneurysm, Ruptured , Embolization, Therapeutic , Endovascular Procedures , Intracranial Aneurysm , Humans , Treatment Outcome , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/surgery , Intracranial Aneurysm/complications , Aneurysm, Ruptured/diagnostic imaging , Aneurysm, Ruptured/surgery , Aneurysm, Ruptured/etiology , Embolization, Therapeutic/adverse effectsABSTRACT
BACKGROUND AND PURPOSE: In previous studies, women had a higher risk of rupture of intracranial aneurysms than men, but female sex was not an independent risk factor. This may be explained by a higher prevalence of patient- or aneurysm-related risk factors for rupture in women than in men or by insufficient power of previous studies. We assessed sex differences in rupture rate taking into account other patient- and aneurysm-related risk factors for aneurysmal rupture. METHODS: We searched Embase and Pubmed for articles published until December 1, 2020. Cohorts with available individual patient data were included in our meta-analysis. We compared rupture rates of women versus men using a Cox proportional hazard regression model adjusted for the PHASES score (Population, Hypertension, Age, Size of Aneurysm, Earlier Subarachnoid Hemorrhage From Another Aneurysm, Site of Aneurysm), smoking, and a positive family history of aneurysmal subarachnoid hemorrhage. RESULTS: We pooled individual patient data from 9 cohorts totaling 9940 patients (6555 women, 66%) with 12 193 unruptured intracranial aneurysms, and 24 357 person-years follow-up. Rupture occurred in 163 women (rupture rate 1.04%/person-years [95% CI, 0.89-1.21]) and 63 men (rupture rate 0.74%/person-years [95% CI, 0.58-0.94]). Women were older (61.9 versus 59.5 years), were less often smokers (20% versus 44%), more often had internal carotid artery aneurysms (24% versus 17%), and larger sized aneurysms (≥7 mm, 24% versus 23%) than men. The unadjusted women-to-men hazard ratio was 1.43 (95% CI, 1.07-1.93) and the adjusted women/men ratio was 1.39 (95% CI, 1.02-1.90). CONCLUSIONS: Women have a higher risk of aneurysmal rupture than men and this sex difference is not explained by differences in patient- and aneurysm-related risk factors for aneurysmal rupture. Future studies should focus on the factors explaining the higher risk of aneurysmal rupture in women.
Subject(s)
Aneurysm, Ruptured/epidemiology , Intracranial Aneurysm/complications , Intracranial Aneurysm/epidemiology , Age Factors , Aged , Cohort Studies , Female , Humans , Male , Middle Aged , Prevalence , Prospective Studies , Risk Factors , Sex Factors , Smoking/epidemiology , Subarachnoid Hemorrhage/complications , Subarachnoid Hemorrhage/epidemiologyABSTRACT
OBJECTIVES: Early detection of hemorrhagic transformation (HT) in patients with large vessel occlusion (LVO) after endovascular treatment is important for postoperative patient management. We investigated the diagnostic performance of intraoperative cone beam computed tomography (CBCT) with reference standard magnetic resonance imaging (MRI) for detecting HT. MATERIALS AND METHODS: Consecutive patients with LVO treated by endovascular treatment who underwent intraoperative CBCT and postoperative MRI were included. Two observers evaluated all images for the presence of HT. Sensitivity and specificity for detecting HT were calculated with MRI as reference standard. The observers classified HT according to the European Cooperative Acute Stroke Study (ECASS). Inter-method and inter-rater agreement for the detection of HT and for the ECASS classification were assessed using kappa or weighted Brennan-Prediger (wBP) statistics. RESULTS: Images of 106 procedures (94 for anterior circulation) were analyzed. The sensitivity and specificity for detecting HT on CBCT were 0.77 and 0.83, respectively, for all procedures and 0.83 and 0.8, respectively, for anterior circulation. The inter-method agreement for HT detection (κ = 0.63 overall, κ = 0.69 anterior circulation) and ECASS classification (wBP = 0.67 overall, wBP = 0.77 anterior circulation) were substantial. The inter-rater agreement for HT detection (κ = 0.87 overall, κ = 0.85 anterior circulation) and for ECASS classification (wBP = 0.95 overall, wBP = 0.92 anterior circulation) were almost perfect. CONCLUSIONS: The diagnostic performance of CBCT for the detection of HT in stroke patients treated for LVO was acceptable with excellent inter-rater agreement. Intraoperative CBCT may be useful to trigger early interventions if HT is detected, although detailed classifications of HT may be difficult.
Subject(s)
Stroke , Humans , Stroke/diagnostic imaging , Stroke/surgery , Cone-Beam Computed Tomography/methods , Magnetic Resonance Imaging , Sensitivity and Specificity , Retrospective StudiesABSTRACT
BACKGROUND AND OBJECTIVES: Communication-type medical smartphone applications enable text, neuroimaging, photos, and videos to be shared securely among the stroke team. Our aim was to investigate whether use of a smartphone application would shorten the duration from admission to reperfusion therapy in patients with hyper-acute ischemic stroke. METHODS: Enrolled were acute ischemic stroke patients who underwent reperfusion therapy (intravenous tissue plasminogen activator (IV t-PA) and mechanical thrombectomy (MT)) at our hospital between October 2012 and September 2018. We divided the patients into two groups based on the date of availability on smartphones of communication-type medical application: (1) Control group, conventional communication prior to September 2015, and (2) App group, communication via the smartphone app from October 2015 onwards. We compared door-to-image time (DIT), image-to-needle time (INT), door-to-needle time (DNT) for thrombolysis, and DIT, image-to-puncture time (IPT), and door-to-puncture time (DTP) for thrombectomy between the groups. RESULTS: We retrospectively enrolled 139 patients (68% male; median age, 69 years; median NIHSS score, 7) who were assigned into the App group (n = 86) and Control group (n = 53). Of the overall patients, 109 underwent IV t-PA (IV t-PA alone, 79 patients), and 63 underwent MT (MT alone, 30 patients), and 33 patients underwent combined IV t-PA and MT. There was no significant difference in DIT between the App and Control groups (23 min vs. 22 min, p = 0.493). DNT, DPT, INT, and IPT were significantly shorter in the App group than in the Control group (DNT, 62 min for the App group vs. 72 min for Control group, p = 0.038; INT, 42 vs. 48 min, p = 0.009; DPT, 106 vs. 129 min, p = 0.046; IPT, 89 vs. 117 min, p = 0.004). CONCLUSION: The present findings indicate that communication-type medical smartphone apps have potential for shortening the time elapsed between admission and reperfusion therapy, especially INT and IPT.
Subject(s)
Brain Ischemia , Stroke , Aged , Brain Ischemia/drug therapy , Brain Ischemia/therapy , Communication , Female , Fibrinolytic Agents/therapeutic use , Humans , Male , Reperfusion , Retrospective Studies , Smartphone , Stroke/diagnostic imaging , Stroke/drug therapy , Thrombectomy , Thrombolytic Therapy , Tissue Plasminogen Activator/therapeutic use , Treatment OutcomeABSTRACT
BACKGROUND: Telestroke has developed rapidly as an assessment tool for patients eligible for reperfusion therapy. OBJECTIVE: To investigate whether vascular neurologists can diagnose intracranial large vessel occlusion (LVO) as quickly and accurately using a smartphone application compared to a hospital-based desktop PC monitor. METHODS: We retrospectively enrolled 108 consecutive patients with acute ischemic stroke in the middle cerebral artery territory who underwent magnetic resonance imaging (MRI) within 24 hours of their stroke onset. Two vascular neurologists, blinded to all clinical information, independently evaluated magnetic resonance angiography and fluid-attenuated inversion recovery images for the presence or absence of LVO in the internal carotid artery and middle cerebral artery (M1, M2, or M3) on both a smartphone application (Smartphone-LVO) and a hospital-based desktop PC monitor (PC-LVO). To evaluate the accuracy of an arterial occlusion diagnosis, interdevice variability between Smartphone-LVO and PC-LVO was analyzed using κ statistics, and image interpretation time was compared between Smartphone-LVO and PC-LVO. RESULTS: There was broad agreement between Smartphone-LVO and PC-LVO evaluations regarding the presence or absence of arterial occlusion (Reader 1: κ=0.94; P<.001 vs Reader 2: κ=0.89; P<.001), and interpretation times were similar between Smartphone-LVO and PC-LVO. CONCLUSIONS: The results indicate the evaluation of neuroimages using a smartphone application can provide an accurate and timely diagnosis of anterior intracranial arterial occlusion that can be shared immediately with members of the stroke team to support the management of patients with hyperacute ischemic stroke.
Subject(s)
Brain Ischemia , Stroke , Carotid Artery, Internal , Humans , Retrospective Studies , SmartphoneABSTRACT
Background and Purpose- Therapeutic decision making for small unruptured intracranial aneurysms (<10 mm) is difficult. We aimed to develop a rupture risk model for small intracranial aneurysms in Japanese adults, including clinical, morphological, and hemodynamic parameters. Methods- We analyzed 338 small unruptured aneurysms; 35 ruptured during the observation period, and 303 remained stable. Clinical, morphological, and hemodynamic parameters were considered. Computational fluid dynamics was used to calculate hemodynamic parameters based on computed tomography images of all aneurysms in their unruptured state. Differences between the ruptured and unruptured groups were tested by the Mann-Whitney U or Fisher exact tests. Multivariate logistic regression was applied to obtain a rupture risk model. Its predictive ability was investigated by receiver operating characteristic analysis. Results- The risk model revealed that rupture may be more likely to in younger patients (odds ratio [OR], 0.92 for each age increase of 1 year [95% CI, 0.88-0.96] P<0.001) with multiple aneurysms (OR, 2.58 [95% CI, 1.07-6.19] P=0.03), located at a bifurcation (OR, 5.45 [95% CI, 1.87-15.85] P=0.002), with a bleb (OR, 4.09 [95% CI, 1.42-11.79] P=0.009), larger length (OR, 1.91 for each increase of 1 mm [95% CI, 1.42-2.57] P<0.001), and lower pressure loss coefficient (OR, 0.33 for each decrease of 1 unit [95% CI, 0.14-0.77] P=0.01). The sensitivity, specificity, and area under the curve were 0.800, 0.752, and 0.826 (95% CI, 0.739-0.914) respectively. Conclusions- Younger age, presence of multiple aneurysms, location at a bifurcation, presence of a bleb, larger length, and lower pressure loss coefficient were identified as risk factors for rupture of small intracranial aneurysms. The risk model should be validated in further studies.
Subject(s)
Aneurysm, Ruptured/complications , Aneurysm, Ruptured/etiology , Hemodynamics/physiology , Intracranial Aneurysm/complications , Adult , Age Factors , Aged , Cerebral Angiography/methods , Female , Humans , Intracranial Aneurysm/etiology , Japan , Male , Middle Aged , ROC Curve , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: High-quality neuroimages can be viewed using a medical app installed on a smartphone. Although interdevice agreement between smartphone and desktop PC monitor was found to be favorable for evaluating computed tomography images, there are no interdevice agreement data for diffusion-weighted imaging (DWI). OBJECTIVE: The aim of our study was to compare DWI interpretation using the Join smartphone app with that using a desktop PC monitor, in terms of interdevice and interrater agreement and elapsed interpretation time. METHODS: The ischemic change in the DWI of consecutive patients with acute stroke in the middle cerebral artery territory was graded by 2 vascular neurologists using the Join smartphone app and a desktop PC monitor. The vascular neurologists were blinded to all patient information. Each image was categorized as either Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores (DWI-ASPECTS) ≥7 or DWI-ASPECTS <7 according to the Japanese Society for Neuroendovascular Therapy. We analyzed interdevice agreement and interrater agreement with respect to DWI-ASPECTS. Elapsed interpretation time was compared between DWI-ASPECTS evaluated by the Join smartphone app and a desktop PC monitor. RESULTS: We analyzed the images of 111 patients (66% male; median age=69 years; median National Institutes of Health Stroke Scale score on admission=4). Interdevice agreement regarding DWI-ASPECTS between the smartphone and the desktop PC monitor was favorable (vascular neurologist 1: κ=0.777, P<.001, vascular neurologist 2: κ=0.787, P<.001). Interrater agreement was also satisfactory for the smartphone (κ=0.710, P<.001) and the desktop PC monitor (κ=0.663, P<.001). Median elapsed interpretation time was similar between the smartphone and the desktop PC monitor (vascular neurologist 1: 1.7 min vs 1.6 min; P=.64); vascular neurologist 2: 2.4 min vs 2.0 min; P=.14). CONCLUSIONS: The use of a smartphone app enables vascular neurologists to estimate DWI-ASPECTS accurately and rapidly. The Join medical smartphone app shows great promise in the management of acute stroke.
Subject(s)
Brain Ischemia/diagnostic imaging , Brain Ischemia/diagnosis , Diagnostic Tests, Routine/methods , Smartphone/standards , Stroke/diagnostic imaging , Stroke/diagnosis , Tomography, X-Ray Computed/methods , Acute Disease , Aged , Alberta , Female , Humans , Male , Reproducibility of ResultsABSTRACT
PURPOSE: To assess the benefit and radiation dose of four-dimensional (4D) digital subtraction angiography (DSA) - a time resolved three-dimensional (3D) DSA application - to evaluate the flow and architecture of aneurysms and vascular malformations. METHODS: All patients with cerebrovascular disease were considered who underwent 4D-DSA at our institution between January 2015 and February 2016. For the aneurysm patients, we evaluated the image quality in terms of the visualization of contrast flow in the aneurysm on a 3-point scale (excellent, fair and poor). Interrater agreement between two raters was estimated using Cohen's Kappa statistics. For the shunt disease patients, the additional information obtained from the 4D-DSA was described for each disease. The median radiation dose and volume of contrast medium required for the acquisitions were estimated. RESULTS: A total of 173 patients underwent 4D-DSA; 126 intracranial aneurysms, 10 arteriovenous malformations (AVM), 15 dural arteriovenous fistula (dAVF) and 22 other diseases. For aneurysm patients, excellent and fair visualization of the intra-aneurysmal flow was observed in 27.7%, 72.3%, and excellent (κ = 0.9) agreement between the raters was found. For AVM and dAVF patients, 4D-DSA clarified the complex vasculature by viewing the discrete time phase of contrast filling. Median radiation dose for intracranial lesions was 79.6 mGy for 6s 4D-DSA, and 175 mGy for 12s 4D-DSA. The median amount of contrast medium used was 18.0 ml for 6s 4D-DSA and 21.0 ml for 12s 4D-DSA. CONCLUSIONS: 4D-DSA provided additional information regarding intra-aneurysmal flow and contributed to detect different component of nidus or shunt points.
Subject(s)
Angiography, Digital Subtraction , Central Nervous System Vascular Malformations/diagnostic imaging , Cerebral Angiography , Cerebrovascular Circulation , Intracranial Aneurysm/diagnostic imaging , Radiographic Image Interpretation, Computer-Assisted , Adolescent , Adult , Aged , Aged, 80 and over , Blood Flow Velocity , Central Nervous System Vascular Malformations/physiopathology , Female , Humans , Intracranial Aneurysm/physiopathology , Male , Middle Aged , Observer Variation , Predictive Value of Tests , Reproducibility of Results , Retrospective Studies , Time Factors , Young AdultABSTRACT
BACKGROUND: Little is known about the micro-debris captured in filter-type distal embolic protection devices (EPD) used for carotid stenting (CAS). This study aimed to determine the histological and immunohistochemical characteristics of such debris by using a new liquid-based cytology (LBC) technique. METHODS: Fifteen patients who underwent CAS using a filter-type distal EPD (FilterWire EZ; Boston Scientific, Marlborough, MA, USA) were included in the study. After gross inspection of each recovered filter device, micro-debris were collected using a new LBC technique (SurePath; TriPath Imaging, Inc., Burlington, NC). Histological and immunohistochemical analysis of the recovered debris was performed. The pre- and postoperative brain magnetic resonance imaging and neurological status of each patient were also reviewed. RESULTS: No patient developed ipsilateral symptomatic stroke due to a thromboembolic event. All 15 patients (100%) had microscopically identifiable debris in the filters, whereas gross inspection detected visible debris only in 5 patients (33.3%). Histological analysis revealed various types of structural components in an advanced atheromatous plaque, including fragments of fibrous cap, calcified plaque, smooth muscle cells, and necrotic tissue fragment infiltrated with monocytes and macrophages. CONCLUSIONS: Filter-type EPDs may contribute to reducing the risk of CAS-related embolic events by capturing micro-debris even when gross inspection of the recovered filter shows no visible debris in the device.
Subject(s)
Carotid Stenosis/therapy , Embolic Protection Devices/adverse effects , Endovascular Procedures/instrumentation , Fibrosis/diagnosis , Immunohistochemistry/methods , Plaque, Atherosclerotic/diagnosis , Actins/metabolism , Aged , Antigens, CD/metabolism , Antigens, Differentiation, Myelomonocytic/metabolism , Carotid Stenosis/diagnostic imaging , Diffusion Magnetic Resonance Imaging , Endovascular Procedures/adverse effects , Female , Fibrosis/etiology , Fibrosis/metabolism , Humans , Male , Middle Aged , Plaque, Atherosclerotic/etiology , Plaque, Atherosclerotic/metabolismABSTRACT
BACKGROUND AND PURPOSE: The natural history of unruptured intracranial aneurysms remains unclear, and management strategy is not well defined. METHODS: From January 2003 to December 2012, we enrolled patients with aneurysm in our institution. In total, 2252 patients with 2897 aneurysms were eligible for analysis, and 1960 eligible aneurysms were conservatively managed. Precise 3-dimensional evaluation was conducted using computed tomography angiography, digital subtraction angiography, or magnetic resonance angiography. We then assessed the risk of aneurysm rupture, mortality, and morbidity associated with aneurysm characteristics, demographics, and known health/lifestyle risk factors. RESULTS: The mean follow-up duration was 7388 aneurysm-years. During observation, 56 aneurysms ruptured, resulting in an overall rupture rate per year of 0.76% (95% confidence interval, 0.58-0.98). The mean initial visit to rupture interval was 547 days. Aneurysm size, location, daughter sac, and history of subarachnoid hemorrhage were significant independent predictors for aneurysm rupture. Aneurysms that were ≥5 mm were associated with a significantly increased risk of rupture when compared with 2- to 4-mm aneurysms (unadjusted hazard ratio, 12.24; 95% confidence interval, 7.15-20.93). Of 56 patients who experienced hemorrhage, 29 (52 %) died or were rendered severely disabled. Of the patients who had large or giant aneurysms, none recovered without deficits, and the mortality rate after rupture was 69%. For aneurysms sized <5 mm, the mortality rate was 18%. CONCLUSIONS: Larger aneurysms are at greater risk for rupture and poor outcome. Ethnic factors may play a role in the risk of rupture.
Subject(s)
Aneurysm, Ruptured/epidemiology , Intracranial Aneurysm/diagnosis , Rupture, Spontaneous/epidemiology , Subarachnoid Hemorrhage/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Aneurysm, Ruptured/mortality , Angiography, Digital Subtraction , Cerebral Angiography , Cohort Studies , Female , Humans , Incidence , Intracranial Aneurysm/epidemiology , Longitudinal Studies , Magnetic Resonance Angiography , Male , Middle Aged , Prognosis , Prospective Studies , Risk , Risk Factors , Rupture, Spontaneous/mortality , Tomography, X-Ray Computed , Young AdultABSTRACT
OBJECTIVE: To build a prediction model that estimates the 3-year rupture risk of unruptured saccular cerebral aneurysms. METHODS: Survival analysis was done using each aneurysm as the unit for analysis. Derivation data were from the Unruptured Cerebral Aneurysm Study (UCAS) in Japan. It consists of patients with unruptured cerebral aneurysms enrolled between 2000 and 2004 at neurosurgical departments at tertiary care hospitals in Japan. The model was presented as a scoring system, and aneurysms were classified into 4 risk grades by predicted 3-year rupture risk: I, < 1%; II, 1 to 3%; III, 3 to 9%, and IV, >9%. The discrimination property and calibration plot of the model were evaluated with external validation data. They were a combination of 3 Japanese cohort studies: UCAS II, the Small Unruptured Intracranial Aneurysm Verification study, and the study at Jikei University School of Medicine. RESULTS: The derivation data include 6,606 unruptured cerebral aneurysms in 5,651 patients. During the 11,482 aneurysm-year follow-up period, 107 ruptures were observed. The predictors chosen for the scoring system were patient age, sex, and hypertension, along with aneurysm size, location, and the presence of a daughter sac. The 3-year risk of rupture ranged from <1% to >15% depending on the individual characteristics of patients and aneurysms. External validation indicated good discrimination and calibration properties. INTERPRETATION: A simple scoring system that only needs easily available patient and aneurysmal information was constructed. This can be used in clinical decision making regarding management of unruptured cerebral aneurysms.
Subject(s)
Aneurysm, Ruptured/epidemiology , Intracranial Aneurysm/epidemiology , Models, Statistical , Aged , Aneurysm, Ruptured/diagnosis , Female , Follow-Up Studies , Humans , Intracranial Aneurysm/diagnosis , Japan/epidemiology , Male , Middle Aged , Prognosis , Reproducibility of Results , RiskABSTRACT
Medical illustrations represent a precious resource for learning surgical anatomy and surgical techniques, allowing preoperative and postoperative reviews. As traditional hand-drawn illustrations are difficult to use and expressing the area of neurointerventional surgery is time-consuming, we proposed methods for neurointerventional surgeons to create digital illustrations (DIs) for neurointerventional surgery using the iPad-exclusive Procreate application (Savage Interactive, Hobart, Australia). Dedicated "digital pens" were created and used for each endovascular device, creating straightforward representations of neurointerventional procedures and changes over time. DIs in neurointervention easily depict changes to highlighted surgical scenes for various devices with complex configurations and structures. DIs are also versatile, allowing easy intrainstitutional and interinstitutional sharing and discussion of technical tips on the manipulation of medical devices (coils, catheters, stents, etc.) among neurointerventional surgeons worldwide. DIs can be applied as educational tools not only in neurointerventional surgery, but also in craniotomy surgery and for surgical records from other specialties.
ABSTRACT
OBJECTIVE: Although it has been proposed that aneurysm morphology is different after rupture, detailed research of the morphological changes using 3D imaging acquired before and after rupture has not been conducted because of the difficulty of data collection. Similarly, hemodynamic changes due to morphological alterations after rupture have not been analyzed. The aim of this study was to investigate the changes in morphology and hemodynamics observed after aneurysm rupture. METHODS: For 21 cerebral aneurysms (21 patients) that ruptured during observation, 3D geometry of the aneurysms and parent arteries were reconstructed based on the angiographic images before and after their rupture. In addition, using the reconstructed geometry, blood flow was simulated by computational fluid dynamics (CFD) analysis. Morphological and hemodynamic parameters were calculated both before and after rupture, and their changes from before to after were compared. RESULTS: In the morphological parameters, statistically significantly higher values were observed after rupture in height (before: 5.5 ± 2.1 mm, after: 6.1 ± 2.0 mm; p < 0.0001), aspect ratio (p = 0.002), aneurysm volume (p = 0.04), and undulation index (p = 0.005). In terms of hemodynamic changes, the mean normalized wall shear stress (NWSS) decreased significantly (before: 5.4 × 10-1 ± 2.9 × 10-1, after: 4.4 × 10-1 ± 2.8 × 10-1; p < 0.001) as well as the other NWSS parameters, including maximum and minimum NWSS, which were associated with stagnant flow due to the morphological changes after rupture. CONCLUSIONS: Aneurysm morphology was found to change after rupture into an elongated and irregular geometry, accompanied by an increase in aneurysm volume. These morphological changes were also associated with statistically significant hemodynamic alterations that produced low wall sheer stress by stagnant flow. The authors' results also provide the opportunity to explore and develop a risk evaluation method for aneurysm rupture based on prerupture morphology and hemodynamics by further exploration in this direction.
Subject(s)
Aneurysm, Ruptured , Intracranial Aneurysm , Humans , Intracranial Aneurysm/diagnostic imaging , Hemodynamics , Aneurysm, Ruptured/diagnostic imaging , Angiography , ArteriesABSTRACT
Introduction: An intermediate catheter (IMC) may pose a risk of intraprocedural rupture (IPR) during coil embolization of ruptured intracranial aneurysms (RIAs), because the pressure on the microcatheter and coil might be more direct. To verify this hypothesis, this study explored whether use of an IMC might correlate with an increased rate of IPR during coil embolization for RIAs. Methods: We retrospectively reviewed 195 consecutive aneurysms in 192 patients who underwent initial coil embolization for saccular RIAs at our institution between January 2007 and December 2023. Patients were divided into two groups with aneurysms treated either with an IMC (IMC group) or without an IMC (non-IMC group). To investigate whether IMC use increased the rate of IPR, a propensity score-matched analysis was employed to control for age, sex, maximal aneurysm size, neck size, bleb formation, aneurysm location, proximal vessel tortuosity, balloon-assisted coiling, type of microcatheter, and type of framing coil. Results: Ultimately, 43 (22%) coil embolization used IMC. In univariate analysis, the incidence of IPR was significantly higher in the IMC group compared with the non-IMC group (14.0 vs. 3.3%, p = 0.016). Propensity score matching was successful for pairs of 26 aneurysms in the IMC group and 52 aneurysms in the non-IMC group. The incidence of IPR was still significantly higher in the IMC group than in the non-IMC group (23.1 vs. 3.8%, p = 0.015). No significant differences in the incidences of ischemic complications and IMC-related parent artery dissection were observed between the two groups. Discussion: When using IMC for coil embolization of RIAs, the surgeons should be more careful and delicate in manipulating the microcatheter and inserting the coils to avoid IPR.
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BACKGROUND: The current 3D-iFlow application can only measure the arrival time of contrast media through intensity values. If the flow rate could be estimated by 3D-iFlow, patient-specific hemodynamics could be determined within the scope of normal diagnostic management, eliminating the need for additional resources for blood flow rate estimation. OBJECTIVE: The aim of this study is to develop and validate a method for measuring the flow rate by data obtained from 3D-iFlow images - a prototype application in Four-dimensional digital subtraction angiography (4D-DSA). METHODS: Using phantom model and experimental circuit with circulating glycerin solution, an equation for the relationship between contrast media intensity and flow rate was developed. Applying the equation to the aneurysm phantom models, the derived flow rate was evaluated. RESULTS: The average errors between the derived flow rate and setting flow rate became larger when the glycerin flow and the X-rays from the X-ray tube of the angiography system were parallel to each other or when the measurement point included overlaps with other contrast enhanced areas. CONCLUSION: Although the error increases dependent on the imaging direction and overlap of contrast enhanced area, the developed equation can estimate the flow rate using the image intensity value measured on 3D-iFlow based on 4D-DSA.
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BACKGROUND AND OBJECTIVES: Radial artery diameter may limit whether a guiding sheath (GS) can be used via transradial artery access (TRA). A smaller GS may reduce the risk of access site-related complications. This study investigated the feasibility and safety of endovascular treatment (EVT) using a straight-shaped 3-Fr GS (Axcelguide; Medikit). METHODS: Patients who underwent EVT with a straight-shaped 3-Fr GS at 3 institutions between April 2022 and March 2024 were retrospectively reviewed. Patient background, anatomic and procedural factors, and complications were recorded. RESULTS: Twenty-six pathologies were treated with EVT using a 3-Fr GS. Median radial artery diameter was 1.9 mm, and distal TRA (73.1%) was selected more often than TRA (26.9%) as the access site. The breakdown of target pathologies and the role of the 3-Fr GS were as follows: 12 unruptured cerebral aneurysms for intra-aneurysmal coiling, with 5 dural arteriovenous fistulas, 5 brain or head and neck tumors, 2 chronic subdural hematoma, 1 arteriovenous malformation, and 1 hereditary hemorrhagic telangiectasia for transarterial embolization. A success rate of 96.2% was achieved, with no access site- or non-access site-related complications observed within 30 days. CONCLUSION: The straight-shaped 3-Fr GS may be applicable for selected pathologies, allowing access even with RAs <2 mm in diameter and facilitating EVT without complications. Preliminary experience with the 3-Fr GS via TRA demonstrated excellent feasibility and safety.
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Objective: To investigate on three-dimensional (3D) fusion images the apposition of low-profile visualized intraluminal support (LVIS) stents in intracranial aneurysms after treatment and assess inter-rater reliability. Materials and methods: Records of all patients with unruptured intracranial aneurysms who were treated with the LVIS stent were retrospectively accessed and included in this study. Two neurosurgeons evaluated the presence of malapposition between the vessel walls and the stent trunk (crescent sign) and the vessel wall and the stent edges (edge malappostion) on 3D fusion images. These images were high-resolution cone-beam computed tomography images of the LVIS stent fused with 3D-digital subtraction angiography images of the vessels. Associations between malapposition and aneurysm location were assessed by Fisher's exact test, and inter-rater agreement was estimated using Cohen's kappa statistic. Results: Forty consecutive patients were included. In all patients, 3D fusion imaging successfully visualized the tantalum helical strands and the closed-cell structure of the nitinol material of the low-profile visualized intraluminal support. A crescent sign was observed in 27.5 % and edge malapposition in 47.5 % of the patients. Malapposition was not significantly associated with location (p = 0.23 crescent sign, p = 0.07 edge malapposition). Almost perfect (κ = 0.88) and substantial (κ = 0.76) agreements between the two raters were found for the detection of crescent signs and edge appositions, respectively. Conclusions: 3D fusion imaging provided clear visualization of the LVIS stent and parent arteries, and could detect malapposition with excellent inter-rater reliability. This technique may provide valuable guidance for surgeons in determining postoperative management.
ABSTRACT
PURPOSE: Although stent-assisted technique is expected to help provide a scaffold for neointima formation at the orifice of the aneurysm, not all aneurysms treated with stent-assisted technique develop complete neointima formation. The white-collar sign (WCS) indicates neointimal tissue formation at the aneurysm neck that prevents aneurysm recanalization. The aim of this study was to explore factors related to WCS appearance after stent-assisted coil embolization of unruptured intracranial aneurysms (UIAs). METHODS: A total of 59 UIAs treated with a Neuroform Atlas stent were retrospectively analyzed. The WCS was identified on digital subtraction angiography (DSA) 1 year after coil embolization. The cohort was divided into WCS-positive and WCS-negative groups, and possible predictors of the WCS were explored using logistic regression analysis. RESULTS: The WCS appeared in 20 aneurysms (33.9%). In the WCS-positive group, neck size was significantly smaller (4.2 (interquartile range (IQR): 3.8-4.6) versus 5.4 (IQR: 4.2-6.8) mm, p = .006), the VER was significantly higher (31.8% (IQR: 28.6%-38.4%) versus 27.6% (IQR: 23.6%-33.8%), p = .02), and the rate of RROC class 1 immediately after treatment was significantly higher (70% vs 20.5%, p < .001) than in the WCS-negative group. On multivariate analysis, neck size (odds ratio (OR): 0.542, 95% confidence interval (CI): 0.308-0.954; p = .03) and RROC class 1 immediately after treatment (OR: 6.99, 95% CI: 1.769-27.55; p = .006) were independent predictors of WCS appearance. CONCLUSIONS: Smaller neck size and complete occlusion immediately after treatment were significant factors related to WCS appearance in stent-assisted coil embolization for UIAs using the Neuroform Atlas stent.